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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