WHO

1
WHOs cervical cancer screening programmes
managerial guidelines

• by
• Naila Baig Ansari
• Research Fellow
• Dept. of Community Health Sciences
• The Aga Khan University
• Karachi, Pakistan

2
Who am I?

• Education
• MSc (Epidemiology), The Aga Khan University,
  2001. Thesis Care and feeding practices and
  their association with stunting among young
  children residing in Karachi-s squatter
  settlements
• BBA (Management), The College of William and
  Mary, Williamsburg, VA, USA, 1989
• Research interest Nutritional and behavioral
  epidemiology, methodological issues in dietary
  assessment methods, household food security and
  gender-related issues, care and feeding
  practices, management of data and questionnaire
  designing

3
Learning Objectives

• To understand the importance of establishing a
  cervical cancer screening programme
• To be familiar with the WHO recommended
  managerial factors to consider prior to setting
  up a screening programme
• To understand the concept of downstaging in
  terms of cervical cancer screening

4
Performance Objectives

• Know the managerial issues to consider when
  setting up a cervical screening program
• Understand the concept of downstaging and
  possible approaches of downstaging cervical
  cancer

5
Introduction

• Cervical cancer is the 2nd most common cancer
  among women globally
• Higher cervical cancer mortality in developing
  countries due to lack of effective screening
  programs

6
Introduction

• High proportion of women are diagnosed at an
  advanced stage due to
• Lack of knowledge among women of the relevance of
  symptoms
• Fatalistic attitude towards cancer and
  possibility of being cured
• Lack of availability of health care in rural
  areas
• Low priority of womens health issues

7
Managerial factors to consider when setting up a
screening programme

• Formulation of screening programmes
• The natural history of cervical cancer
• Implications of screening policy

• Service delivery
• Information systems
• Programme evaluation
• Downstaging where cytological screening not
  possible

8
Natural History

• Cervical cancer develops slowly, and the key
  precursor is severe dysplasia. The natural
  history begins with
• the onset of sexual activity at about age 13,
• cervical dysplasia appears about age 18 through
  35 years
• Carcinoma in situ begins about age 35 years
  through to about age 50 when invasive cancers
  begin to appear as a prelude to death at about
  age 55.

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Risk Factors identified

• Human papillomavirus (HPV DNA is present 93 of
  cervical cancer and its precursor lesions)
• Epidemiologic studies ongoing on cofactors and
  host factors that may explain the natural history
  of HPV infections and their associated lesions.
• Factors under investigation include smoking use
  of hormonal contraceptives number of live
  births young age at first sexual intercourse
  use of vitamins such as carotenoids, vitamin C,
  and folic acid co-infection with other sexually
  transmitted diseases (e.g., herpes simplex, HIV,
  chlamydia) growth factors

10
Implementation and evaluation of cervical
screening

• Decision to implement screening for cervical
  cancer should be based on
• Evidence that cervical cancer is a major health
  problem
• Characteristics of individuals and populations at
  risk
• An appropriate health service infrastructure
• Technical resources for smear collection and
  cytological examination
• Resources for diagnosis and treatment

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Which health service sector?

• Decision on which health service sector to
  utilize for screening based on
• Epidemiology
• Coverage of women at risk
• Use of maternal and child health /
  family-planning services
• Occupational health services
• Mobile units of screening
• Cost of screening in different health sectors

12
Frequency of screening

• Women with negative cervical smear have low rates
  of invasive cancer for 5 years. Also rates below
  those in general population for 10 or more years
• Cost-effective approach to recruit high
  proportion of the population and screen them
  infrequently rather than low proportion and
  frequent screening

13
Estimated reduction in the cumulative incidence
of invasive cervical cancer in Chile as a result
of a single screen at various ages
Age of single screen reduction in cum. incidence No. of tests in population (based on 1985 est pop. of Chile)
30 11 88,000
35 15 81,000
37 17 81,000
40 20 70,000
45 26 57,000
50 26 45,000
60 21 34,000
14
Cost-effectiveness of two different strategies
for cervical cancer screening in Chile

Programme 1 Programme 2
Age 30-55 years 30-50 years
Frequency 3-yearly 10-yearly
Compliance 30 90
Reduction in mortality 15 44
Reduction in treatement costs US 0.13 million US 0.25 million
Cost per case detected US 2,522 US556
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Screening in Primary Health Care

• Setting up a screening service
• Target group
• Ensuring target group is screened
• Recording and reporting
• Management of women with abnormal smears

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What is downstaging for cervical cancers

• Downstaging is the detection of the disease in
  the earlier stage when still curable, by nurses
  and other non-medical health workers using a
  simple speculum for visual inspection of the
  cervix

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Possible approaches to downstaging for cervical
cancer

• Health education
• Restrict examination to women over 35 years
• Train female primary health workers to examine
  the cervix visually and to identify abnormalities
  
• Establish a link between identification of an
  abnormality and referral

18
Example of process and impact measures to monitor
and evaluate downstaging

• Process Measures
• More than 80 of women in the 35-50 year target
  group are educated on cervical cancer.
• More than 80 of primary health workers are
  educated and trained in visual examination of the
  cervix.
• Impact Measures
• Over 80 of women in the target 35-50 year group
  are examined at least once.

19
Example of outcome measures to monitor and
evaluate downstaging

• Outcome Measures
• Short Term More than one-third of cervical
  cancers are discovered by examination
• Medium Term There is more than a third reduction
  in cases presenting with advanced disease
  (Stage II and beyond).
• Long Term There is more than a third reduction
  in the mortality of cervical cancer.

20
Cancer Control Program

• A cancer control program is like a chair with
  four legs, a seat and a back.
• Four legs represent interventions or programs
  of prevention, screening, treatment and
  palliation.
• Seat joins the four legs into a functional chair.
  It represents the organizational structure,
  management and governance of a national cancer
  control program that integrates its four programs
  into a functional unity.
• Back of the chair provides support. Represents
  the infrastructure that needs to be in place for
  the four programs to function.

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Online sources of interest

• The Merck Manual of Diagnosis and Therapy,
  Section 18. Gynecology And Obstetrics Chapter
  241. Gynecologic Neoplasms
• Cervical Cancer Screening Training Modules
• MedlinePlus Health Information on cervical cancer
• Reproductive Health Outlook (RHO) cervical
  cancer