1. IARC’s Cervical Screening Progamme - Cairo
IARC’s CERVICAL CANCER SCREENING PROGRAMME
R. Sankaranarayanan MD
Screening Group
World Health Organization
International Agency for Research on Cancer,
Lyon, France

2. IARC’s CERVICAL CANCER SCREENING PROGRAMME
OBJECTIVE
To guide public health policies on cervical cancer control in different regional, national and sub-national settings

3. IARC’s CERVICAL CANCER SCREENING PROGRAMME
Evaluates the role of cytology and various non-cytology based screening in the early detection and prevention of cervical neoplasia world-wide

4. IARC’s CERVICAL CANCER SCREENING PROGRAMME SCREENING TESTS EVALUATED
Conventional cervical cytology
Unaided visual inspection (“downstaging”)
Naked eye visual inspection with 3-5% acetic acid (VIA)
Visual inspection with acetic acid using low-level (2-4X) magnification (VIAM)
Visual inspection with Lugol’s iodine (VILI)
HPV testing

5. SCREENING APPROACHES EVALUATED
IARC’s CERVICAL CANCER SCREENING PROGRAMME
SCREENING APPROACHES EVALUATED
Low-intensity screening (“once a life-time”)
Screen, triage, treat approaches with aposteriori histology (1- or 2-visit approach)

6. LEEP by mid-level clinicians
IARC’s CERVICAL CANCER SCREENING PROGRAMME
EVALUATION OF TREATMENT OF CERVICAL PRECANCERS
Cryotherapy by nurses
LEEP by mid-level clinicians
LEEP (LLETZ)
Cryotherapy

7. IARC’s CERVICAL CANCER SCREENING PROGRAMME
STUDY DESIGNS
Cross-sectional studies
Follow-up (cohort) studies
Non-randomised controlled trials
Cluster-randomised controlled trials
Randomised trials
Demonstration programmes

8. IARC’s CERVICAL CANCER SCREENING PROGRAMME
OUTCOMES STUDIED
Accuracy
Reproducibility
Detection rates of CIN/Ca
Cure rates of CIN
Side-effects and complications of Rx of CIN
Stage-distribution
Reduction in incidence/mortality
Determinants of participation

9. IARC’s CERVICAL CANCER SCREENING PROGRAMME
STUDY LOCATIONS
Vientiane
Bangkok
Singapore
Trivandrum
Emakulam
Kannur
Mumbai
Barshi/ Osmanabad
Hyderabad
Coimbatore
Ambillikai
Calcutta
Bhaktapur
Banepa
Barathpur
New Delhi
Jaipur
Dar es Salaam
Luanda
Brazzaville
Ibadan
Ouagadougou
Niamey
Bamako
Nouakchott
Dakar
Conakry
Lima
Bogota
Randomised control trials
Cross-sectional studies
Training facilities
Planned projected

10. COLLABORATING INSTITUTIONS: AFRICA, EUROPE AND SOUTH AMERICA
IARC’s CERVICAL CANCER SCREENING PROGRAMME
COLLABORATING INSTITUTIONS: AFRICA, EUROPE AND SOUTH AMERICA
Maternity Hospital, Luanda, and MOH, Angola
University Hospital, Ouagadougou, Burkina Faso
University Hospital, Brazzaville, Republic of Congo
University Hospital, Conakry, and MOH, Guinea
Hospital Point G, Bamako, Mali
University Hospital, Nouakchoutt, Mauritannia
Medical College, Ibadan, Nigeria
University Hospital, Niamey, Niger
Ocean Road Cancer Institute, Dar es Salaam, Tanzania
Regional Office of the WHO, Arican Region (AFRO)
Hospital Edouard Herriot, Lyon, France
Centre Leon Berard, Lyon, France
University Hospital, Grenoble, France
INCTR, Brussels, Belgium
Health Economics Research Centre, University of Oxford
National Cancer Institute, Lima, Peru
National Cancer Institute, Bogota, Columbia

11. COLLABORATING INSTITUTIONS: INDIA
IARC’s CERVICAL CANCER SCREENING PROGRAMME
COLLABORATING INSTITUTIONS: INDIA
Tata Memorial Centre, Mumbai,
Nargis Dutt Memorial Cancer Hospital, Barshi
Christian Fellowship Community Health Centre, Ambillikai
Regional Cancer Centre, Trivandrum
Chittaranjan National Cancer Institute, Kolkata
Cancer Foundation of India, Kolkata
Cancer Institute (WIA), Chennai
All India Institute of Medical Sciences, New Delhi
Bhagwan Mahaveer Cancer Hospital & Research Centre, Jaipur
PSG Institute of Medical Sciences and Research, Coimbatore
Christian Medical College, Vellore
Malabar Cancer Care Society, Kannur
MNJ Cancer Institute, Hyderabad
Institute for Rural Health Studies, Hyderabad

12. IARC’s CERVICAL CANCER SCREENING PROGRAMME COLLABORATING INSTITUTIONS
BP Koirala Memorial Cancer Hospital, Bharatpur, Chitwan, Nepal
Bhakthapur Cancer Care Centre, Bhakthapur, Nepal
Nepal Network for Cancer Treatment & Research, Banepa, Nepal
University Hospital, Vientiane, Laos
National Cancer Institute, Bangkok, Thailand

13. IARC’s CERVICAL CANCER SCREENING PROGRAMME
300,000 women in 11 countries
38 Institutions in 5 continents
436 investigators and workers

14. IARC’s CERVICAL CANCER SCREENING PROGRAMME
CROSS-SECTIONAL STUDIES OF ACCURACY TO DETECT CIN 2-3 LESIONS
56,939 women
22,633 with cytology
18,085 with HPV testing/HCII
54,918 tested with VIA
16,900 withVIAM
49,080 with VILI
56,939 had colposcopy
9590 had biopsy
3369 CIN 1
1063 CIN 2 & 3
269 Cx Cancers

15. IARC’s CERVICAL CANCER SCREENING PROGRAMME ACCURACY OF SCREENING TESTS
Int J Cancer 2004; ; J Med Screening 2004; 11:77-84; Int J Cancer 2004 (in press); Cancer Detect Prev 2004 (in press)

16. Cancer Institute (WIA), Chennai, India
Cluster Randomised Controlled Trial of VIA Screening, Dindigul District, India
Christian Fellowship Community Health Centre (CFCHC), Ambillikai, India
PSG Institute of Medical Sciences and Research (PSGIMSR), Coimbatore, India
Cancer Institute (WIA), Chennai, India
World Health Organization-International Agency for Research Cancer (WHO-IARC), Lyon, France

17. Flow chart of the design and preliminary results of the study
DINDIGUL RCT OF VIA SCREENING, INDIA
Flow chart of the design and preliminary results of the study
Assessed for eligibility (n= 80,422)
Excluded (n=2,030)
Randomised 113 clusters (n= 78,392)
Allocated to VIA screening 57 clusters (n= 48,225)
124,144 PYO
Allocated to control group 56 clusters (n= 30,167)
90,172 PYO
Received VIA screening (n= 30,577)
Did not receive VIA screening (n= 17,648)
34 invasive cancers diagnosed
CR: 37.7/100,000 PYO
ASR: 43.1/100,000 PYO
Screened positive
n=2,939 (9.6%)
CIN 1
n= 1,778 (5.8%)
Treated
n= 1,263 (71.0%)
CIN 2-3
n= 222 (0.7%)
n= 178 (80.2%)
Screen detected invasive cancer n=69 (0.2%)
n= 52 (75.4%)
Clinically detected invasive cancer
n=28
97 invasive cancers diagnosed
CR: 78.1/100,000 PYO
ASR: 92.4/100,000 PYO
Sankaranarayanan et al., Int J Cancer: 109, (2004)
PYO: person years of observation; CR: crude incidence rate; ASR: age-standardized incidence rate; CIN: cervical intraepithelial neoplasia; Percentages refer to proportion of screened women (N=30,577) except for treatment where they refer to lesion detected

18. IARC’s Cervical Screening Progamme - Cairo
Comparative efficacy of visual inspection with acetic acid, HPV testing and conventional cytology in cervical cancer screening: a randomized intervention trial in Maharashtra state, India
Tata Memorial Centre (TMC), Mumbai, India
Nargis Dutt Memorial Cancer Hospital (NCMCH), Barshi, India International Agency for Research Cancer (WHO-IARC), Lyon, France

19. FLOW CHART OF THE STUDY DESIGN AND FINDINGS
Eligible population 52 PHCs (n=142,701)
Randomization
Cytology arm (13 PHCs)
VIA arm (13 PHCs)
Control arm (13 PHCs)
HPV arm (13 PHCs)
Screening coverage 71.9% (positivity rate: 14.0%)
Screening coverage 72.9% (positivity rate: 7.0%)
Screening coverage 69.5% (positivity rate: 10.3%)
Compliance with colposcopy in the field 98.5%
Compliance with colposcopy at NDMCH 87.1%
Compliance with colposcopy at NDMCH 88.2%
Detection rates
CIN %
Condyloma/ CIN 1 5.6%
cancer0.3%
CIN %
Condyloma/ CIN 1 2.0%
CIN %
Condyloma/ CIN 1 2.3%
cancer0.2%

20. STAGE DISTRIBUTION OF INVASIVE CANCER IN THE STUDY ARMS
OSMANABAD RCT OF CERVICAL SCREENING, INDIA
STAGE DISTRIBUTION OF INVASIVE CANCER IN THE STUDY ARMS
VIA arm
Cytology arm
HPV arm
Control arm
Stage
Number (%) I 52
(52.5) 61
(62.3) 50
(66.6) 10
(18.6) II 18
(18.2) 12
(11.2) 14
(18.7) 8
(14.9)
III 24
(24.2)
(24.5)
(13.3) 33
(61.1) IV 5
(5.0) 1
(0.0)
(1.3) 3
(5.6)
Total 99
(100.0) 98 75 54
Study

21. OVERTREATMENT IN SCREEN, SEE AND TREAT APPROACH: OSMANABAD AND DINDIGUL DISTRICT SCREENING PROJECTS, INDIA
Disease status based on histology
Number (%)
Normal
1595 (36)
CIN 1
2157 (49)
CIN 2 & 3
629 (15)
Total
4381
Supported by the ACCP through the Bill & Melinda Gates Foundation

22. HOW EFFECTIVE ARE THE TREATMENT OF PRECANCERS IN THE DEVELOPING WORLD?
Cryotherapy: Data from Indian studies
Lesion
Total
Cured at 1 year
CIN 1
1264
90% (N=1137)
CIN 2 & 3
234
79% (N=184)
LEEP: Data from Indian studies
Lesion
Total
Cured at 1 year
CIN 1
296
96% (N=283)
CIN 2 & 3
336
86% (N=288)
Overall 1 cure rate in CIN = 89% (1892/2130)
Supported by the ACCP through the Bill & Melinda Gates Foundation

23. 300 women with CIN randomized
IARC’s CERVICAL CANCER SCREENING PROGRAMME
EFFICACY OF SINGLE- VS DOUBLE-FREEZE CRYOTHERAPY
300 women with CIN randomized
Preliminary findings indicate same efficacy : 89% NED at 1-year

24. IARC’s CERVICAL CANCER SCREENING PROGRAMME
TRAINING
QUALITY ASSURANCE

25. IARC’s CERVICAL CANCER SCREENING PROGRAMME
TRAINING MATERIALS

27. Contraceptive practice
IARC’s CERVICAL CANCER SCREENING PROGRAMME
DETERMINANTS OF PARTICIPATION IN SCREENING
Low SES
Low income
Education
Parity
Contraceptive practice
Sankaranarayanan et al., Cancer Detect Prev 2003; 27:

28. IARC’s CERVICAL CANCER SCREENING PROGRAMME COST EFFECTIVENESS STUDIES

29. Unit costs of intervention in Osmanabad district cervical cancer screening project

30. Costs per CIN 2/3 detected in Osmanabad district cervical cancer screening project

31. IARC’s CERVICAL CANCER SCREENING PROGRAMME
TRAINING CENTRES
Chittaranjan National Cancer Institute, Kolkata, India
Regional Cancer Centre, Trivandrum, India
University Hospital, Conakry, Guinea
Maternity Hospital, Luanda, Angola
Ocean Road Cancer Institute, Dar es Salaam, Tanzania
Instututo de Enfermedades Neoplasicas, Lima Peru
National Cancer Institute, Bogota Columbia

32. Awareness Test Recall Follow-up SCREENING VS EARLY CLINICAL DETECTION
IARC’s CERVICAL CANCER SCREENING PROGRAMME
SCREENING VS EARLY CLINICAL DETECTION
Awareness
Test
Recall
Follow-up

33. Cervix Cancer Screening
Volume 10
Cervix Cancer Screening
2004 (in press)

34. IARC’s CERVICAL CANCER SCREENING PROGRAMME
SUPPORTED BY
The Bill & Melinda Gates Foundation through the ACCP
WHO-AFRO
International Network for Cancer Treatment and Research (INCTR)
International Union Against Cancer (UICC)
Association for International Cancer Research (AICR)
Program for Appropriate Technology in Health (PATH)