Making Early Detection Possible: Medicare and National Cancer Screening Programs

Modelled estimates for changes in cancer incidence, staging, and demand on health services are presented for a range of potential COVID-related disruptions to national population screening programmes for breast, cervical, and colorectal cancer, indicating markedly different impacts for each programme.

Modelled estimates for changes in cancer incidence, staging, and demand on health services are presented for a range of potential COVID-related disruptions to national population screening programmes for breast, cervical, and colorectal cancer, indicating markedly different impacts for each programme.

The Policy Committee of the International Papillomavirus Society describes how lessons learnt from the COVID-19 pandemic could propel a new approach to the elimination of cervical cancer that is more likely to be successful.

Cancer screening policy in Hungary.

Background: Cervical cancer is the third most common cancer affecting Malaysian women despite being highly preventable through screening. A national cervical cancer screening program has been established since 1969 to ensure early detection of cervical cancer. Nonetheless, the prevalence of cervical cancer in Malaysia remains high. Malaysia has been offering Pap tests for free in community health clinics since 1995, however only 47.3% of women have been screened. It has also been reported that nearly 40% of patients with cervical cancer presented at advanced stages of the disease. Government community healthcare professionals are the main stakeholders in the national cervical screening program. Therefore, understanding these healthcare professionals’ perspective of barriers associated with underutilization of cervical cancer screening is key to increase overall screening uptake. Aim: This study aimed to explore healthcare professionals’ views on perceived barriers to cervical screening in Malaysia. Methods: Qualitative in-depth semistructured interviews were carried out with 44 primary healthcare professionals consisting of family medicine specialists (N = 5), medical officers (N = 9), matrons and nurses (N = 20), laboratory technician (N = 5), registration staff and IT technicians (N = 5) involved in the cervical screening program at 5 different urban government healthcare clinics in Petaling district. The interviews were transcribed verbatim and analyzed using a thematic analysis approach. Results: Themes emerged were individual and system barriers. Individual barriers include knowledge/risk perception (lack of knowledge and awareness of cervical screening, low perceived risk), distress (Pap test is embarrassing or painful, previous negative Pap test experience and fear of a cancer diagnosis) and coping skills (remembering the appointment, managing responsibilities such as getting child care/elder care/coverage at work, ability to get transportation), social-cultural barrier (family support); while system barriers highlight the long waiting time for cervical screening, poor documentation, no national call-recall system, patient overload, lack of resources and manpower, lack of educational materials and problems with opportunistic screening. Conclusion: Sustainable screening interventions require approaches that address and resolve both individual and system barriers, such as exploring new methods and delivery of cervical screening, and providing education for the public and healthcare providers.

BackgroundMongolia is the leading country in the incidence and mortality rate of gastric cancer. According to the national data, TNM stage at the time of cancer diagnosis, a gastric cancer...

Screening for cervical cancer

Background and context: The WHO has presented that more than 90% of deaths from cervical cancer happened in low and middle-income countries. Albania is one of them. Albania has a national cervical cancer screening program. However, the program is not well-promoted and the service is not always available at the primary public health care level. The situation worsens when it comes to rural areas. In 2016, to bridge the gap and achieve health equity the Albanian Center for Population and Development (ACPD) initiated a series of activities to promote the utilization of visual inspection with acetic acid (VIA) and cryotherapy for the first time as a pilot study in rural Albania. ACPD sees this as a health priority to strengthen the existing national screening program through advocacy with the Ministry of Health and Social Protection (MoHSP). Aim: To enable VIA and cryotherapy provision in rural Albania to expand cervical cancer screening by advocating for its integration into the national cervical cancer screening program. Strategy/Tactics: The strategy applies a client-centered and bottom-up approach. The changes are driven through four sections, namely: context understanding, providers' engagement, partnership strengthening, and sustainability development (Fig 1). Program/Policy process: Following the proposed strategy, four main approaches were developed. · Demand generation: ACPD promoted relevant cervical cancer prevention and treatment information as well as redressed misconceptions through developing education materials and carrying out education sessions. · Provide services in rural settings: ACPD engaged different health providers into the VIA and cryotherapy training and institutional protocol development. · Collaborate with key stakeholders: ACPD worked closely with stakeholders, such as civil society organizations (CSOs), media, and health facilities. · Provide medical evidence to affect national policy-making processes: ACPD provided strong evidence to support the integration of VIA and cryotherapy into the existing cervical cancer screening program. Outcomes: In line with aforementioned process, the project succeeded to establish an effective model improve national cervical cancer screening program. All achievements and outcomes are summarized in Table 1. What was learned: The proposed strategy enabled VIA and cryotherapy in rural Albania. From clients' perspectives, this cost-effective cervical cancer screening tool is well-accepted, and most women were thrilled by the idea that the precancerous lesions could be screened and eliminated at the same visit. It is evident that ACPD distributed this desired service in rural Albania through collaborating with key stakeholders, including media, CSOs and public health facilities. ACPD still works on integrating VIA and cryotherapy into the national cancer screening program to reduce cervical cancer deaths. [Figure: see text][Table: see text]

Screening for cancer is intuitively attractive. Well-run cancer screening programmes can save lives, reduce morbidity, provide reassurance to individuals about their health and encourage a focus on prevention and early detection. Despite the intuitive appeal, the harmful effects of screening (both potential and actual) are well documented. Harm to an individual includes over-diagnosis and treatment of questionable abnormalities, anxiety for those with false positive results and false reassurance for those with false negative results. One of the important, but often not well articulated, harmful effects at a population level is the potential for cancer screening to increase health inequalities between population groups. Screening can be divided into two types. First, there are ‘organized screening’ programmes, which work within pre-agreed structures, policies and standards, and typically focus on mortality reduction for screened individuals. Secondly, there is ‘opportunistic screening’ where screening occurs either as a result of a request from an individual or from contact with a health professional who offers the screening test. In this issue, Palencia et al. combine individual-level data from the WHO World Health Survey covering 22 European countries, with information about the organizational structures of breast and cervical cancer screening programmes within countries, to examine in multi-level analyses whether socioeconomic disparities in breast and cervical screening participation are affected by the type of screening offered. They found that for breast cancer screening, there was higher participation in screening in countries with organized programmes, but no such pattern was seen for cervical cancer screening. For both breast and cervical cancers, socio-economic inequalities in participation measured both on relative and absolute scales were more likely to be found in countries without organized screening programmes. One of the arguments for organized screening is that participation rates are likely to be optimized. Therefore, the finding that cervical cancer screening participation was not affected by the type of screening was surprising. It is worth noting that, while in the study by Palencia et al. participation in cervical screening was measured using a cut-off point of screening in the previous 3 years, all five countries with national (organized) cervical screening programmes recommend intervals of 5 years for at least some women (in the UK, Denmark and Sweden recommendations vary by age). In contrast, almost all of the countries included in this study with opportunistic screening recommend screening intervals of 1–3 years. As a consequence, it is possible that screening participation was underestimated in countries with organized screening. This is not true for breast cancer screening as almost all countries, regardless of how screening is organized, recommend screening at either a 2or 3-year interval. Four other important points should be made. First, while the paper by Palencia et al. focuses on socioeconomic inequalities determined by education level, such inequalities can occur on many axes e.g. ethnicity, gender, geography, age, sexuality and disability. Although most social determinants of health are not controlled by the health sector, there is increasing evidence that health-care systems, including screening programmes, can actively alter inequalities in health outcomes. The ‘inverse equity hypothesis’ describes how inequalities in health care occur as new health interventions are introduced. This theory suggests that as a new intervention is introduced into a population, those that are most deprived, and usually most in need of the intervention, are most likely to take it up later and at a lower rate than more privileged groups. An example of this hypothesis in action occurred with the introduction of the breast cancer screening programme in Published by Oxford University Press on behalf of the International Epidemiological Association

BackgroundCervical cancer disproportionately affects women in sub-Saharan Africa, compared with other world regions. In Ethiopia, a National Cancer Control Plan published in 2015, outlines an ambitious strategy to reduce the incidence and mortality of cervical cancer. This strategy includes widespread screening using visual inspection with acetic acid (VIA). As the national screening program has rolled out, there has been limited inquiry of provider experiences. This study aims to describe cancer control experts’ perspectives regarding the cancer control strategy and implementation of VIA.MethodsSemi-structured interviews with 18 participants elicited provider perspectives on cervical cancer prevention and screening. Open-ended interview questions queried barriers and facilitators to implementation of a new national screening program. Responses were analyzed using thematic analysis and mapped to the Integrated Behavioral Model. Participants were health providers and administrators with positionality as cancer control experts including screening program professionals, oncologists, and cancer focal persons at town, zone, and federal health offices at eleven government facilities in the Arsi, Bale, and Shoa zones of the Oromia region, and in the capital Addis Ababa.ResultsThe cancer control plan and screening method, VIA, were described by participants as contextually appropriate and responsive to the unique service delivery challenges in Ethiopia. Screening implementation barriers included low community- and provider-awareness of cervical cancer and screening, lack of space and infrastructure to establish the screening center, lack of materials including cryotherapy machines for the “screen-and-treat” approach, and human resource issues such as high-turnover of staff and administration. Participant-generated solutions included additional training for providers, demand creation to increase patient flow through mass media campaigns, decentralization of screening from large regional hospitals to local health centers, improved monitoring and evaluation, and incentivization of screening services to motivate health providers.ConclusionsAs the Ethiopian government refines its Cancer Control Plan and scales up screening service implementation throughout the country, the findings from this study can inform the policies and practices of cervical cancer screening. Provider perspectives of barriers and facilitators to effective cancer control and screening implementation reveal areas for continued improvement such as provider training and coordination and collaboration in the health system.

In the UK, the national cervical cancer screening programme is probably the most established, robust and rigorous of all screening programmes that has evolved over 25 years. It has seen a multitude of changes based on evidence obtained from a vast amount of research and observations, as well as from advances in technology. This success has led to a definite impact on cervical cancer incidence with reduced mortality and morbidity related to cervical cancer. More recently, the changes introduced to the programme have been exponential and in the UK we are at the brink of a new direction and a new style of provision of the screening programme. Throughout the years, there has been a continued effort to understand morphological aspects of the cytology and histology in cervical neoplasia and many new entities have been recognised or variations of known entities realised. The intricate measures to ensure quality in the screening programme have led to close working relationships between cytologists, histopathologists, colposcopists, and now, molecular biologists. The UK cervical cancer screening programme (CCsP) is likely to change significantly in the next few years, and although reduced in quantity, cytology will still remain an important aspect of it. The importance of histopathology is unlikely to change, but more onus will be placed on the molecular biologists and colposcopists. In order to discuss and understand the importance of cytology and histology in the cervical screening programme and the absolute requirement of correlation between the two, it is important first to appreciate how the UK CCsP has evolved and how it has taken with it the evolution of new technologies in cytology leading to improved correlation between histology and cytology and quality assurance with obvious benefits to the patient.

The aim of the study was to determine the breast, cervical, and colorectal cancer screening rates and the influencing factors in a group of Turkish females. This descriptive study was conducted in a School of Nursing. The study sample consisted of 603 females who were the mothers/neighbors or relatives of the nursing students. Data collection forms were developed by the investigators after the relevant literature was screened and were used to collect the data. Of the women aged 30 and over, 32.8% had undergone a pap smear test at least once in their life. Of those aged 50 and over, 48.2% had undergone mammography at least once and FOBT had been performed in 12% of these women in their life. Having heard of the screening tests before, knowing why they are done, and having information on the national cancer screening program were important factors influencing the rates of women having these tests done. The results of this study show that the rates of women participating in national cervical, breast, and colorectal cancer screening programs are not at the desired levels. Having heard of the screening tests before, knowing why they are done, and having information on the national cancer screening program were important factors influencing the rates of women having these tests done. It is suggested that written and visual campaigns to promote the service should be used to educate a larger population, thus increasing the participation rates for cancer screening programs.

Objectives The objectives of this study were threefold. First, to examine the long-term association between implementation of South Korea’s National Cancer Screening Programme and trends in incidence and mortality for major gastrointestinal cancers at the population level. Second, to assess whether programme-associated effects differed across implementation phases and population subgroups defined by age, sex and region. Third, to evaluate the specificity of observed trends by comparing screened cancers with pancreatic cancer, which is not included in the national screening programme, using a quasi-experimental difference-in-differences approach. Design Population-based quasi-experimental study using a difference-in-differences approach. Setting Nationwide analysis using publicly available national cancer registry, screening and mortality data obtained from Statistics Korea (Korean Statistical Information Service) and related national databases. We applied a quasi-experimental difference-in-differences design comparing pre-intervention (1999–2002), early implementation (2003–2011) and long-term effect (2012–2021) periods, reflecting the expected latency between screening implementation and population-level outcome changes. Participants Individuals eligible for NCSP screening based on age and programme criteria between 1999 and 2021, compared with contemporaneous populations not eligible for screening. Primary outcome measures Age-standardised and sex-standardised incidence and mortality rates for colorectal, gastric, liver and pancreatic cancers. Results After the implementation of the National Cancer Screening Programme, age-standardised and sex-standardised incidence and mortality declined substantially for screened cancers. Between 2012 and 2021, gastric cancer incidence and mortality decreased by 28.1% and 24.1%, respectively, while colorectal cancer incidence declined by 22.4% and mortality by 28.6%. Liver cancer mortality decreased by 38.2% over the same period. In contrast, no significant decline was observed for pancreatic cancer. Difference-in-differences and joinpoint analyses confirmed statistically significant trend changes for screened cancers (p<0.05), whereas no beneficial trend was detected for pancreatic cancer. Subgroup analyses indicated persistently lower screening participation and follow-up among rural and socioeconomically disadvantaged populations. Conclusions South Korea’s National Cancer Screening Programme was associated with long-term declines in incidence and mortality for gastrointestinal cancers targeted by organised screening. These findings suggest that sustained, population-based screening programmes may contribute to reductions in cancer burden, while underscoring the importance of improving equitable participation and follow-up care.

IntroductionTo reduce the high prevalence of cervical cancers among the Bangladeshi women, the Government of Bangladesh established a national cervical cancer screening programme in 2005 for women aged 30 to 60 years. The District Health Information System Version 2 (DHIS2) based electronic aggregated data collection system is used since the year 2013. This study summarises data from the year 2014 to 2022 to assess the effectiveness of the electronic data collection system in understanding the outcome of the screening programme.MethodsThis is a descriptive study based on secondary data extracted in MS Excel from the DHIS2-based electronic repository of the national cervical cancer screening programme of Bangladesh. The respondents were women aged 30–60 years, screened for cervical cancer using VIA (Visual Inspection of cervix with Acetic acid) method in 465 government health facilities. The data were collected on the participants’ residential location, month and year of screening, name and type of health facilities performing VIA, and VIA screening results.ResultsThe national screening programme reported a total 3.36 million VIA tests from 465 government hospitals in 8 years (2014 to 2022). The national average VIA-positivity rate was 3.6%, which varied from 1.4 to 9.5% among the districts. This national screening programme witnessed an exponential growth, year after year, with 83.3% increase in VIA test from 2014 to 2022. The primary and the secondary care hospitals were the highest collective contributors of VIA tests (86.2%) and positive cases (77.8%). The VIA-positivity rates in different hospital types varied widely, 7.0% in the medical university hospital, 5.7% in the medical college hospitals, 3.9% in the district/general hospitals, and 3.0% in the upazila health complexes.ConclusionsA national cervical cancer screening programme using VIA method and a DHIS2-based electronic data collection backbone, is effective, sustainable, and useful to understand the screening coverage, VIA positivity rate and geographic distribution of the participants and case load to initiate policy recommendations and actions. Decentralization of the screening programme and more efforts at the primary and secondary care level is required to increase screening performances.

Background CervicalCheck, Ireland's national cervical cancer screening programme, will transition to primary HPV testing in March 2020. CervicalCheck sought an evidence review to inform the screening pathway for HIV-positive women in this context, with regard to age of initiation and frequency of screening. Currently, HIV-positive women commence cervical screening at age 20 in Ireland with annual screening thereafter. Methods An electronic literature search was conducted to identify relevant peer-reviewed publications using the database Pubmed. A hand search of reference lists of suitable articles and international cervical screening guidelines was conducted to check for additional material. Publications pertaining to international cervical screening guidance and practice were sourced via internet searches using Google. The relevant grey literature was also explored. Results The prevalence of multiple and more persistent high-risk HPV types is higher among HIV-positive women compared to HIV-negative women. HIV-positive women are also at an increased risk of progression and post-treatment recurrence of HPV-associated cervical lesions. The degree of immunosuppression is a key factor in the relationship between HPV and HIV. There is significant heterogeneity internationally as regards cervical screening pathways for HIV-positive women. Many programmes commence screening at the time of diagnosis with HIV. Most developed countries screen HIV-positive women more frequently than HIV-negative women, although the screening interval varies. Conclusions HIV-positive women warrant special attention within an organised population-based cervical screening programme. The evidence synthesised in this review was used to inform change to the screening pathway for HIV-positive women as part of the planned transition to primary HPV testing. Cervical screening for these women using primary HPV testing will now commence at the time of diagnosis with HIV, with annual screening thereafter. Key messages HIV-positive women warrant special attention within an organised population-based cervical screening programme. The evidence synthesised in this review was used to inform change to the screening pathway for HIV-positive women as part of the planned transition to primary HPV testing in Ireland.