Cervical screening outside of Europe: Asia

http://screening.iarc.fr/

R. Sankaranarayanan MD

Special Advisor on Cancer ControlHead, Early Detection and Prevention Section (EDP)

Head, Screening Group (SCR)

Age-standardised incidence rates (ASR) of cervical cancer (1987–2003) and the projected incidence (2004–2008)

Age-standardised mortality rates (ASDR) of cervical cancer (1987–2003) and the projected incidence (2004–2008)

Number of cervical carcinoma in situ cases among female residents in Singapore (1983–2008)

Cervical Cancer Screening in Singapore

Jin et al., Singapore Med J 2013;54(2):96

• Targets women aged 25-69 years

• Pap smear every 3 years

• Recently switched over to liquid-

based cytology (LBC)

0

10

20

30

40

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Singapore: Chinese

Singapore: Indian

Singapore: Malay

Singapore: Mortality

Years

Cervical cancer in Singapore

Cancer Incidence in Five Continents Volumes I to X: Available at http://ci5.iarc.fr/CI5i-ix/ci5i-ix.htm

World Health Organization, mortality database http://www.who.int/healthinfo/statistics/mortality_rawdata/en/index.html

Oh et al., PLoS One. 2013;8(8):e72012Konno et al., Jpn. J. Clin. Oncol. 2010;40(suppl 1):i44-i50

Treads in age standardized in situ and invasive cervical carcinoma rates and

Ratio of age-standardized invasive to in situ cervical carcinoma rates, Korea,

1993–2009

Cervical cancer screening in Korea

Cervical Screening Programme. Department of Health. The Government of Hong Kong Special Administrative Region.

http://www.cervicalscreening.gov.hk/english/sr/sr_statistics_cc.html

Trend of Age-standardised Incidence and Mortality Rates of Cervical Cancer in Hong Kong (1989-2009)

2002-2009 2002-2009

Actual cervical cancer cases diagnosed11,096

Expected number of cervical cancer cases in the absence of screening

19,384

Total costs for screening and treatment of cancer cases157.5 million USD

Expected costs of treatment of cervical cancer cases

199.7 million USD

Cost savings during 2002-200942.2 million USD (21.2%)

Projected cost savings following introduction of cervical cancer screening in 1995 in Taiwan

Thailand national cytology screening programme

• 3.13 million women aged 35-60 years in 75 provinces were screened during 2005-2009 in the organized program

• Infrastructure consists of 145 cytology labs, 299 cytotechnologists

• 0.7% (N=20 991) inadequate smears

• 1.5% (N=45 879) had LSIL or worse lesions

• Information capture on colposcopy, treatment of lesions incomplete

• Around 2.5 million smears were taken in the private sector during 2005-2009

• National sample survey in 2007 indicated that 38-72% of women aged 35-60 years had a Pap smear in the preceding 5-years.

Khuhaprema et al., Int J Gynecol Obstet 2012; 118: 107-111

Single visit “screen and treat” cervical screening in Thailand: a programme driven by research

• According to the Ministry of Health, Thai Government, 1175 nurses and 150 doctors have been trained in single visit VIA screen and treat approach

• Nurse providers have screened around 800 000 women aged 30-44 years in primary health centers in 29 provinces

• Of those women, an estimated 3–5% were VIA positive for precancerous lesions, and around 90% of them received immediate cryotherapy

• More serious cases with suspected cancer were referred to the hospital for biopsy and treatment

Flow chart of study results (2000-2006)Eligible Population

113 clusters(n=80 282)

Randomization

VIA Group (n=49 311)(in 57 clusters)274 430 PYO

Control Group (n=30 958)(in 56 clusters)178 781 PYO

Screened (n=31 343)Screen-positive

(n=3088, (9.9%)

Cancer cases (n=167)CR: 60.9/100 000 PYOASR: 75.2/100 000 PYO

Cancer cases (n=158)CR: 88.6/100 000 PYOASR: 99.1/100 000 PYO

Cancer deaths (n=38)CR: 30.2/100 000 PYOASR: 39.6/100 000 PYO

Cancer deaths (n=92)CR: 51.5/100 000 PYO ASR: 56.7/100 000 PYO

Hazard ratio(95% CI)*

Control group 1.0

Intervention group (VIA)

Overall

Cervical cancer incidence

0.75 (0.59-0.95)

Cervical cancer death

0.65 (0.47-0.89)

* C.I.: Confidence interval

Overall and age-specific hazard ratio for incidence and deaths for all cervical cancers

Sankaranarayanan et al., Lancet, 2007;370:398-406In collaboration with CFCHC, Ambillikai, India

Study

Cluster Randomized trial of Visual Screening for Cervical Cancer in Rural South India:Dindigul District Cervical Screening Study, Tamil Nadu, India

Scaling up of VIA screening in Tamil Nadu State: promising yet has to be prudent!

Tamil Nadu state

Phasing of districts

Phase I (16 districts)

Phase II (16 districts)

The Nilgiris

Coimbatore

Tirunelveli

Kanniyakumari

Thoothukkudi

Ramanathapuram

Vellore

Tiruvan-namalai

Krishnagiri

Erode

Dharmapuri

Solem

Narnakkal

Karur

Thiruvallur

Kancheepuram

Viluppuram

Cuddalore

PudukkottaiNagapattinam

Thiruvarur

Tiruchirappalli

Thanjavur

Perambular

Dindigul

Theni Madurai

Virudhunagar

Sivaganga

Karaikal

Based on the success of the pilot and the lessons learnt, the Non Communicable Diseases intervention programme has been scaled up to the entire state of Tamil Nadu, targeting 4 NCDs, namely• Cancer cervix• Cancer breast• Hypertension• Diabetes

Mellitus

Census adjusted Population (in million)Total 149.8

Male 75.0

Female 74.8

Female Population (in million)Age group Total Rural Urban> 30 years 27.4 21.4 6.0

30-49 years 17.9 13.7 4.2

Source: Gender Statistics of Bangladesh-2012, Population Census, BBS 11

0

50000

100000

150000

200000

250000

300000

350000

400000

450000

Number Screened for CaCx Number detected Positive in screening

Total Screened: 7420886VIA / VILLI +VE: 279711

State level screening and detection of positive cases of cancer cervix from July 2012-November 2014

Cervical screening in Tamil Nadu State(July 2012 – December 2014)

Total target women: 17.9 million women

Target women screened: 7.43 million (41.5%)

Screen positive women: 279,380 (3.8%)

VIA+ve women undergoing colposcopy: 132,380 (47.3%)

No of women receiving biopsy: 45,743 (16.4%)

Women detected with CIN 1: 3147

CIN 2-3: 2026

Cancer: 1562

Cervical screening using VIA: Coverage and detection rates

TNHSP*(2012-2014)

Osmanabad**(2000-2003)

Dindigul**(2000-2003)

Target population 14,392,034 34,074 49,320

Screened (%) 7,420,556 (52%) 26,275 (78.5%) 31,343 (63.6%)

VIA positive (%) 279,711 (3.8%) 3,733 (13.9%) 3,088 (9.9%)

Compliance to colposcopy 132,380 (47.3%) 3,684 (98.7%) 3,052 (98.8%)

Biopsy 45,743 (34.6%) 2,359 (82.2%)

CIN 1 3,147 (0.04%) 1,429 (5.3%) 1,656 (5.1%)

CIN 2-3 2,106 (0.03%) 195 (0.7%) 218 (0.7%)

Cancer 1,562 (0.02%) 82 (0.3%) 67 (0.2%)

CIN 2+ 3,668 (0.05%) 277 (1.0%) 285 (0.9%)

CIN 2+ detection rate 1/2000 women screened

20/2000 women screened

18/2000 women screened

• Total Screened for Cancer Breast 95,90,209 • Total Coverage 66.63%

• Women who were CBE positive 1,17,612; positivity rate 1.22%

• Referred for Mammogram : 5100

• Follow up data related to breast cancer being compiled

• HMIS phase III underway following which the data in tertiary care institutions would be linked on line for both cervical and breast cancer

Breast cancer screening

Bangladesh National Cervical Screening Programme (BNCSP) (2005-ongoing)

• Aims to provide VIA screening to >70% of 30-49 year old women (17.9 million) during 2010-2014

• Women are screened by 1341 providers in 360 VIA screening centers; CBE also provided

• 303 trained doctors provide colposcopy and treatment services in 15 colposcopy/treatment centres

• 886,490 (4.95% coverage) women have been screened; 45,353 (5.12%) were VIA+ve

Well developed

Moderately developed

Distribution of the responsibilities to Medical College and District Hospitals

Colposcopy clinics

BSMMU

SSMC & MH

CoMCHFMCH

RajMCH

RpMCH

SBMCH

KMCH

OMCH

CMCH

MMCH

DMCH

Rangpur

RajshaniDhaka

Sylhet

KhulnaBarisal

Chittagong

Cervical screening

• China

• Indonesia

• Philippines

• Japan

• Other Asian Countries