Organized cervical screening: the role of primary health care

Abstract

Cervical cancer is a serious and persistent public health problem in the Republic of Moldova. Cervical screening programmes can reduce both the incidence as well as the mortality of cervical cancer by up to 80%. However, reductions of this size will only be produced by well organised programmes in which a large proportion (70% or more) of the target population is regularly screened, all the component services are of high quality, all the services are efficiently coordinated and all women with a positive screening test are properly followed-up so any clinically relevant disease can be treated [1]. In 2015, cervical cytology laboratories in the Republic of Moldova (RM) reported processing 236,579 Pap tests. This would have been enough to screen about 90% of the target population so it should have produced substantial reductions in cervical cancer rates. However, data from Moldovan National Cancer Registry show that cervical cancer incidence and mortality, and the proportion of late stage diagnoses (FIGO stages III & IV) all remained very high and without any statistically significant improvement since 2009 [2]. The reason for this is that cervical screening in RM is being conducted opportunistically without any of the elements that are required for it to be effective [3]. Therefore, RM must now move forward with the process of implementing an effective organised cervical screening programme that complies with the European Guidelines for Quality Assurance in Cervical Screening (the European Guidelines) [4]. Primary Health Care (PHC), as the key health service interacting with the public, must play a central role in the design, planning, implementation and delivery of an organised cervical screening programme, as recommended by both international and national policy documents: 1. The European Strategy for the Prevention and Control of Non-communicable Diseases [5] sets-out a comprehensive, integrated approach to tackling NCDs through population-level health promotion and disease prevention programmes that are coordinated with PHC providers who should actively identify high-risk individuals to maximise population coverage and deliver effective services to reduce NCDs including cervical cancer. 2. The Action Plan for Implementation of the European Strategy for the Prevention and Control of Non-communicable Diseases 2012–2016 [6] specifies a set of priority interventions to reduce NCD morbidity and mortality. These include PHC delivery of cervical screening for the detection of cervical intraepithelial neoplasia (pre-cancer) with subsequent referral for the treatment of any clinically relevant disease. 3. The WHO Better Non-communicable Disease Outcomes: Challenges and Opportunities for Health Systems. Republic of Moldova Country Assessment [7] also specifies the PHC delivery of cervical screening for the detection of cervical pre-cancer with subsequent referral for the treatment of any clinically relevant disease. 4. The RM Ministry of Health Order no. 695 of 13.10.2010 on the Provision of Primary Health Care [8] specifies that family physicians and family nurses are responsible for: Family physicians: 97.1 Providing health education and promote healthy lifestyles. 97.3 Identifying people in high-risk groups and early stages of disease. 97.4 Conducting annual prophylactic medical examinations. Family nurses: 103 d Conducting disease screening of patients and recording of results. 104.2 d Performing prophylactic gynaecological examinations. 104.2 j Monitoring and evaluating the effects of the prophylactic activities. Therefore, international recommendations clearly identify PHC providers as the foundation of cervical screening programmes while the relevant Moldovan regulations enable PHC providers to provide the required services. Indeed, an organised cervical screening programme cannot function without the active involvement of PHC providers. However, to ensure PHC providers can effectively support the operation of the cervical screening programme, a number of actions must first be undertaken. The key actions include: 1. New cervical screening guidelines that are specifically for PHC providers need to be prepared by people who are PHC providers and who will therefore fully understand the realities of delivering these services within the Moldovan health system. 2. Based on the new PHC cervical screening guidelines, relevant curricula for family doctors and family nurses need to be updated to ensure they are coordinated with the guidelines. 3. Family doctors and family nurses need to be re-trained so everyone fully understands what their roles are within the cervical screening programme. 4. An effective quality assurance programme programme with regular feedback needs to be established so PHC providers will know what they are doing well and what needs to be improved. Together, these actions will enable PHC providers to effectively support the implementation and operation of the cervical screening programme and thereby substantially reduce the burden of cervical cancer in Moldova.