preventing cervical cancer in east europe and central asia ...1) most have cancer control strategies...

1

Preventing Cervical Cancer

in

East Europe and Central Asia (EECA)

Dr Philip Davies

Non-EU/EEC Eastern Europe & Central Asia

Cervical Cancer Prevention in the EECA Region

Two approaches to cervical cancer prevention in EECA

1) Primary prevention

• HPV vaccination

2) Secondary prevention

• Cervical screening (Pap test, LBC, HPV testing)

• Must be implemented as an organised programme with:

o Good coordination of the component health services

o High coverage of the target population

o Strict QA of all services

Cervical Screening in the EECA Region

Two views on implementing cervical screening in EECA

1) Focus on establishing cervical screening as a separate service

• Simpler and quicker to implement but often leads to a situation in

which (the existing) opportunistic and (the new) organised

screening co-exist and ‘compete’ for women

• Organised coverage rates are lower so the programme is less cost-

effective and less sustainable

2) Focus on strengthening the existing health services so they can

provide the cervical screening programme

• More complicated to implement as it requires detailed knowledge of

existing health services and active involvement of all stakeholders

in planning and implementing the programme

• More sustainable because the local stakeholders are given

ownership of the programme and it is implemented as an integral

part of the existing health services

The Situation in the EECA Region

The Soviet Union had lots of problems but it also had:

1) Excellent tertiary education, particularly in the sciences and medicine

(based in Moscow)

2) Extensive networks of health facilities with ample well-trained health

providers at all levels

3) Good public heath services

But then…

The Situation in the EECA Region

… the collapse of the Soviet Union led to catastrophic

economic disruption:

1) Governments had no money so all government services were severely

cut-back

2) Health administration services were largely abandoned so there was no

ability to:

• Coordinate different medical services

• Assess current capacities or future needs

• Do any health system planning – including adapting the health system to the

new economic situation

3) Many skilled health professionals emigrated

4) Medical education stagnated as it was previously led from Moscow, so

medical education and healthcare providers missed out on all the

developments that occurred in the West from +/- 1985 onwards –

evidence-based medicine, QA, clinical audit, etc.

Survey of Cervical Screening in the EECA Region

Survey of 16 EECA countries (one with 2 entities) conducted

by the ECCA for the UNFPA in 2015:

Note: the UN works with governments so the information provided can be

what the government wants the world to see.

Countries:

Albania (ALB) Kyrgyzstan (KGZ)

Armenia (ARM) FYR Macedonia (MKD)

Azerbaijan (AZE) Moldova (MDA)

Belarus (BLR) Tajikistan (TJK)

Bosnia and Herzegovina (BiH-FBiH) Turkey (TUR)

Bosnia and Herzegovina (BiH-RS) Turkmenistan (TKM)

Georgia (GEO) Ukraine (UKR)

Kazakhstan (KAZ) Uzbekistan (UZB)

Kosovo (RKS)


Cervical screening age ranges:


National cancer control plans and related legislation:

1) Most countries/territories have cancer control plans and 8 of 17 have

plans that include free cervical screening with related legislation

2) Free of charge cancer treatment is legislated in most

countries/territories

3) Very few countries/territories have legislation that provides for free

follow-up of positive screening tests


Cervical screening strategy and related clinical guidelines:

1) Only 7 of 17 countries/territories have cervical screening strategies

2) Far fewer countries/territories have approved related clinical guidelines

• Cervical sampling – 3 of 17 (if registration, counselling, etc. were

included, this would be 0 of 17)

• Follow-up of positive screening test – 2 of 17

• Treatment of cervical cancer – 1 of 17


Characteristics of cervical screening delivery:

1) Geographical coverage is theoretical – in the Ukraine, +/- 50% of PHC providers

did not provide cervical screening. Screening recruitment figures were

unavailable or unreliable for all countries

2) Organised recruitment – FYR Macedonia and Turkey

3) Cytology is Romanowsky except in Georgia and Bosnia; VIA is used in

Kyrgyzstan and Turkmenistan; HPV testing is used in Turkey

4) Free of charge does not account for unofficial payments that are very common

Cervical Screening in the EECA Region

Summary of survey findings:

1) Most have cancer control strategies and legislation regarding free of

charge cancer treatment (policies promoted by the WHO)

2) Fewer countries/territories have legislation on cancer prevention only 8 of

17 have legislation for free of charge cervical cancer prevention.

3) Of these 8, legislation specifies free cervical screening for all or for

insured women, but only 3 include free follow-up of a positive test – and

none account for unofficial payments.

4) Clinical guidelines for cervical sampling or follow-up of a positive

screening test have been approved in only 3 and 2 countries/territories

respectively. And where they do exist, they are not enforced / followed:

5) 9 countries/territories have very good geographical coverage ≥75% and

therefore have the potential to achieve high recruitment.

6) At least 9 countries have an existing cervical cytology infrastructure. Most

of these use Romanowsky staining but the lack of CME, QA, etc. mean the

quality will be suboptimal.

Implementing Cervical Screening in the EECA Region

Despite the problems – there is a foundation to build upon:

1) Many countries still have good networks of healthcare providers at the

primary level and +/- at the secondary level but skills need to be updated

2) Facilities are available and serviceable but would be considered

dilapidated by Western standards

3) Basic equipment is usually serviceable and sufficient to meet

requirements

4) Record keeping is good in most countries but is almost entirely paper-

based - IT systems are scarce (although the doctors themselves have

computers, laptops, internet access, etc.)

5) Younger healthcare providers have a strong interest in improving the

services they provide and in meeting Western standards

6) Healthcare budgets in many countries are increasing – and in some

would be sufficient to fund cervical screening programmes if the money

was spent properly


Cancer screening programs are complex networks of administrative and clinical services

• All services in the network must:

• Be well coordinated

• Be high quality

• Work closely together

Suboptimal performance of any service or poor coordination of the services will prevent the program from working

Capacity development must target all the services simultaneously, not individual services


• Many of the required services already exist but need to be reorganised, expanded or updated

• Many specialists have substantial political influence

• Capacity development must recruit all relevant specialists and actively involve them in the planning and implementation process:

• Utilise national skills, networks, political contacts, etc. to facilitate program implementation and operation

• Use international expertise to complement national expertise, not replace it

• Must be a program implemented by national stakeholders, not a program imposed on national stakeholders

• Gives national stakeholders ownership of the program and responsibility for making it successful


Therefore, the focus must be on stakeholder involvement and

strengthening the capacities of the exiting health services:

Identify &

engage

stake-

holders

Quantify

capacity

deficits

Quantify existing

health system

capacity for

relevant services

Estimate capacity

needed to meet

cancer screening

targets

Plan capacity

building

program to fill

all deficits

Implement

capacity

building

actions

Monitor &

evaluate

capacity

building

program

Specify

cancer

screening

targets

Quantify

contributions

from comple-

mentary

programs

Implementing Cervical Screening in Moldova

Initial actions:

1) Advocacy actions to build political will started in 2009 with a delegation

of senior politicians attending the Cervical Cancer Summit Meeting in

the European Parliament.

2) Identification and recruitment of all stakeholders with >75 people who

were actively involved in:

• Individual and group meetings over a 3-year period

• Undertaking a situation analysis to identify required legislative and

regulatory changes

• A full capacity assessment of all the services required to deliver the

screening programme: PHC; cervical cytology screening &

cytopathology; colposcopy; gynae pathology


Acknowledgements:Thisdocumentrepresentstheworkofmanyorganisationsandpeople.TheauthorsareparticularlygratefulforthecontributionofNataliaCojohari,ProgrammeAnalyst,UnitedNationsPopulationFund,RepublicofMoldovaand

IrenaDigol,CenterforReproductiveHealthandMedicalGenetics,RepublicofMoldova.Inaddition,theauthors

expresstheirsincerethankstothepeoplelistedbelowwhohaveparticipatedinthisproject:

· ParliamentoftheRepublicofMoldova- LilianaPalihovici,DeputySpeakeroftheParliament- ValentinaStratan,MemberofParliament

· MinistryofHealthoftheRepublicofMoldova- AndreiUsatii,MinisterofHealth- MihaiCiocanu,DeputyMinisterofHealth- OctavianGrama,DeputyMinisterofHealth- RodicaScutelnic,Head,Dept.Emergency&HospitalCare- TatianaZatic,Head,Dept.ofPrimaryHealthCare- CarolinaCerniciuc,Head,Dept.ofPublicHealth- EugeniaBerzan,Head,Dept.Ext.Relations&EUIntegration

- AndreiMatei,Head,Dept.Budget,FinanceandInsurance- AlexandruHolostenco,Head,Dept.ManagementofHealthPersonnel

- DorinRotaru,Head,NationalProgrammesSection- GalinaMorari,DeputyChief,Dept.Emergency&HospitalCare

- LuminitaAvornic,DeputyChief,Dept.PrimaryHealthCare

- AlionaAndronatii,SeniorConsultant,Emergency&HospitalCare

· NationalHealthInsuranceCompany- MirceaBuga,DirectorGeneral- IurieOsoianu,DeputyDirector- CostelSura,Head,Dept.ofInformationSystems- CorneliaNistor,SpecialistCoordinator- JucicanAdrian,Head,Dept.ofManagementofProphylaxisMeasuresFund

· NationalCenterforHealthManagement- PetruCrudu,DeputyDirector

· NationalCenterforPublicHealth- IonSalaru,DeputyDirector- NeleaTabuncic,Head,Dept.NCDControl

· StateUniversityofMedicine&Pharmacy“NicolaeTestemiteanu”- OlgaCernetchi,DeputyRector,Chief,Dept.ofOB/GYN- GrigoreBivol,HeadofDept.FamilyMedicine,MemberofMoHCommittee

- UlianaTabuica,Dept.OB/GYN- RaisaRotaru,OB/GYN,UniversityClinicforPHC

· NationalCollegeofMedicine&Pharmacy- AlaManolache,Director- MarianaNegrean,ClinicalDeputyDirector

· InstituteofOncology- VictorCernat,Director- JanaPunga,DeputyDirector- DumitruSofroni,ScientificCoordinator,CytologyLab- VasileJovmir,MainSpecialist,MoHOncologyCommittee- VeronicaCiobanu,MoHOncologyCommittee- AlionaNicorici,CytologyCoordinator

· InstituteofMotherandChild- StefanGatcan,Director,MemberofMoHOB/GYNCommittee

· CenterforReproductiveHealth&MedicalGenetics- MihailStratila,Director,Member,MoHOB/GYNSpecialistCommittee

- VictoriaCibotaru,ScientificResearcher· CenterforContinuousTrainingforMiddleLevelHealthPersonnel- VeraLoghin,Director

· RepublicanClinicalHospital- SvetlanaToderas,Researcher,HealthServ.Management

· MunicipalClinicalHospitalNo.1- IurieDondiuc,DeputyDirector,MemberofMoHOB/GYNCommittee

· RepublicanDiagnosticCentre- TatianaCuznetova,Chief,CytologyService

· MedicalTerritorialAssociation„Centru”- OlgaCaras,Chief,CytologyService

· Women'sHealthCenter„Dalila”,Chisinau- VeraMelenciuc,Director

· MunicipalHospital,Balti- LarisaLungu,Chief,CytologyService- TamaraAlexandriuc,OB/GYN

· PerinatalCenter,Balti- PetruNedelciuc,Director- CarolinaFrumusachi,OB/GYN

· DistrictHospital,Cahul- BotosanGheorghe,DeputyDirectorAMSA- ConstantinCojas,Chief,CytologyService

· DistrictHospital,Calarasi- SilviaBobescu,Director

· DistrictHospital,Causeni- VasileGodoroja,DeputyDirectorMedical- AnastasiaCeban,ChiefCytologyService

· DistrictHospital,Edinet- AnatolGutu,Director- ValentinaColosova,Chief,CytologyService

· DistrictHospital,Ialoveni- LidiaHanganu,Director

· DistrictHospital,Orhei- AndreiStratulat,Vice-DirectorMedical

· DistrictHospital,Ungheni- LidiaCraciun,Director- ValentinaMamaliga,Chief,CytologyService

· FamilyMedicalCenter,Soroca- LudmilaCeban,Director- VeraPogorevici,CytologyService

· FamilyMedicalCenter,Balti- AngelaNica,OB/GYN

· FamilyMedicalCenter,Cimislia- LudmilaCapcelea,Director- SvetlanaMoroz,OB/GYN

· FamilyMedicalCenter,Comrat- SvetlanaMavroghi,OB/GYN

· FamilyMedicalCenter,Calarasi- GalinaMotricala,OB/GYN

· FamilyMedicalCenter,Criuleni- VioletaPanico,Director- AlexIacub-Culava,OB/GYN

· Women'sHealthCenter„Ana”,Drochia- SvetlanaNicov,Director

· FamilyMedicalCenter,Edinet- TatianaGutan,OB/GYN

· FamilyMedicalCenter,Falesti- IonIonesii,Director

· FamilyMedicalCenter,Hincesti· FamilyMedicalCenter,Ocnita

- CorneliaCozma,OB/GYN· FamilyMedicalCenter,Straseni

- AndreiIatisin,Director· FamilyMedicalCenter,StefanVoda

- MarianaHaret,Director· FamilyMedicalCenter,Ungheni

- LiliaScurtu,Director- VeraMunteanu,Director

· FamilyMedicalCenter,Nisporeni- MariaDaschevici,OB/GYN

· AssociationofObstetriciansandGynaecologists- ValentinFriptu,president


Capacity building actions completed or being undertaken:

1) Established the Screening Coordination Office

• Identify, recruit and train staff – training exchanges undertaken with

CervicalCheck (Ireland), Swedish national cervical screening office

2) Established the National Advisory Committee (stakeholders involved in

the design and preparation of the capacity building plan)

3) Prepared the cervical screening specification – based on models

obtained from CervicalCheck and Cervical Screening Wales

4) Developing the cervical screening registry – based on specifications

obtained from CervicalCheck, Cervical Screening Wales and the

Swedish nation cervical screening office

5) Increased PHC capacity – CervicalCheck PHC training team undertook a

train-the-trainer exchange to create 12 Moldovan PHC training teams

that are now training PHC providers (with grant funding from the SDC)


6) Organised by the ECCA and the Italian Society for Pathology and

Cytopathology with funding from the UICC:

• 2 cytopathologists from the Moldovan State Medical University are being

trained by Prof Giovagnoli at Università di Roma La Sapienza.

7) Organised by the ECCA and RCPath with funding from the UICC:

• 2 gynae pathologists from the State Medical University are training with Dr

Mike Coutts at the West Kent Gynaecological Oncology Centre, Maidstone

Hospital

8) Organised by the ECCA and the BSCCP with funding from the BSCCP:

• 1 colposcopist from the State Medical University will train with Dr Charles

Redman at the UHNS Stoke-on-Trent

9) Subsequently, the Moldovans will work with the Italian Society of

Pathology and Cytopathology, the RCPath and the BSCCP to:

• Integrate the training curricula into the Moldovan relevant residency

programmes and develop CME modules to train existing staff.

• Prepare laboratory/clinical guidelines/SOPs


Summary:

• Most EECA countries do have a good foundation for implementing cervical screening programmes

• The economic situation in many countries has been (slowly) improving – so health professionals are now more interested to stay and improve health care provision

• Capacity development can be undertaken very inexpensively using training exchanges with Western European organisations with good results

• Capacity development must target all the component services +/- simultaneously

• Capacity development must be led locally so national stakeholders have ownership of the programme and responsibility for making it successful

22

Thank you for your attention

22

preventing cervical cancer in east europe and central asia ...1) most have cancer control strategies...

Documents