CERVICAL SCREENING IN MOROCCO : CURRENTSTATUS & FUTURE

Zaki El HanchiPr Gynecology , National Institute of Oncology

Rabat

International Symposium about Ovarian and Cervical Cancer, April 6-7th 2018, Marrakech/Morocco

Introduction

• Cervical cancer is a big public health

problem in Morocco :

High frequence ;

High Mortality ;

Delay in diagnosis in more 2/3 cases.

Lead Group Log

• 2th cancer of women.

• 11.2 % of women cancers.

• Incidence : 14,8 / 100.000 women.

• ¾ cases advanced stage (2 et 3).

Epidemiological data of cervical cancer in

Morocco[Casablanca Registry 2004-2008-2012]

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Cervical cancer repartition / age

[RCGC 2008-2012]

32% of cases between 2008 et 2012 :

45 - 54 years old

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• Before 2010NO strategy

• After 2010

Strategy of organised screening endorsed

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In Morocco

• STRONG WILL TO FIGHT CANCER

• LEADERSHIP

– HIGHNESS PRINCESS

LALLA SALMA

– FLCC (Lalla Salma Fondation against cancer)

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Practitioners

Gynecologists

Surgeons

Radiologists

Pathologists

.

.

Administrator

Decision Makers

NGO

rs

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GAOLS

• To Reduce Mortality and Morbidity of cervical cancer

• To Reduce the Incidence of cervical cancer

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National Plan AgainstCancer

• 2010 - 2019

Prevention

Early Detection

Diagnosis

Treatement

palliative care

Social back

Communication & social mobilization

Follow up and evaluation

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Screening of cervical cancer

TARGET :

Women aged : 30 - 50 years old

TEST : VIA at primary health structure

Repeat : every three years

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Cervical cancer screening steps

Women Invitation

Screening by VIA

Invitation after 3 years

Abnormal Results

Complementary evaluation• Colposcopy• Biopsy• Histology

Intra-epith. Lesion : DLR

Management of cancer

Normal Results

LEVELI

LEVEL II

L III

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Strategic orientations

Fonction Actions Assurance Quality Norms

Structures Suffisant number of health center IActivity in public health system

Humans Ressources Personnel in charge of screening in suffisant number, skill

Obligatory training with certification;verification of individual performance; reorientation

Equipement and laboratory

Availability and maintenance equipement; use of standard shape for creation ofrepports; proper quality of tests

Process of quality control conducted by medical physicists ;Quality control of Laboratories

Information System Suitable System to collect data , analysis and repports; follow of women with abnormal results

Update of registries

or computerized register

Direction Chief identified to manage of changes , improve of quality and manage of incidents

Coordinator of the program is mandatory

Lead Group Log

System of

information

Register and information technology

Health Center I

Reference Center II

National Institut Oncology

Maternity III

Data of all H.C. I

Reference

Feed Back

HealthMinistry

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Quality Assurance

Structure

• Indicators

•Norms

Process

• Indicators

•Norms

Results

• Indicators

•Norms

Improve the quality

Evaluation

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Principal implementations

Lead Group Log

• Construction of Reference Centers

• Aquirement of necessary equipements

Improvement of service’savailability

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Reference Centers

30 centers

functioning

4 sooner

10 in project

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Strategy of training

• Elaboration guide;

• Training of teachers ;

• Training of 3000 personnels;

• Training in Communication and Counseling;

• Training in matters of management and follow up of

program;

• Including the early detection in nurses school, lSPITS (2015)

Communication about the program

Breast cancer :• Annual campaign ;

• Plans of regional

communication ;

• Supports (posters and

folds);

• NGO

Cervical cancer :Regions : yes

National : Not yet

Follow up / Evaluation

•First evaluation of the whole activity :

2016

Fondation LC , IARC commission

• Accompaniment et oversight of activities.

Studies and research

• Prospective study about patient circuit (2010-2012) ;

• Global study of the program (2013);

• Study about profile, reasons and the becoming ofwomen lost after being screened for cervicalcancer (2015-2016);

• Retrospective study about the becoming womenscreened for cervical cancer (2015-2016);

Indicators of performance

Screening test results

108,421

177,011

216,196

8,518 9,45319,230

0

50,000

100,000

150,000

200,000

250,000

2014 2015 2016

participants

VIA -

VIA +

8 % 5,3 % 9 %

≈ 167209 per year

Participation rate evolution

2010 - 2015

0.00%

1.60%

3.20%

3.50%

4.70%

6.60%

7.80%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

2010 2011 2012 2013 2014 2015 2016

Colposcopy

85189453

19230

43865413 5399

0

5000

10000

15000

20000

25000

2014 2015 2016

VIA +

colposcopy

Results of colposcopy

4,386

5,413 5,399

386661

956

61 71 990

1,000

2,000

3,000

4,000

5,000

6,000

2014 2015 2016

colposcopy

CIN

cancer

CIN and cervical cancer

8.80%

12.20%

17.70%

1.30% 1.30%1.80%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

20.00%

2014 2015 2016

CIN

cancer

Results of cervical cancer screening program

evaluation in Morocco

• Low coverage rate :– No campaign about cervical cancer

– Screening no available every where

• Positif VIA test is high and variable

• Low rate of colposcopy :– Number of gynecologist is not sufficient

• Low rate of diathermic loop excision :– Number of gynecologist is not sufficient

– Not all gynecologist have the skill of ER or have fear to do it at the Reference Center.

Challenge and perspectives

• To reinforce the AVAILABILITY of structures and equipements all around the country ;

• To INCREASE the rate of participants ;

• To ensure the DIAGNOSIS of all women withpositive VIA;

• TO ensure the TREATMENT of all womenwith CIN or cervical cancer

Challenge and perspectives

• To be sure that every participant return every 3 years ;

• To implement an efficient information technology in order to follow up all participant in every steps.

• To reinforce the evaluation of the program.

How to be sure that every

woman with a positive VIA

could have a colposcopy ?

• Training more caregivers in coposcopy :

– Gynecologists

– General practitionners ++++

• To organize a certified training

• Good accompaniment

Vaccine

• Quadrivalent Vaccine : 6 11 16 18– Prevention of CIN 2/3– Cervical cancer– VIN 2/3– VaIN 2/3– Genital wart

• Bivalent Vaccine : 16 18– Prevention of CIN 2/3– Cervical cancers

Available in Morocco since 2008

Individualvaccination

Conclusion

Evolution very good of the program :

– Successful partnership between HealthMinistry and LS Fondation ;

–Commitment and involvement of all collaborators.