Organized cervical screening: an overview

Abstract

Cervical cancer primarily affects younger women with the majority of cases diagnosed between 35 and 50 years of age, a period when many women are working, caring for their families or doing both. In the European Union (EU), about 34,000 new cases of cervical cancer and 16,000 deaths are reported every year [1, 2]. Eastern Europe has substantially higher rates of cervical cancer than Western Europe and this is primarily due to the extensive opportunistic screening or nationally organized cervical screening programs in Western Europe [3]. 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 organized 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 and any clinically relevant disease is treated [4]. In 2015, cervical cytology laboratories in the Republic of Moldova (RM) reported processing 236,579 Pap tests which would have been enough to screen about 90% of the target population. This should have produced substantial reductions in cervical cancer rates, but data from Moldovan National Cancer Registry show that cervical cancer incidence and mortality have remained high and without any statistically significant improvement since 2009 (table 1, figure 1). In addition, the proportion of late stage diagnoses (FIGO stages III & IV) has remained very high and stable at about 50% over the period from 2009-2015 (figure 2). However, these incidence and mortality rates are based on the 2004 census and the true at-risk population is now known to be smaller so the actual rates will be even higher [5]. Therefore, the main issue with cervical cancer in RM is not whether there is enough money to provide cervical screening (as the services already being paid for would be sufficient to screen 90% of the target population), but rather why all the resources that are currently being spent on these services are not producing any results. The reason for this is that cervical screening in RM is being conducted opportunistically without proper staff training, standardization of procedures, and coordination of the component health services, effective patient management or quality assurance (QA). It therefore will not reduce cervical cancer rates but will increase the harms of screening (see Table 2) [6]. Because of this, the European Guidelines for Quality Assurance in Cervical Screening recommend that cervical screening should be delivered only through well organized programmes [7]. Therefore, effective measures must be taken to organised cervical screening, including the introduction of: • A screening coordination unit run by staff that can effectively organize, monitor and evaluate the health services that are required to deliver the screening programme, • Training curricula with training standards and certification criteria, • Working practice recommendations, • Performance indicators,performance standards and QA procedures, • Systemstomonitorandevaluateallofthecomponent health service and ensure compliance with international, evidence-based recommendations. Undertaking these measures will substantially improve the accessibility, the effectiveness and the cost-effectiveness of cervical screening, while simultaneously minimizing the harms of screening [8, 9].