Cancer screening policy in Hungary.

Abstract

Basu et al. published an excellent overview on the status of implementation and organization of cancer screening in the European Union Member States.1 This paper provides a valuable description of current cancer screening policies of the European countries. We would like to give some detailed information on the Hungarian screening programs. Mammography-based breast cancer screening has a long tradition in Hungary. Mammography-based opportunistic breast cancer screening started in Hungary as early as the late 1960s in the city of Bonyhád.2-4 Even the first scientific evidences for the effectiveness of mammography screening in reducing the breast cancer mortality came from large randomized controlled trial performed by a Hungarian radiologist, Prof. László Tabár, in two Swedish counties, Kopparberg and Östergötland.5 Later several mammography screening pilot programs were performed in Hungary.6 Following the evaluation of pilot programs for mammography screening, a nationwide, organized population based breast cancer screening program was announced in 2001 and started in January 2002.7 Unlike the ones (45–64 years) given in table 2 of the paper by Basu and coworkers, women aged between 45 and 65 years old were invited for participating in the breast cancer screening program.8 Opportunistic cervical cancer screening started in Hungary during the 1970s.9 One should bear in mind that at that time Hungary was a socialist country, behind the “iron curtain” with limited access to the achievements of the developed countries.10 After the socialist system collapsed in 1990, Hungary initiated new pilot program for the early detection of cervical cancer. This program was financed by the World Bank.11 After three decades of opportunistic cervical cancer screening activities, an organized, nationwide cervical cancer screening was introduced in Hungary in July 2003 for women aged between 25 and 65 years old.12 Although in figure 2 of the paper mentioned that the Hungarian cervical cancer screening program's rollout ongoing, we would like to emphasize that rollout was completed. However, we have several problems with the low participation rate of invited women13: “The Hungarian organized, nationwide cervical screening program managed to moderately increase (+3.7%) the screening coverage of the target population in the first screening round; therefore, it failed to attract women with high risk outside of the scope of both the previous opportunistic and the newly introduced organized cervical cancer screening program.”14 Between 2013 and 2015, a new element was added to the organized cervical cancer screening program, in order to increase the participation rate. A pilot program was introduced in 2013 for the involvement of health visitors. It meant that in addition to gynecologists, health visitors, having a B.Sc. degree in health sciences, were allowed to take the smears.15 The involvement of health visitors resulted in 8.3% increase in the participation rate.16 In Hungary, we had several pilot programs for colorectal cancer screening. In 1997–1998, the first Hungarian colorectal cancer screening pilot program was done in a well-defined administrative area of the Capital, Budapest, with support from the World Bank Close the gap public health programme.17 The next colorectal cancer screening pilot program was organized in a small city of Ajka, and the surrounding area in 2003–2004.18 Later some other small scale pilot programs were organized in different Hungarian cities (Balatonfüred, Békéscsaba, Kecskemét, Nagyatád). In 2015, we had a new colorectal cancer screening pilot program in County Csongrád, financed from European Union's funding (“Social Renewal Operational Programme: SROP-6.1.3A-13/1–2013-0001 To support the extension of pilot screening programs—cervical cancer screening by health visitor and colorectal cancer screening programs”).19 These pilot programs used immunochemical fecal occult blood test (FOBT) for the early detection of fecal blood. Following the evaluation of this pilot program, Hungarian health policy leaders committed to the introduction of a nationwide colorectal cancer screening program. We hope this program will be launched as soon as possible. Hungary can be considered as a pioneer with the application of immunochemical testing for colorectal cancer.20, 21 But in Hungary we still did not have a nationwide colorectal cancer program, as it was stated in figure 3. The legal regulation of colorectal cancer screening was a bit confusing in Hungary. Since 1997, a ministerial decree regulates both the opportunistic and nationwide organized screening programs in Hungary.22 This decree defines breast and cervical cancer screening as an organized, nationwide screening program. Colorectal cancer screening program was mentioned as an organized, nationwide screening program in Hungary on a single day, the December 31, 2005! Never before or after this day colorectal cancer screening was not an organized, nationwide screening program, only opportunistic and/or pilot programs were carried out. We emphasize that the current Hungarian legal regulation (law) also does not mention colorectal cancer screening among the nationwide, organized cancer screening programs. Regarding cancer screening programs, we should mention their cost-effectiveness. In a country, with limited resources for healthcare, financial issues are important. In 2001–2002, the Hungarian National Health Insurance Fund Administration, the only healthcare financing agency in Hungary, conducted formal health-economics analysis for the evaluation of the cost-effectiveness of breast, cervical, and colorectal cancer screening programs. All of these screening programs proved to be cost-effective which means that their medical outcome (health gain) can be achieved by a reasonable cost. During the history of the Hungarian National Health Insurance Fund Administration, these three cost-effectiveness studies were the first health-economics analysis when the decision on the introduction of a new medical technology was based on cost-effectiveness analysis.23 We highly appreciate the efforts of Basu and coworkers regarding the detailed overview on the current situation of cancer screening programs in the European Union. It is widely known that the participation rate in the Hungarian organized nationwide breast and cervical cancer program and also in the colorectal pilot programs is very low compared to the European Guideline. We learnt that Hungarian cancer screening program performance reports are not published for any of our programs. For Hungary, we have an important conclusion regarding the dissemination of the results of our screening programs. We hope, this might increase the low participation rate in Hungary. This study was supported by the European Union and the Hungarian Government within the frame of “Social Renewal Operational Programme: SROP-6.1.3A-13/1–2013-0001 to support the extension of pilot screening programs (cervical cancer screening by health visitor and colorectal cancer screening programs)” [“Társadalmi Megújulás Operatív Program: TÁMOP-6.1.3A-13/1-2013-0001 Pilot jellegű szűrőprogramok (védőnői méhnyakszűrési illetve vastagbélszűrési programok) kiterjesztésének támogatása”]