Meeting of 2 July 2016 at the Hotel Ibis Bastille Opera in
Paris, under the auspices of
Introduction by Guy SCHLAEDER, Strasbourg, Past President of
As decided at our previous meeting on October 2015, today we
shall hold a roundtable
discussion on cervical cancer prevention. The second topic will
be primary care for women.
The UPIGO Annual General Assembly will be held at the end of the
MAIN THEME : CERVICAL CANCER PREVENTION
Coordinator : Jean-Jacques BALDAUF (Strasbourg).
The reports were very detailed. Each participant was asked to
summarise and outline
1- CERVICAL CANCER AND CERVICAL CANCER PREVENTION IN
André KIND (Basel)
Switzerland has one of the lowest cervical cancer incidence and
mortality rates in the world
and the lowest in Europe: the age-standardized incidence rate is
3.6 / 100 000 and the agestandardized
mortality rate is 1.1 / 100 000. 240 women are diagnosed with
and 94 women
die from cervical cancer each year. Nevertheless these rates
differ between regions within
Switzerland. Rural areas have higher rates compared to urban
ones. This is a pattern which
is seen throughout the world.
Switzerland is a small country with a high level of economic
wealth. The World Bank ranks
Switzerland as number 4 in the list of countries with the
highest gross domestic product in
the world. Nevertheless, socioeconomic status and education have
an impact on the
incidence and mortality of women with cervical cancer, even in a
system where prevention
measures and treatment of cervical cancer are free. Women with a
low level of education
have a 50% higher risk of dying from cervical cancer compared to
women with a high level of
The incidence rate of cervical cancer has dropped since the late
1960s by 50-60% and it is
so low now that other disease associated with Human Papilloma
Virus (HPV) such as Anal,
Vulva and Oropharyngeal Cancers are gaining more importance.
It is not completely understood why the cervical cancer rate is
so low in Switzerland. There is
no national screening programme for cervical cancer. Screening
is opportunistic and cytology
based. The Swiss Society of Obstetrics and Gynaecology
recommends cervical cytology
screening every 2 years between 21 and 29 years and every 3
years between 30 and 70
years. Insurance companies pay for theses examinations. There is
no good data on
attendance at screening, but existing data suggest rates of
around 70% every 3 years, with
differences between women getting screened every year and about
10-15% women never
As no good data is available, we do not know how many
precancerous lesions are diagnosed
and treated, how many colposcopies are performed, how many
adverse outcomes such as
preterm labour are due to the treatment of precancerous lesions
occurring, and what sort of
psychological impact our screening has. We have no good
estimates of the costs of our
cervical cancer screening, but know that it is one of the most
New guidelines are currently being developed by a working group
within the Swiss Society of
Obstetrics and Gynaecology. One option is to have HPV-based
screening included above 30
years of age.
Bi- and quadrivalent HPV-vaccines are available in Switzerland.
The nonavalent vaccine has
not yet been licenced. The national vaccination programme
suggests HPV-vaccination at 11-
14 years with a free catch up at 26 years. Vaccination is not
mandatory in Switzerland and
vaccination rates remain below 60%.
Switzerland has a very low rate of cervical cancer, but even so,
240 women are diagnosed
with and 94 women die of cervical cancer. To reduce these rates,
it will be necessary to
introduce a national screening programme with a call/re-call
system and quality assurance
measures. HPV-vaccination rates need to be increased
substantially. This is not only
important for the primary prevention of cervical cancer, but
also for the prevention of other
HPV-related cancers such as anal cancer, for which no screening
methods have been
2- CERVICAL CANCER PREVENTION – DATA ON GREECE: Athanasios
• In Greece there is no organized population-based cervical
cancer screening program.
• The existing program is opportunistic.
• Eligible age is 20+ or one year after the initiation of sexual
• Interval period is one year.
• There is no registry concerning the total amount of pap smears
of Hellenic territory.
Unfortunately in Greece there is no official screening program
monitoring Pap smear records.
From public health records, it can be concluded that there is a
slight decline in the number of
Pap smears performed annually from 49.524 in 2012 to 45.940 in
2014 even though Pap
smears are available free of charge in the public sector. This
can be attributed to the period of
austerity and high rates of unemployment during the same period
The same trend concerning the decline of the number of Pap
smears can be noted in a
random private hospital in Athens during the same time period.
What is of great importance, based on the IMS Data (March 2016),
is an increase in the
vaccination coverage from 20% in 2010 to 40% in 2015. Lately,
the high vaccination coverage
rates can also be partly attributed to the announcement that the
HPV vaccine will stop being
publically funded in women older than 18 years of age from 2017.
3 - INCIDENCE AND PREVENTION OF CERVICAL CANCER IN ALBANIA:
Gjergji THEODOSI (Tirana)
From the data of the University Hospital of Tirana, the
incidence of cervical carcinoma in
Albania during the years 2004-2013, were diagnosed about 9.3
cases for 100.000 women.
They were treated using, surgery, chemo and radiotherapy, but
still the women's mortality is
The most of cases were from 45 to 64 years of age, more from the
The main directions of cervical carcinoma prevention were
a. The careful treatment of all small, benign, pathologies of
the uterine cervix, like polyps,
b. The careful treatment of every type of inflamatory cervical
process, till the normal aspect.
c. The current use of specific recommended examinations, like:
Papanicolaou Test, every 1-
The Pap- Smear results were mostly normal, and about 6-8%
histopathologic features like: ASCUS; HSIL or LSIL. When
considered necessary, we used
colposcopic of cervical biopsy and the treatment was later based
on the examens results..
The use of Anti HPV vaccine is not regular, and not financially
The molecular biology laboratory of the Public Health Institute,
is using currently, the
examens for HPV types testing, The number of exams, is every
year higher. ( about 2500
examens for 5 years)
Up to now, there is not a National Screening Programme
concerning genital carcinoma and
not an organized vaccination using anti HPV vaccines.
4 - Ideas for screening in the future: Michael MENTON
In the future, when 80-90% of the population is vaccinated and
the effectiveness of
vaccination is proved, screening may be reduced.
Currently this condition has not been met in Central Europe.
The practice in Germany is as follows:
Diagnosis based on high quality cytology test is good enough for
screening cervical cancer.
The PPV (positive predictive value) is very high (90-95% for a
smear indicating a major
dyplasia). However, the PPV of the HPV test is 10%. Therefore
there is a clear and
significant danger of over-treatment.
A cytology test gauges the size of the lesion. It is possible to
find cancers of the body of the
uterus which are HPV negative. Furthermore, adenocarcinomas of
the cervix are on the
increase. There is evidence that the HPV-test is often not
reliable and negative where a
cervical adenocancer is present.
The HPV test has a high sensitivity rate (85-90%) for the
detection of HPV infection. Only
10% of positive cases reveal a dangerous lesion requiring
The HPV test should be added to the cytology test for older
women (over 35 or 40). This
would have two advantages. First, there is less risk of
over-treatment because most women
are no longer taking family planning measures. Secondly,
cytology tests do not always make
it possible to make a diagnosis in cases of atrophy. The
combination could lead to increased
sensitivity and specificity.
For women over 40, sensible screening would include a smear
every two or three years and
an HPV test every six years.
If an HPV test is positive, it is completed by a colposcopy,
cytology and possibly biopsy.
The US industry is promoting “triage”.
This is inacceptable for several reasons:
‐ It is contradictory to first ask for a test with a higher
sensitivity and then sort using this
method, which is not considered sufficient.
‐ If a test is positive, the patient has a right to a proper
examination, i.e. a colposcopy,
cytology and histology depending on the situation.
‐ Industrial triage is not sufficient.
‐ Triage is a military process for when there insufficient
resources (disasters, accidents
or in war). In Europe, we currently have neither war nor a
shortage of gynaecologists.
This military method cannot be accepted in civil circumstances.
Commentaire [S1]: Importance or
5 - Prevention of cervical cancer in Mali
1 °) Screening and treatment of precancerous cervical lesions in
Mali using visual inspection
methods further to application of acetic acid and Lugol’s
solution, by Toure Moustapha,
Traoré Alassane, Binta Keita, Tegueté Ibrahim, Traoré Cheick and
Cervical cancer is the second most common cancer among women in
the world with 452,000
new cases per year. In Mali it is the most common cancer among
women. According to a
study conducted in 2008, its rate of occurrence is 27 per
100,000 women per year. Cervical
cancer mortality and morbidity rates are growing. In Mali, as in
most developing countries,
three-quarters of the cases are diagnosed at a late stage. It is
a real public health problem in
Visual tests after application of acetic acid and Lugol’s
solution were used with the following
The study was conducted throughout the country, under the aegis
of the National Directorate
of Health and the Malian Society of Gynaecology Obstetrics and
with the participation of 28
physicians, 52 midwives and 3 health technicians, between
February 2001 and April 2010.
26,164 women were screened. 2,093 (8%) tested positive and
24,070 (92%) tested negative.
The age range was between 25 and 59 years, with an average of
39.6 years plus or minus 7.
38% were illiterate.
The number of pregnancies varied from 0 to 20, with an average
of 5.25 (the fertility rate is
about 6 children per woman).
The histological diagnosis was as follows: 489 cases of
cervicitis; 332 condylomas, 680
dysplasias and 261 cancers, observed mostly at a late stage.
Treatment methods included cryotherapy, loop diathermy treatment
(in about 40% of cases),
conisation and surgery.
In conclusion: screening for precancerous lesions of the cervix
by acetic acid and Lugol’s
solution offers an alternative to vaginal cervical smears for
countries with limited resources
and insufficient qualified personnel. It can be used at low
cost, is easy to organise with staff
in basic centres. Rapid availability of results allows immediate
treatment of lesions.
2) Vaccination against the papilloma virus in Mali, by Toure
Moustapha, Diallo Fanta Siby
and Traoré Alassane
Like other countries in the epidemiological area of West Africa,
Mali has embarked on a new
process to strengthen its expanded routine vaccination programme
vaccination against the papilloma virus. This is in line with
commitments under the Global
Vaccine Action Plan as part of efforts to meet the Millennium
According to a study carried out in Mali in 2008, the occurrence
of cervical cancer is
estimated to be 27 per 100,000 women per year; with 89.7% of
cervical cancer cases
associated with HPV.
A pilot study was undertaken under the aegis of the National
Health Directorate’s National
Vaccination Centre, in two urban and rural areas covering 416
villages and 38
neighbourhoods, with 231 vaccinators, 4 national supervisors and
8 district supervisors. It
produced the following results.
In rural areas, the target population was estimated at 7,373
10-year-old girls, of whom 5,335
were enrolled at school and 2,038 were in the community. 100%
were vaccinated during their
In urban areas, the target population was estimated at 3,668
10-year-old girls, of whom
3,235 were enrolled at school and 169 were in the community. 93%
Conclusion: The results of this pilot study (100% of the
vaccination rate in rural areas and
93% in urban areas) revealed that HPV vaccination is possible in
our country. It is hoped that
it will be possible to roll the programme out across the whole
of Mali. The results of the
second visit should be received soon.
Mali is keen to cooperate with UPIGO cooperation in various
sectors, particularly in the field
of training and research.
6 - Cervical cancer prevention in France, Jean-Jacques Baldauf,
In France there are still nearly 3,000 new cases of cervical
cancer each year, causing 900 to
1,000 deaths. Screening for cervical cancer is opportunistic
except in 13 départements,
which are experimenting with organised screening. The highly
improved effectiveness of
organised screening is due both to the increased participation
of women, especially older
women, and the better quality of samples, the interpretation of
smears and the follow-up of
women showing abnormal results. As a result, a ministerial order
has been issued to
designate regional organisations responsible for rolling out
organised screening for cervical
cancer on the basis of terms of reference drawn up by the
National Cancer Institute (INCa).
The aim is to have organised screening rolled out across the
country in 2018. The main
systematic sending of invitations letters/reminders to women
participated in screening,
monitoring of all women who test positive (whether they have
spontaneously or have been invited to participate in screening
the diversification of ways of taking samples involving GPs,
midwives and other
healthcare professionals by providing training and offering
quality assurance for
samples and information measures for professionals and women.
In parallel, vaccination in France is both non-organized and
non-systematic. Nine years after
the introduction and reimbursement of HPV vaccination in France,
vaccination coverage is
inadequate, with less than 20% of 16-year-old girls receiving
three doses. In addition, since
2010, vaccination coverage has been decreasing among girls aged
14-16. In response to
these poor vaccination coverage figures, the French High Council
for Public Health changed
its recommendations on HPV vaccination in 2013 by targeting the
vaccination of girls aged
11 to 14, that is, before they become sexually active, with a
catch up between 15 and 19.
This new target age range target involves both GPs and
paediatricians, and it already entails
a vaccination appointment. Moreover, it “desexualizes” the
vaccine and produces a better
immune response, as it permits a schedule where two doses are
administered with a sixmonth
interval. The 31% increase in the number of doses of vaccines
sold in 2013 compared
to 2012 reflected the larger target group but has not led to an
increase in vaccination
coverage over the medium and long term. However, the lowering of
the target age (girls aged
11 to 14) should help increase the proportion of uninfected
girls at the time of vaccination
because they will not have become sexually active. It must be
noted that vaccination
coverage in France is too low to obtain a significant impact
which would make a change in
screening strategy possible.
7 - Prevention of cervical cancer in Slovakia: Martin Rocheda,
Cervical screening is carried out for women between the age of
23 and 64 years in the form
of a conventional Pap smear, taken by a gynaecologist.
Laboratories are certified and
recognised on condition that they have a sufficient number of
smears each year.
The incidence of cervical cancer is among the highest in Europe,
at about 17.2%.
Only 30% of eligible women are enrolled on the screening
programme. Participation is better
in cities than in rural areas.
Planned: a National Centre for Cervical Screening to guarantee
the quality of screening. A
recall system is planned to improve participation in screening.
In Slovakia: Gardasil, Cervarix and Gardasil 9 are available.
Despite the efforts of various
expert associations, HPV vaccination is not offered in the
national vaccination programme
financed by the national health authorities.
8 - Prevention of Cervical Cancer in Luxembourg: Annik Conzemius
This summary should be considered provisional and subject to
future modifications. Cervical
screening is done in an opportunistic manner via annual checks.
The participation rate is
A working group at the Ministry of Health is planning to improve
the current system.
It is hoped to improve the vaccination rate of girls aged 11 to
14. There is currently a high
degree of reluctance among both parents and doctors.
The vaccine currently used is Cervarix, with 2 injections
between 11 and 14 years and 3
injections if the vaccine is used later.
- between the age of 20 and 30: a single, annual cytology test.
- between the age of 30 and 60: joint HPV test and cytology
test, repeated every 3 years if
negative, more frequent tests if positive with colposcopy and
biopsy according to the case,
- after 60: back to normal.
The working group has not yet completed its work. It is hoped
that approval will be given in
9 ‐ Prevention of cervical cancer In Italy: Pier Francesco
Tropea, Calabria Region
Cervical screening is free on the Health Service for women aged
25 to 64, with a smear every three
years. Participation is better in northern Italy, at 90 %,
compared to 60% in southern Italy
When cytology is positive, an examination takes place in
With colposcopy, biopsy and sometimes HPV test.
12‐year‐old girls are vaccinated (regional governments cover the
cost) with a second dose after two
months and a third dose after six months. Some regions even
vaccinate for free between the ages of
15 and 18.
The percentage of vaccinees is 76 to 86%, in the north of the
country, depending on the region, and
62 to 74% in the south.
Type of vaccine: most often bivalent (types 16 and 18),
sometimes quadrivalent (16, 18.6 and 11).
Comments: Italian epidemiologists aim to vaccinate 95% of
The HPV test is used in some areas in further to abnormal
10 - In Europe
Cervical cancer is well suited for screening. Its natural
development is characterised by the
long-term presence of pre-cancerous lesions which can be
detected by a smear and then
The lack of screening is the biggest risk factor for cervical
cancer in all countries. Experts
from the World Health Organisation and the International Agency
for Research on Cancer
agree that the best solution is organisation, with a system
where women are invited for
Organised screening is the most appropriate way to combat lower
participation caused by
socio-economic inequalities. The introduction of well-organised
cytological screening for
cervical cancer in certain Nordic countries (Denmark, Finland,
Iceland, Norway and Sweden)
has reduced the occurrence of this cancer and mortality rates by
up to 80%. In Europe,
screening methods vary. Fourteen countries have a national
programme. Seven others, including France, are developing
regional programmes, covering
between 4 and 72% of the population. Eleven countries only have
voluntary screening at
people’s own initiative. This group includes Switzerland, where
smears are carried out
annually and yet cervical cancer rates are among the lowest
recorded in Europe, probably
thanks to the significant resources made available.
In countries where HPV vaccine coverage is high, we are
currently obtaining initial results
that show a significant decrease in precancerous cervical
lesions among the vaccinated
population. In Europe there are different ways of organising
vaccination programmes (school
campaigns, vaccination centres, private provision, tender
processes), and vaccination is
either free or reimbursed to varying degrees depending on the
country. The target age range
for vaccination is broadly identical. Coverage rates vary
between 17% and 86%, with France
at the low end of this range.
The organisation of screening is essential to ensure quality of
care and the limitation of bad
practices, especially with regard to the involvement of health
professionals other than
gynaecologists and obstetricians, the use of screening processes
requiring triage and even
the development of specific strategies for particular target
groups (women under 30,
vaccinated women, etc.). Without waiting for the impact of
vaccination to be seen, it is
appropriate to replace individual screening with organised
screening. This ensures increased
safety and fairer treatment for patients, reduced costs for
society and invaluable assistance
for health professionals in dealing with anomalies in the
recommended manner. This
approach is a prerequisite for possible screening using the HPV
test, which requires
essential triage procedures.
97% of cervical cancers could be avoided by the optimal
implementation of the two