Asturias, 23 October, 2011 Asturias, 23 October Screening for Cervical Cancer in Europe M. Arbyn Unit Cancer Epidemiology, IPH, Brussels, Belgium Rue Juliette Wytsmanstraat 14 1050 Brussels Belgium T +32 2 642 50 73 F +32 2 642 54 10 email: amidu.raifu@iph.fgov.be http://www.iph.fgov.be
Contents 1. European evidence indicating that organised screening is more effective and cost-effective Screening interval, target age 2. Screening systems in Europe 3. Screening coverage 4. EU guidelines
Impact of organised screening
Effectiveness opportunistic versus organised screening Case-control studies FL (Nieminen, Int J Cancer, 1999); UK: Sasieni, BJC 2003, BMJ 2009); SE: Andrae JNCI 2008 Cohort studies (IARC 1986; vanden Akker, BJC 2003; Ronco, BJC 2005, Nygard, J Med Screen 2002, Lynge J Med Screen 2006) Trend analyses: Nordic Countries (Anttila/Sigurdsson), EU (Arbyn EJC 2009, IJC 2009), Miscan.xls
Age standardised incidence of invasive cervical cancer and coverage of screening (England, 1971-95) Quinn, M. et al. BMJ 1999;318:904 Copyright 1999 BMJ Publishing Group Ltd.
Coverage (%) 80 60 40 20 0 Norway 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-67 25-67 Age group Nationwide organised screening since 1995 Obligatory registration of cytology Before ( 92-94) vs after (2001-4) intro organised screening Coverage: +7% Pap smear use: from 533,000 to 494,000 Incidence cancer: -22% 1992-95 2001-04 Nygaard: Thesis, 2005 Miscan.xls
Successful changes in cervical cancer screening in The Netherlands Organized screening versus opportunistic: Higher coverage Less positive tests without an increase of interval cancers Better follow-up compliance Limitation of excess smears while maintaining high coverage rate Rebolj et al, Int J Cancer 2006
Cervical cancer incidence in Europe (2008) W-age standardised rate (Cases/100 000 women-years) 3.0 to 5.99 (7) 6.0 to 8.99 (10) 9.0 to 8.99 (6) 12.0 to 14.99 (9) 15.0 to 17.99 (4) 18.0 to 20.99 (2) 21.0 to 23.99 (3) Arbyn, Ann Oncol 2011
Arbyn, IJC 2011 World-age standardised trends of cervical cancer incidence & mortality Incidence Mortality
Target age group for screening
Cervical cancer screening systems
National cervical cancer policies in EU countries Countries Target age group Screening Start End interval (years) Number of smears per woman in target age group Population covered by programme Austria 18-1 50 - Belgium 25 64 3 14 61% Denmark 23 59 3 (<50)/5 12 100% Finland (25) 30 60 (65) 5 7-9 100% France (20) 25 (60) 65 3 14 5% Germany 20-1 >50 90% Greece 20-1 >50 - Ireland 25 60 3 (<45)/5 10 100% Italy 25 64 3 14 64%* Luxemburg 15-1 >50 100% The Netherlands 30 60 5 7 100% Portugal 25 64 3 14 - Spain 18-35 59-65 3/5 5-15 - Sweden 23 60 3 (<50)/5 12 100% UK (20) 25 (60) 64 3 (<50)/5 12 100% Anttila, Eur J Cancer 2009 Nationwide organised Regionally organised/national rolling out ongoing Miscan.xls
National cervical cancer policies in new EU member states Countries System Start End Interval Bulgaria Opportunistic 31 65 2 Cyprus Opportunistic - - 1 Czech Republic Opportunistic 25 69 1 Estonia National rolling out 30 59 5 Hungary National rolling out 25 64 3 Latvia Intention to organise 20 70 3 Lithuania Start to organise 30 60 3 Malta Opportunistic - - - Poland Organised since 2007 25 59 3 Romania Pilot (Cluj) 25 65 5 Slovakia Opportunistic 18-1 Slovenia Organised 20 64 3 Nationwide organised Anttila et al, Eur J Cancer 2008 Regionally organised/national rolling out ongoing Miscan.xls
Screening coverage in EU countries (% had at least 1Pap/LBC since screening interval) Countries Coverage Screening interval (years) Belgium 59% 3 Denmark 69% 3 Finland >70% 5 France 60% * 3 Germany 80% $ 1 Greece ~80% µ 3 Ireland (S-West) 71% 3 Italy >59% 3 The Netherlands 77% 5 Portugal (Central) 58% 3 Spain 76% 3 Sweden 73% 3/5 UK 74% 3/5 **Arbyn, Prev Med 2009 Anttila, EJC 2009 * Rousseau A, Bull épid hebd 2002 $ European Network Cervical Cancer Screening, EJC 2000 µ Simou, J Women s Health 2010 Puig-Tintore, JLGTD 2008 Blue: derived from surveys
Used screening test Pap smear: still frequently used in EU LBC: UK/Ireland Denmark (Fynn) Increasing used in other member states HPV: advised by official boards of experts (NL, FL); RCT (5 countries), pilot projects (GE, ES, France, Italy) Cytology & colposcopy in several East- European countries Miscan.xls
Invitation systems: Who is invited in organised systems? All (call): Finland, Ireland, The Netherlands, UK Not recently screened women (callrecall): Hungary, Slovenia, Denmark Miscan.xls
Cytological report form Bethesda or Bethesda-like 21 member states Other systems Germany: Munich system Austria: derived from Munich system, adapted to match Bethesda categories KOPAC: Netherlands (matching TBS) No national system: Malta, Cyprus Bulgaria? Miscan.xls
EU guidelines First of all: screening should be well organised Reach the target population Monitor quality In agreement with evidence-based guidelines Registration of screening, follow-up, (and HPV vaccination) linked to the cancer registry
Acknowledgements European Commission: EUROCHIP-3, ECCG, EUROCOURSE, PREHDICT (FP7) Belgian Foundation Against Cancer