Cervical Cancer Screening Assessment in Romania- Problems, Present, Future Iuliana Apostol, MD Dr Victor Babes Foundation, Bucharest, Romania

Epidemiological Data

National Epidemiological Data Source: CCSS

Why These Epidemiological Figures ? Romanian Statistic Annual 2004:  Cervical cancer incidence =33,88: women  Cervical cancer mortality =16,38: women  The highest rates (first place) in Europe regarding specific mortality (CC) 1981-The Commission of Oncology from the Health Ministry; the first preventive cancer strategy , , : successive preventive cancer strategies, but not finalized (bad management, frequent changes in high-level management, inconstant financing).

PAST IN ROMANIA

Organized Screening  the first pilot study in Cluj district - run by IOCN.  the second pilot study for cervical cancer in Bucharest (3 out of 6 areas) and neighboring rural areas - run by CPSS.  a screening program for cervical cancer in Cluj district - run by IOCN.

The Pilot Studies First pilot study - in Cluj district: planning and implementing an organized CC prevention program; it demonstrated the efficiency of primary medicine in CC prevention. Second pilot study - in Bucharest and neighboring rural areas: an estimated women PAP tested; developing guidelines for GPs and other specialists, I & E campaigns, screening activities and organizing reference centers.

The Best Screening:  Women aged 25-65, screened with PAP test at three year interval, in Cluj district.  Results: Built up the screening network at the primary medicine level; GPs – key providers in the network. Elaborated the methodology and quality standards for the screening program. Organized a reference cytology laboratory (with pap smears). Set up a regional registry for cervical cytology (a computerized informational system).

PRESENT IN ROMANIA

Screening at present time opportunistic screening for CC, through the national subprogram of the Health Ministry. The subprogram 2.2: “Prevention and Control in Oncology” a regionally organized screening for CC, through another project: “A model for early detection of genital-urinary cancer”. It has been financed by JSI Research & Training Institute, USA.

The National Oncology Subprogram  Objective: early detection (stages 0, I, II) of cervical cancer cases. The monitoring of the program is done through the two national institutes: IOB and IOCN.  Physical indicators: number of screening tests =  Efficiency indicators =medium cost/screening test =10 Euro.  Result indicators: cancer mortality target-decrease under 197/ ; proportion of early detection through screening-increase by 3%.

A Regionally Organized Screening The target group: women from rural areas, aged 25-65, from 4 districts and Cluj city. The objectives: increase the accessibility of women from rural areas to the preventive strategies and increase awareness of the importance of this examination (I & E campaign).

COMPONENT 1- Community Information and Education

I & E Activities in the Community  There are only regional campaigns of I &E regarding CCP in Romania, limited in time and most focusing on urban areas; there is only one regional project with rural focus, regarding the importance of CCP.  A national survey study -”Reproductive Health Survey in Romania in 2004” - indicated a low impact of I & E campaigns.

I & E Activities in the Community  Attitudes regarding own health: 80% of sexually active women have never been tested with PAP smear and 37% never heard of it.  Women that never heard about PAP smear: low educational level (62%), low socio-economic status (60%), women with three or more children (56%), younger women (53% between years), rural women. Source: Final report of Reproductive Health Survey in Romania 2004, a national study.

I & E Activities in the Community Success of this component requires good selection of important stakeholders, experienced in training of formulators and involving them into the new CCP. Broadcasting information through the mass media, combined with personal invitation to the screening are the single most important means of attaining high coverage. The new program needs designing and large dissemination of informative materials, adapted to the target population, in order to increase the impact of I&E campaigns.

INVITATION LEAFLET & POSTER

PAPER ADD

COMPONENT 2- Screening Services

Screening Services - policy Some changes in health policy are needed:  Organizing a GP centered program.  Setting up a unique cervical cancer screening guide, adapted to the international standards.  Setting up the desired covering and the frequency of screening test.  Reducing ambiguous policies and incompatibilities between Health Ministry (organization and service providing) and CNAS (financing) regarding CCP.

Screening Services – Role of GPs  GPs activities inside the screening services are: cartography, active recruitment, screening tests, patient files & reports, communication of test results.  The best covering can be obtained only through active intervention of GPs in the patients recruitment process for the screening.  The program needs some financial incentive for GPs.

Screening Services - Limitations Currently no active recruitment of eligible women takes place; the process needs to involve GPs as key providers of services and also better media dissemination. There is no unique PAP smear processing and interpretation in Romania. There is no unique model for registration of data in screening process at national level. There are not enough GPs properly trained for CCP; a tremendous need for specific training.

Screening Services - Limitations There are few resources in a GP’s office, imposing an important financial limitation to high attendance. There are no monitoring and evaluation indicators for the screening services; mandatory: constant evaluation of the proportion of dysplasia or cancer detected, false positive and false negative readings. European Guidelines for Quality Control in Cervix Cancer Screening must be implemented.

Screening Services - Covering Source: Final report of Reproductive Health Survey in Romania proportion of women with the PAP smear in the last 3 years

Screening Services-publications IOB & IOCN Institutes are the leaders in the design of clinical national guidelines in CC screening. The existing guidelines need continuous updating. It is necessary to use the latest version of international guidelines in CC screening in order to have only one national model for collecting, storing, transportation and interpretation of PAP smears (e.g. implementation the Bethesda system).

PUBLICATIONS CPSS : CD-ROM & VIDEO RECORDING

PUBLICATIONS CPSS-CERVICAL CANCER SCREENING GUIDELINE

PUBLICATIONS-IOCN

Screening Services - burden for GPs 1 GP has patients, of which approximately 600 women targeted (33%) who need to be tested each year. Testing of all 600 women in a year necessitates roughly 2 hours/daily X 2 times weekly of GP’s working time, considering a screening test of 15 min/test. Source: Cervical cancer screening: from theory to practice, national Conference of Family Practice, Calimanesti, Oct 2002; Teresa Franciuk, C. I. Chirciu.

COMPONENT 3- Diagnosis And/ or Treatment Services

Diagnosis and/or Treatment Services Not sufficient linkage between GPs and diagnostic and histopathology laboratories; no adequate reference & feedback. Not enough information about the reference centers in CCP, no databases. No generally accepted monitoring and evaluation indicators for these services. No qualitative guidelines for the services provided and a need for continuous training for pathologists and gynecologists.

Conclusions –things to do Obtain policy agreement from central authorities and implement policy changes. Contact central institutions (MoH, CNAS, INS) and also territorial institutions (DJSP, CJAS, IJS) to promote the program. DJSP contact GPs from territory, managers of cytology laboratories and diagnostic & treatment centers (gynecology, oncology, histopathology laboratories).

Conclusions - things to do (cont’d) MoH: validate the updated clinical guidelines for CCP program; organize the training plan for GPs & specialists; set up a guide for quality control and accreditation of laboratories/centers, which participate into the CCP program. DJSP: disseminate the guide for CCP to GPs & specialists; plan the educational sessions for GPs and specialists; evaluate the quality of services provided in territory. CNAS estimates the necessary equipment, materials and also incentives for GPs involved in screening; CJAS verifies the costs associated with CCP program.

Conclusions - things to do (cont’d) Set up & analyze system indicators: for infrastructure - databases with GPs office, cytology labs, diagnosis and treatment centers; economic- estimates of the consumables and costs; outcome measure -% of reducing invasive cancer. Set up & analyze human resources indicators: number of GPs/ specialists trained, number of I&E campaigns, quantity & type of informative materials. Set up & analyze target group indicators: number of eligible persons, coverage, number of screening tests, number of FP or FN tests, number of TP tests (cases of dysplasia/cancer identified).

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