The challenges of organising cervical screening programmes in the 15 old member states of the European Union
Introduction
Among all malignant tumours, cervical cancer is the one which can be most effectively controlled by screening. Detection of cytological abnormalities by microscopic examination of Pap smears, and subsequent treatment of women with high-grade cervical intraepithelial neoplasia (CIN), avoids the development of cancer.1 In 1986, the high effectiveness of cervical cancer screening using Pap smears was established through the expert review of case-control and cohort studies as well as by comparisons between areas or periods with different population coverage.2 Further evidence has been generated from more recent studies,3, 4, 5, 6 confirming the conclusion that well organised cytological screening, every 3 to 5 years in the age range 35–64 years reduces the incidence of cervical cancer by 80% or more among screened women.7
In 1993, when the European Union (EU) comprised 12 member states (Belgium, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Denmark, Portugal, Spain and the United Kingdom), the first edition of the European Guidelines for Cervical Cancer Screening was published in this journal.8 Two years later, Austria, Finland and Sweden joined the Union. In the 1990s, cytological screening was well organised in only a few countries, such as the Nordic countries, the United Kingdom, the Netherlands and parts of Italy.9 In the other countries, screening was mainly opportunistic, depending on the initiative of the individual woman or her doctor. The first edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening established the principles of organised screening. It was pivotal in initiating some new pilot projects in Europe and pioneering in launching the concept of quality assurance.10 Nevertheless, the 1993 version has had limited impact on opportunistic screening in countries with a ‘liberal’ health care system.11 In 2003, the national ministers of health of all member states endorsed the European Council Recommendation on Cancer Screening and proposed that screening for breast, colorectal and cervical cancer should be offered only in organised settings.12 In 2008, the European guidelines were updated in a 2nd edition, which corroborated the principles of organised screening and assessed the level of evidence regarding the effectiveness of new methods of cervical cancer prevention.13
In the current paper we demonstrate that well organised screening programmes have a greater impact than opportunistic screening because they have the potential to achieve greater participation of the target population at regular intervals, equity of access and high quality. In the second part, we discuss the challenges for health authorities and health professionals in implementing recommendations to organise screening where it is not yet standard. The current paper is restricted to screening in the 15 old member states of the EU in 1995, with some relevant references to Iceland and Norway, which are not EU members. Cervical cancer prevention in the new member states, where the burden of cervical cancer is of a higher order of magnitude,14, 15 is discussed separately.16
Section snippets
Trends in Nordic countries
Trend analyses in Denmark, Finland, Iceland, Norway and Sweden have revealed a strong correlation between the decline in the burden of cervical cancer and the geographical extent and the population coverage of organised cytological screening.17 In Norway, with only 5% of the population covered by organised screening, the cumulative mortality rates (0–74 years) fell by only 10% between the late 1950s and the early 1980s, whereas in Finland and Iceland, with nationwide implementation of organised
Imperfections of organised programmes
Organised screening is more effective than non-organised screening but is not free from imperfections and achieved effects are not permanent if attention wanes. However, an intrinsic characteristic of organised screening is that imperfections come to the fore more easily and can be corrected in due time.
In England, since the year 2000, overall screening attendance has remained at a high level (80% screened <5 years ago, in the age group 25–64 years) but a continuing slow but steady fall-off has
Challenges for the future
Despite evidence indicating greater effectiveness and cost-effectiveness of organised screening and in spite of the European Council Recommendation,12 detection of cervical cancer precursors remains mainly opportunistic in eight of the 15 old member states. It should be considered as a compelling responsibility for national or regional health authorities of these countries to set up organised programmes preferably extending over the whole country in agreement with current European Guidelines
Conclusions
The major take-home message for policy makers is that screening must be well organised with optimal screening coverage and follow-up of women with a positive screening test. The quality of screening should be assured and monitored at each stage of the screening process.
Achieving a high coverage for HPV vaccination is expected to reduce the burden of disease substantially which will require modification of screening policies, in the mid- to long-term. Meanwhile, cervical screening will need to
Conflict of interest statement
None declared.
Acknowledgements
Financial support was received from (1) the European Commission (Directorate of SANCO, Luxembourg, Grand Duchy of Luxembourg), through the networks EUNICE (European Network for Information on Cancer) and ECCG (European Cooperation on development and implementation of Cancer screening and prevention Guidelines), via IARC (Lyon, France); (2) IWT (Institute for the Promotion of Innovation by Science and Technology in Flanders, project number 060081 (Brussels, Belgium)); and (3) the National Cancer
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