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Meeting of 2 July 2016 at the Hotel Ibis Bastille Opera in Paris, under the auspices of
UPIGO
Introduction by Guy SCHLAEDER, Strasbourg, Past President of UPIGO
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 afternoon.
MAIN THEME : CERVICAL CANCER PREVENTION
Coordinator : Jean-Jacques BALDAUF (Strasbourg).
The reports were very detailed. Each participant was asked to summarise and outline
desired improvements.
1- CERVICAL CANCER AND CERVICAL CANCER PREVENTION IN
SWITZERLAND
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
education.
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
getting screened.
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 expensive worldwide.
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%.
Conclusion
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
established.
2- CERVICAL CANCER PREVENTION – DATA ON GREECE: Athanasios CHIONIS
(Athens)
• 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 activity.
• 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 in Greece.
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
very high.
The most of cases were from 45 to 64 years of age, more from the north-east regions.
The main directions of cervical carcinoma prevention were considered:
a. The careful treatment of all small, benign, pathologies of the uterine cervix, like polyps,
ectropions, etc
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-
2 years,
The Pap- Smear results were mostly normal, and about 6-8% considered with
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 covered.
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 (Reutlingen, Germany)
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 treatment.
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
seriousness
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 Traoré Youssouf.
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
Mali.
Visual tests after application of acetic acid and Lugol’s solution were used with the following
results:
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 by introducing
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 Development Goals.
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
first visit.
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% were vaccinated
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, Strasbourg
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
recommendations are:
 systematic sending of invitations letters/reminders to women who haven’t
participated in screening,
 monitoring of all women who test positive (whether they have participated
spontaneously or have been invited to participate in screening by post);
 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, Bratislava
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.
HPV vaccination
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 (Luxembourg)
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
72%.
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.
Planned:
- 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
the autumn.
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 hospital.
With colposcopy, biopsy and sometimes HPV test.
HPV vaccination
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 12‐year‐old girls.
The HPV test is used in some areas in further to abnormal cytology results.
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
treated effectively.
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
screening.
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 organised screening
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.
Conclusion
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
preventive measures.