Italian Cervical Screening Programme. 17ème congrés de la Société Marocaine de Cancerologie Avril, Marrakech Marco Zappa ISPO, Scientific Institute of Tuscany Region Clinical and Descriptive Epidemiology Florence - Italy Ministero della Salute Centro Nazionale per la Prevenzione e il Controllo delle Malattie Conferenza del Presidenti delle Regioni e delle Province Autonome

Cancer screening programmes have been developed on a voluntary basis till In 2001 cancer screening programs have been included in the Basic Healthcare Parameters 3 screening programmes are recommended :  mammographic screening  cervical screening  colorectal cancer screening All examinations are free charged. The Italian context

 Guidelines are provided by the Minister of Health -Department of Prevention (largely based on European guidelines)  Regional Governments are responsible for organization, management and control of screening programmes The Italian context

 Founded in 2001 in cooperation with Scientific Societies for Breast Cancer, Cervical Cancer and Colorectal Cancer.  In 2005 formally charged by the Italian Minister of Health of promoting and monitoring screening programmes nationwide.  The ONS is located in ISPO – Florence National Centre for Screening Monitoring (Osservatorio Nazionale Screening)

Aims Monitoring the spreading of screening activities Evaluating the impact of screening programmes on incidence and mortality Training Improving quality assurance for each phase of screening programmes Developing comunication tools to help people to make an informed choice Aims

The Data collection Data come from several different programmes (120), most of them organized at a Regional level (20) programmes, For every Region, a referent for data collection has been identified; Aggregated data collection by a structured questionnaire - referred to the previous year of activity Monitoring : Data Collection

Computerized form ( Excel spreadsheets) 1. general information on procedures/participation 2. performance parameters (initial screening) 3. performance parameters (subsequent screening) 4. performance parameters (self-registrations) Automatic formulas to calculate performance indicators All data should be provided by age groups and by screening test (first vs subsequent) The questionnaire

Data collection The feasibility of a National datawarehouse based on individual records is going on Data collection

Why a monitoring system? Identify critical points in the pathway of the programme Sharing the best experiences Benchmarking

ONS 2008 Cervical Screening Calabria Region : Referral Rate to colposcopy by programme Screened womenCANCROHSILLSILASCHAGCASCUSOTHERTOTAL CALABRIA ,1% ITALIA ,4% COSENZA ,8% CROTONE ,3% LAMEZIA TERME ,1% LOCRI ,4% PALMI ,8% ROSSANO ,5% VIBO VALENTIA ,2%

Incidence and mortality rates for cervical cancer Italy da I Tumori in Italia –Rapporto 2006 AIRT Working Group

Previous pap test in women affected by Invasive Cervix Cancer Tuscany Region – Courtesy of A. Iossa, P. Mantellini, E.Paci, C.Visioli 194 cases No previous pap Pap > 5 years ago

Cervical screening programme in Italy Recruitment  by personal letter Age  Screening interval  3 years Test  Pap smear (HPV in the future? ) Triage  for ASCUS (new smear or HPV) Assessment Phase  Colposcopy + biopsy (in case) Treatment  Leep etc.

% of women aged 25-64yrs living in an area where an organized programme is active 20 Regions 117 programmes 71.8% coverage 3,021,734 invitations 1,217,001 screened woman

ITALY NORTHERN ITALY CENTRAL ITALY SOUTH and ISLANDS Compliance to invitation

Lines represent the range between 10th and 90th centile of programme distrubution within each Region, n. of programmes in each bar. (no lines for regions with a single regional programme) Compliance to invitation by Region

NMean10 centile 90 centile NMean10 centile 90 centile NMean10 centile 90 centile %1.0%11.0%1065.8%0.5%11.3%986.1%1.0%10.8% % of recommandation to repeat smear

% of recommendation to repeat smear (and reason) by Region

NMean10 centile 90 centile NMean10 centile 90 centile NMean10 centile 90 centile %41.2%87.7%7761.7%38.7%85.3%7557.3%34.3%89.7% Compliance to Recommendation to repeat citology

Each bar rapresents one Region.Lines represent the range between 10th and 90th centile of programme distrubution within each Region, n. of programmes in each bar. (no lines for regions with a single regional programme) Compliance to recommendation to repeat smear by Region

NMean10 centile 90 centile NMean10 centile 90 centile NMean10 centile 90 centile %1.0%4.4%1152.3%1.0%3.9%1072.3%0.8%4.4% Referral rate to colposcoy

Referral rate to Colposcopy by Italian Region Lines represent the range between 10th and 90th centile of programme distribution within each Region, n. of programmes in each bar.

Reason for Referral to colposcopy by Region

Positive Predictive Value (PPV) for CIN2+ of indication to colposcopy

Compliance to colposcopy for ASCUS+ cytology % of programmes with desirable or acceptable level

NMean10 centile 90 centile NMean10 centile 90 centile NMedia10 centile 90 centile CIN2+ Detection Rate

Detection rates of CIN2+ lesions by Region

NMean10 centile 90 centile NMean10 centile 90 centile NMean10 centile 90 centile %6.0%29.4% %5.4 %32.4%9216.8% 5.7%36.3% VPP of cytology ASCUS+ for histologically confirmed CIN2+

Conclusion (1) Cervical Cancer is almost a preventable cancer by a regular pap testing Almost 75%-80% of Italian women aged refer to have performed a pap smear in the last 3 years  Half of them perfom a test within a spontaneous activity  Within an organized activity we can check the quality of the whole process from invitation to diagnosis and treatment

Conclusion (2) Screening programmes for cervical cancer in Italy are widespreading Differences between and within Italian Regions Room for quality improvement

In the future? HPV’s era  HPV as primary test (with pap smear as triage) : at the moment nine pilot programmes are based on such a test HPV Vaccination : all girls aged 12 years are actively invited to vaccination (with different policies within Regions in the older age group).