Cancer Early Diagnosis and Screening: Understanding the Difference & the Potential André Ilbawi, M.D.

Transcription

1 Cancer Early Diagnosis and Screening: Understanding the Difference & the Potential André Ilbawi, M.D. Medical Officer, Cancer Control Department of Management of NCDs, Disability, Violence and Injury Prevention (NVI) World Health Organization

2 Comprehensive Cancer Control Prevention Early detection Treatment Palliative care Early detection: Aims to identify cancer in early stages or pre-cancerous lesions; Process includes diagnosis & link to Two strategies: screening & early diagnosis

3 Objectives of Early Diagnosis Prevention Early diagnosis Treatment Palliative care Goal = early identification Improved survival Reduced costs of care Less morbid

4 Comprehensive Cancer Control Prevention Early detection Treatment Palliative care Screening Early diagnosis Organized Unorganized

5 Screening vs. Early Diagnosis

6 Screening vs. Early Diagnosis Screening: Presumptive identification of unrecognized disease in general population More than a test it is a process Population sensitized High quality, accurate, accessible screening test Confirmatory diagnosis, pathology & staging Early diagnosis: Focuses on persons with disease More than symptoms awareness; link to health system Referral for Accessible, affordable, high quality Awareness of symptoms Accurate clinical diagnosis Confirmatory pathologic diagnosis & staging Referral for Accessible, affordable, high quality

7 Organized Screening WHO screening targets: 1. Organized: a. Greatest impact b. Fewest harms c. Equitable 2. >70% participation Criteria for Organized Screening National program to make service available Coordination, centralized at national/regional level Protocol for screening frequency, target population Mechanism of inviting target population systematically Functioning health information system including registries Monitoring & Evaluation program Benchmark Participation Link to Participation Participation Quality Quality

8 Building Blocks of Cancer Screening Components of Organized Screening Benchmarks Goals Coordinated service delivery Competent health professionals High participation Reduce mortality Adequately funded programme Information system including quality assurance National programme to promote access Organizational resources and capacity Quality assured Link to Identify precancerous lesion or early cancer

9 Understanding the Impact Coordinated service delivery Competent health professionals Benchmarks High participation Reduce mortality Adequately funded programme Information system including quality assurance National programme to promote access Organizational resources and capacity Quality assured Link to Identify precancerous lesion or early cancer Sample screening programme Evaluate impact & cost-effectiveness

10 Breast Cancer Screening Population sensitized to screening test High quality, accurate, accessible screening test Confirmatory pathologic diagnosis & staging Referral for definitive Treatment accessible, high quality Sample population: 1 million 55,000 women screened with mammography each year 5,000 with abnormal screening test 280 with confirmed cancer found on screening 4,720 require follow-up & found to have no abnormality 450 women will require 340 women will survive without screening 20 women avoid death from breast ca due to screening 30 women will not receive any major benefit (due to overdiagnosis) Breast ca screening costs in HIC: ~$10mil per 1mil population Breast costs in HIC: ~ $15mil per 1mil population

11 Understanding the Impact Coordinated service delivery Competent health professionals Benchmarks High participation Reduce mortality Adequately funded programme Information system including quality assurance National programme to promote access Organizational resources and capacity Quality assured Link to Identify precancerous lesion or early cancer

12 Understanding the Impact Situation Favourable conditions (Efficacy) Women screened Abnormal screening results Women harmed Women benefitting from screening Program costs 55,000 5,000 4, $ 1 million Low participation 22,500 2,000 1,700 10

13 Understanding the Impact Situation Favourable conditions (Efficacy) Women screened Abnormal screening results Women harmed Women benefitting from screening Program costs 55,000 5,000 4, $ 1 million Low quality 55,000 9,400 9,300 16

14 Understanding the Impact Situation Favourable conditions (Efficacy) Women screened Abnormal screening results Women harmed Women benefitting from screening Program costs 55,000 5,000 4, $ 1 million Poor link to diagnosis and 55,000 5,000 4, or

15 Putting it all together Efficacy vs. Effectiveness Situation Favourable conditions (Efficacy) Incidence 50% Participation 50% Poor quality Link to dx & rx 50% Women screened Abnormal screening results Women harmed (FP+FN+OD) Women benefitting from screening Program costs 55,000 5,000 4, $ 1 million 22,500 1,500 1,400 <5 $0.5-1 million LMIC Incidence Poor quality 50% link to 50% participation <5 life saved due to screen Not costeffective

16 Where Are We Now? Participation rates greater than 50% 100% Percent of Countries 80% 60% 40% 20% 0% AFRO AMRO EMRO EURO SEARO WPRO Breast Cancer Cervical Cancer Colon cancer

17 Understanding the Building Blocks Preparedness for cancer control globally No early diagnosis strategy: 60 / 173 (35%) No referral mechanism: 51 / 171 (30%) Cancer diagnosis & Percent Responding Service Absent 70% 60% 50% 40% Screening 30% cannot succeed without basic cancer 20% 10% 0% Countries without Pathology or Subsidized Treatment services & strong health system. AFRO AMRO EMRO EURO SEARO WPRO WHO Region Pathology services Subsidised chemotherapy services

18 Early Diagnosis Building health system for cancer control Awareness & access to care Clinical evaluation, diagnosis & staging Access to Public not informed / empowered System does not accurately detect and diagnose Lack referral mechn Care not accessible to high % of population Does not assure accessible, appropriate Up to 50% of all premature NCD deaths are linked to weak health systems that don t respond effectively and equitably to the needs of the people with NCDs

19 CANCER EARLY DIAGNOSIS Awareness & access to care Clinical evaluation, diagnosis & staging Access to >80% of patients aware of symptoms >80% of patients receive timely diagnosis >80% of patients initiate <90 days from symptom onset to initiating Awareness of symptoms Accurate clinical diagnosis Confirmatory pathologic diagnosis & staging Referral for definitive Accessible, equitable, quality

20 Building the Health System Basic diagnostic & services (Foundation) Strengthen early diagnosis (Phase I) Demonstration projects (Phase II) Expand screening services (Phase III) Phased approach Utilize building blocks of health systems Prioritize demonstration projects before population level screening

21 Building the Health System Early diagnosis Strong primary care Pathology Radiology Surgical staff Basic services & devices Central funding M&E framework Screening Strong primary care Call recall mechanisms Coordination between facilities 2 6x more pathologists 3 6x more radiologists 1-2x more surgical staff Additional programme staff 5 10x more breast services provided 7 10x more basic devices 2-4x central funding for breast disease M&E with 10 20% of overall programme costs

22 Assessing Readiness & Priorities Perform SAT of early diagnosis & screening Early diagnosis limited 1. Focus on early diagnosis Screening absent 2. Provide basic diagnostic tests & Early diagnosis limited Screening ineffective 1. Focus on improving coordination of services 2. Consider limiting screening activities to one demonstration project Early diagnosis Screening ineffective 1. Identify deficits in screening services 2. Devise programme to strengthen screening, focus on regional demonstration projects

23 THANK YOU André M. Ilbawi