PROJECTPROJECT

Situation analysis and Situation analysis and cost-effectiveness analysis cost-effectiveness analysis of cervical cancer of cervical cancer screening in Russia screening in Russia

Coordinator Coordinator

of the project: of the project:

N. KorolevaN. Koroleva

PURPOSEPURPOSE

To undertake a situation analysis in relation of existing cervical cancer screening programs in Russia, supplemented by an economic analysis of various options to systematize and extend coverage, so as to be able to recommend an effective and acceptable method of population screening

Cost-effectiveness of cervical cancer screening programs for Russia

GENERAL OBJECTIVESGENERAL OBJECTIVES1. To describe the epidemiology of cervical cancer in

Russia

2. To describe the current policy of the MoH on screening for cervical cancer

3. To understand and explain the existing infrastructure and resources available

4. To identify factors that affect screening uptake in Russia

5. To carry out a cost-effectiveness analysis of existing and potential screening protocols using data specified to the Russian context

6. To make evidence-based recommendations to the Government of Russia and non-governmental organizations on options for implementation of cervical cancer screening in Russia

PILOT REGIONSPILOT REGIONS

• Tver Tver

• St-Petersburg St-Petersburg

• Nalchik Nalchik

• TulaTula

MAJOR FINDINGSMAJOR FINDINGS 1. Epidemiology of cervical cancer in Russia1. Epidemiology of cervical cancer in Russia

• Cervical cancer is a second cause of cancer related death Cervical cancer is a second cause of cancer related death among women in Russiaamong women in Russia

• Average age of cervical cancer is 45.6 yearsAverage age of cervical cancer is 45.6 years

• Russia has one of the highest (7 per 100000 women) SDR Russia has one of the highest (7 per 100000 women) SDR among European countries among European countries

• 70% of all cervical cancer cases are diagnosed at an 70% of all cervical cancer cases are diagnosed at an advanced, incurable stagesadvanced, incurable stages

• 5-years survival rate is: 92% for local, 49% regional, 15% 5-years survival rate is: 92% for local, 49% regional, 15% distantdistant

• Stage distribution in %: CIS – 6.6, I - 8.8, II – 28, Stage distribution in %: CIS – 6.6, I - 8.8, II – 28, III – 36.7, IV – 19.9III – 36.7, IV – 19.9

1

2

3

4

5

6

7

8

9

1970 1975 1980 1985 1990 1995 2000 2005

France

Germany

Russia

Sweden

United Kingdom

100302 +SDR,cancer of cervix,all age,per 100000

9

10

11

12

13

14

15

16

17

18

19

20

1970 1975 1980 1985 1990 1995 2000 2005

France

Germany

Russia

Sweden

United Kingdom

100401 +Cervix uteri cancer incidence per 100000

MAJOR FINDINGSMAJOR FINDINGS

2. Description of the current policy 2. Description of the current policy of the Russian Ministry of Health of the Russian Ministry of Health on screening for cervical canceron screening for cervical cancer

The current policy of the Russian The current policy of the Russian Ministry of Health in relation to Ministry of Health in relation to the screening for cervical cancer the screening for cervical cancer is consistent to the international is consistent to the international standards such as proposed by standards such as proposed by WHO and EUWHO and EU

MAJOR FINDINGSMAJOR FINDINGS3. Existing infrastructure and 3. Existing infrastructure and

resources availableresources available

Review of the medical equipment Review of the medical equipment condition in the hospitals and condition in the hospitals and gynecological consultations showed that gynecological consultations showed that equipment has been 80% depreciated equipment has been 80% depreciated

Some types of medical equipment have Some types of medical equipment have been exploited for 15-20 years been exploited for 15-20 years

Requirements of the hospitals and Requirements of the hospitals and policlinics with medical equipment are policlinics with medical equipment are satisfied to 30-40% satisfied to 30-40%

Specific ratio of expenditures in the total amount of allocations provided to finance the equipment

Funds to purchase equipment

Total health expenditures

MAJOR FINDINGSMAJOR FINDINGS

4. To identify factors that affect 4. To identify factors that affect screening uptake in Russia screening uptake in Russia

1)1) Knowledge, attitudes, beliefs and  Knowledge, attitudes, beliefs and practices of medical personnel and practices of medical personnel and women in relation to cervical women in relation to cervical cancercancer

Methods:Methods: a face-to-face interviews a face-to-face interviews of 400 randomly selected women of 400 randomly selected women were conducted at home by family were conducted at home by family physicians using a structured physicians using a structured questionnaire questionnaire

MAJOR FINDINGSMAJOR FINDINGSScreening Coverage:Screening Coverage:

30% of women reported ever having PAP 30% of women reported ever having PAP testtest

• About 2/3 of them had it more than once About 2/3 of them had it more than once

• About 2/3 of them had it less than two years agoAbout 2/3 of them had it less than two years ago

AGE GROUPSAGE GROUPS

• 69,6% of them at age 35-64 years 69,6% of them at age 35-64 years (p (p ≤≤ 0.001) 0.001)

• 22,7% at age 15-34 22,7% at age 15-34

MAJOR FINDINGSMAJOR FINDINGSKnowledge of women about Pap smear Knowledge of women about Pap smear

• 42% of interviewed have never heard about 42% of interviewed have never heard about screening as a method of cervical cancer screening as a method of cervical cancer prevention, PAP smearprevention, PAP smear

• 1/3 of those who know about PAP smear 1/3 of those who know about PAP smear aware that test is used to diagnose CANCER aware that test is used to diagnose CANCER (rather than CIN)(rather than CIN) Fear to go to the physicianFear to go to the physician

Sources of informationSources of information

• Most of those who know about screening reported Most of those who know about screening reported that they received an information about cervical that they received an information about cervical cancer from physicians (gynecologists)cancer from physicians (gynecologists)

MAJOR FINDINGSMAJOR FINDINGSResults:Results:

• Most of women recognized age as a risk factorMost of women recognized age as a risk factor

At the same time At the same time

• 1/3 of interviewed reported that cervical cancer 1/3 of interviewed reported that cervical cancer is not curable and there is no method to prevent is not curable and there is no method to prevent or influence the disease outcome or influence the disease outcome

• Only few women were aware that cervical cancer Only few women were aware that cervical cancer is one of the most commonly occurring among is one of the most commonly occurring among Russian women Russian women

• Heredity is the main factor for cervical cancer Heredity is the main factor for cervical cancer and the are not at risk as they have a “good and the are not at risk as they have a “good heredity”heredity”

MAJOR FINDINGSMAJOR FINDINGS

Role of physicians Role of physicians

• The lack of physicians recommendations The lack of physicians recommendations came up spontaneously from all pilot came up spontaneously from all pilot regionsregions

• 25% of women who ever had Pap smear 25% of women who ever had Pap smear reported that they were not informed reported that they were not informed about results of the analysis about results of the analysis

• Most of women said that doctors don’t Most of women said that doctors don’t encourage them to have screening encourage them to have screening

MAJOR FINDINGSMAJOR FINDINGS

Role of physiciansRole of physicians

Almost all women reported that they Almost all women reported that they want to have more information on want to have more information on what tests they are having, the what tests they are having, the reasons for these tests and the results reasons for these tests and the results but if they express any interest and but if they express any interest and ask doctors what is it used for the ask doctors what is it used for the most common answer they receive is : most common answer they receive is : you don’t need to know it you don’t need to know it

MAJOR FINDINGSMAJOR FINDINGS

5. Results of cost-5. Results of cost-effectiveness analysiseffectiveness analysis: : CEA of 3 screening policies (depending on model of screening design, guidelines of follow up of women with detected CIN, interval of screening)

Cost-effectiveness of cervical cancer screening programs for Russia

Cost-Effectiveness Cost-Effectiveness Analysis - Validity of Analysis - Validity of Screening testsScreening tests

Validity of screening tests makes a great influence on the results of cost-effectiveness analysis.

There is no data on validity of screening tests in Russia

Therefore,

84 schemes (depending on the validity of screening test)

Cost per life-year saved by validity of cytology

0

50000

100000

150000

200000

250000

300000

350000

86 90 95 100

Specificity of cytology

Cost

per

life

-yea

r sav

ed

Sensitivity 50

Sensitivity 60

Sensitivity 70

Sensitivity 80

Sensitivity 87

Cost and LYS for 84 screening Cost and LYS for 84 screening alternativesalternatives

Estimates of cost and life-year saved

for 84 screening alternatives

Cost per life-year saved

4000003000002000001000000

Lif

e-y

ear

saved

3.0

2.5

2.0

1.5

1.0

.5

0.0

Efficient screening combinations Efficient screening combinations (as the World Bank proposed we used GNP per (as the World Bank proposed we used GNP per capita in 2002 as a cut-off-point below which capita in 2002 as a cut-off-point below which

the program is not effective)the program is not effective)

MAJOR FINDINGSMAJOR FINDINGS

 

Results of cost-effectiveness analysis:

12 efficient screening policies (i.e., no alternative policy exists that results in more life-years gained for lower costs).

For the efficient policies, the predicted gain in life expectancy ranged from 2.04 to 2.45 life-year saved per 1000 women per year of screening depending on the screening strategy

The total cost of screening program varies between 2950 and 4100$ US per 1000 women per year of screening

In the whole of Russia it is result in total 2.8-3.8 billion rubles (from 93 to 127 mln dollars US) in the frame of 12 effective strategies varies between

CONCLUSIONCONCLUSION The current screening program is not effective The current screening program is not effective

in reaching the majority of population in reaching the majority of population

A major negative factor of low test currency A major negative factor of low test currency was low educational level. was low educational level.

With few exceptions, beliefs and attitudes With few exceptions, beliefs and attitudes were not very important barriers were not very important barriers

Lack of recommendations coming from Lack of recommendations coming from physicians physicians

Negligence, absence of medical problem, Negligence, absence of medical problem, fear, lack of knowledge were the main reasons fear, lack of knowledge were the main reasons given for not being screenedgiven for not being screened

Validity of screening tests - crucialValidity of screening tests - crucial

ReferencesReferences

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