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)
Survey of Cervical Screening in the EECA Region
Cervical screening age ranges:
Survey of Cervical Screening in the EECA Region
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
Survey of Cervical Screening in the EECA Region
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
Survey of Cervical Screening in the EECA Region
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
Implementing Cervical Screening in the EECA Region
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
Implementing Cervical Screening in the EECA Region
• 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
Implementing Cervical Screening in the EECA Region
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
Implementing Cervical Screening in Moldova
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
Implementing Cervical Screening in Moldova
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)
Implementing Cervical Screening in Moldova
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
Implementing Cervical Screening in the EECA Region
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
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Thank you for your attention
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