SPECIFIC ASPECTS OF THE NATIONAL CERVICAL CANCER EARLY DETECTION SUB-PROGRAMME IN THE WESTERN REGION OF ROMANIA
Received for publication: 15th of April, 2013
Revised: 15th of May, 2013
SUMMARY: (Hide the summary)
Introduction: Cervical cancer remains an important public health problem in the EU, with large variations between countries standardized incidence and mortality rates. Unfortunately, Romania has the highest globally-standardized annual rate of mortality in the European Union. Organized programs of early detection implemented in many EU countries led to a substantial reduction of cervical cancer. The aim of the study is to observe thedirect impact and results in various subgroups of population includedin the national cervical cancer early detection sub-programme in the Western Region of Romania. Methods: The study was conducted during the period September 2012 - March 2013, on a sample of 13569 patients that participated in the national cervical cancer screening sub-programme in Regional Management Unit West (Arad, Caras-Severin, Hunedoara and Timis counties). The study complies with European guidelines for quality assurance in cervical cancer screening in terms of inclusion and exclusion criteria.
Results:The results show low participation of women in rural areas, a staggering number of women who have not done any test for early detection of cervical cancer prior to this one and the existence of3 clusters distribution in the Western Region. Regarding the incidences of epithelial cell abnormalities, they have similar values to those found by other screening programs that also used Pap smear as testing method.
Conclusions:The study demonstrated once again the absolute necessity of conducting a screening program at national level, but also the need to improve preventive measures. Although one of the objectives of the sub-programme clearly stipulates the need of increased awareness for this type of screening in the general population, this is still far from being realized.
cervical cancer, screening, Pap smear
Worldwide, every two minutes a woman dies of cervical cancer. Overall, the prevalence of this form of cancer ranks second in cancers among women, with about 500 000 new cases each year, while occupying the third place in terms of cancer mortality in women after breast and lung cancer.Each year, about 270 000 women die because of this disease, 85% of them coming from developing countries, where cervical cancer kills more women than any other form of cancer.Lack of information and health education results in late presentation to physician, aggressive treatments, suffering, impairment of quality of life for patients, families, institutions and society at large. In addition, the diagnosis and treatment of pre-cancerous abnormalities, even the minor ones, produce significant anxiety among the patients. Cervical cancer is a major health problem in Romania, being the main cause of mortality in women of childbearing age. In Romania, cervical cancer is the second cancer considering incidence in women, after breast cancer and the third considering mortality, after breast and colon cancers . Romania has the largest globally-standardized annual rate of mortality in the European Union.
National cervical cancer early detection subprogramme, conducted by the Government of Romania since September 2012, is a mix of multiannual actions held for a period of 5 years to prevent and combat this malignancy. Active screening for early detection of cervical cancer is performed in the female population using as testing methodthe cervical smear, also known as Papanicolaou test or simply Pap test.Organized programs of early detection implemented in many EU countries led to a substantial reduction of cervical cancer. However, this type of cancer remains a common disease in the EU and there is still need to improve preventive measures.One of the most important issues in screening is women's participation in this program. Some women are not included in the program, and the rates of cervical cancer in women who have never had Pap test are considerable. Behavioral studies in the Netherlands have demonstrated the usefulness of alternative methods like self-sampling of the probe by enrolling 3500 previously non-surveyed women in the early detection programme(1).
The study was conducted during the period September 2012 - March 2013, on a sample of 13 569 patients participating in the sub-national cervical cancer screening in Regional Management Unit (RMU) West, which groups Arad, Caras-Severin, Hunedoara and Timis Counties (Figure 1). We used anonymised medical recordsand as software for data processing and statistical analyzes we utilised SPSS15.1 and Weka 3.7.
This study is therefore an interimary analysis at 6 months after onset of the data collected by the national cervical cancer screening sub-programme in the Western Region.It should be noted that the study complies with European guidelines for quality assurance in cervical cancer screening with the following important features:
- It is part of a screening program for a period of five years, financed by government.
- Uses as a method of testing of the female population the Pap test.
Has as inclusion criteria the age of 25 years or older, while we excluded from the study all women with age over 64 years with three consecutive normal Pap test results, congenital absence of the cervix or total hysterectomy for benign disease, diagnosis of cervical cancer and other genital cancers.
Figure 1. Distribution of patients in the four counties of RMU West
Table 1. Health care providers in the RMU West and screening networks within their jurisdiction.
Figure 2. Percentage analysis of patients according to area of residence
In RMU West, 9 health care providers (named sanitary units with beds)participated in the sub-programme (Table 1.), each being eligible after proving specific screening network organization.Practically, behind the results presented in this study, one can find the combined work of594 family physicians, 122 medical practitioners for sampling the probes (mainly gynecologist working in ambulatories) and 38 laboratories. In order to achieve the necessary steps and assure the smooth running of the programme, they all filled a standardized formulary - FS1 and respected specific protocols, the most important being the harvesting protocol.
Percentage analysis of patients according to area of residence (Figure 2.) showed a major discrepancy in favor of urban areas, large and small cities aggregating for 80.9% of all reports. Surprisingly or not, rural areas contribute for only 19.1% of all patients. These values are not consistent with the population structure by area of residence in the West, which, according to the INS Statistical Yearbook of Romania 2006, is distributed 63.60% in urban areas and 36.40% in rural areas. We therefore observe a reduced presence of patients and simultaneously a low penetrance of the program in rural areas. This conclusion is, unfortunately, the result of many social and cultural factors and fits within the pattern of national health programs in Romania.
Figure 3. Procentual distribution of patients considering the moment of last Pap test
Table 2. The absolute number and procentual distribution of patients considering the moment of the last Pap test and the residential area of origin.
Regarding the moment of the last Pap test before the one included in the program, we found a negative aspect which justifies again the screening effort at national level:
9102 patients (67.1%) had no history whatsoever of smear test (Figure 3.). There is one category of patients, totaling almost one fifth of the total, which performed a cervical-vaginal cytology in the last 3 years. Despite this, the female population awareness of the importance and need for regular testing remains low.
The results also show there are no statistically significant differences between the three residential areas in terms of the percentage of patients who have never done a Pap test before (Table 2). This demonstratesthat low levels of awareness of cervical cancer prevention are present both in the rural and urban areas.
We also revealed an increased incidence of untreated sexually transmitted diseases, inflammations, cellular abnormalities and infections among women aged between 35 and 55 years (Table 3).
Regarding the incidence of the most common infections (Table 4), there is an alarming amount of infection with Candida albicans (20%).
Non-neoplastic changes (Table 5.) are dominated by inflammations, which are present in more than half of the patients (55, 2%).
Regarding the incidence of epithelial cell abnormalities (Table VI), they have similar values to those found in the results of other screening programs that also used Pap smear as testing method. Most abnormal results were either ASC-US (2.1%) or LSIL (2.4%). HSIL lesions represent 0.4% of all cases and HSIL outcomes with suspicion of invasion donot exceed 0.3%. These values cervical cancer in their medical history (67.1% of the patients, with no significant difference between residential areas), which proves the low health educationof the population. Mandatory involvement of primary care is required to ensure referral to recurrent genital check-up of all age groups and especially mature women (35-55 years), where we observed the highest incidence of sexually transmitted diseases,
inflammations and infections.In terms of non-neoplastic changes found, more than half of them (55.2%) are inflammatory in nature.Regarding the incidence of epithelial cell abnormalities, they have similar values to those found in the results of other screening programs that also used Pap smearastesting method, proving once again the relatively low sensitivity of this type of test in detecting high-grade intraepithelial lesions.Although one of the objectives of the sub-programme clearly stipulates the need ofincreasing awareness in the general population regarding the use of screening, the study showed that there is still a remarkable distribution in 3 clusters in the Western Region.Having in mind thelong-term improvement of the sub-programme, the 21-25 years age subgroup should be included. This is imposed taking into account the decreasing threshold age at which sexual life debuts, the increased incidence of this disease in young women and the implementation of this consideration already done in other countries.
Furthermore, routine Pap testing should be adopted as mandatory exam within the national health system for insured patients aged 25 or even younger, given the high number of women who do not use at all this prophylaxis.
Unfortunately, coercive methods seem to be the only effective way to achieve the necessary continuity of screening for early detection of cervical cancer after completion of the current program and inthe long term.
This conclusion is inspiredfrom the national programs of other countries, is based on considerations of cost-effectiveness and rules out ethical issues. As a supplement to the sub-programme, management strategy of abnormal results should be improved, in regards of a more obvious involvement of family medicine. The need for follow-up is equally important to the ultimate goal, that of reducing the incidence of invasive cervical cancer and its mortality.Although Pap test has proven its effectiveness after several screening programs implemented in EU countries, which led to a substantial reduction of cervical cancer, this type of cancer remains a common disease and the need to improve preventive measures is still present.
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