1. Italian Cervical Screening Programme. 17ème congrés de la Société Marocaine de Cancerologie 23-25 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

2. Cancer screening programmes have been developed on a voluntary basis till 2000. 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

3.  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

4.  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)

5. 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

6. 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

7. 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

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

9. www.osservatorionazionalescreening.it

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

11. ONS 2008 Cervical Screening Calabria Region : Referral Rate to colposcopy by programme Screened womenCANCROHSILLSILASCHAGCASCUSOTHERTOTAL CALABRIA316656187730310352226712,1% ITALIA129777214425601003012494178813432102304612,4% COSENZA484900000040 0,8% CROTONE11613110329041901561,3% LAMEZIA TERME2321001000010,1% LOCRI46083114940001122,4% PALMI2601105550120732,8% ROSSANO179914133661 182 243 13,5% VIBO VALENTIA3874031228030461,2%

12. Incidence and mortality rates for cervical cancer Italy 1988-2002 - da I Tumori in Italia –Rapporto 2006 AIRT Working Group

13. Previous pap test in women affected by Invasive Cervix Cancer Tuscany Region – 2004 - Courtesy of A. Iossa, P. Mantellini, E.Paci, C.Visioli 194 cases No previous pap Pap > 5 years ago

14. Cervical screening programme in Italy Recruitment  by personal letter Age  25-64 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.

15. % 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

16. 2007 20062005 ITALY 39.838.536.7 NORTHERN ITALY 46.945.646.7 CENTRAL ITALY 40.235.7 35.6 SOUTH and ISLANDS 27.128.721.0 Compliance to invitation

17. 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

18. 200720062005 NMean10 centile 90 centile NMean10 centile 90 centile NMean10 centile 90 centile 1065.1%1.0%11.0%1065.8%0.5%11.3%986.1%1.0%10.8% % of recommandation to repeat smear

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

20. 200720062005 NMean10 centile 90 centile NMean10 centile 90 centile NMean10 centile 90 centile 8560.4%41.2%87.7%7761.7%38.7%85.3%7557.3%34.3%89.7% Compliance to Recommendation to repeat citology

21. 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

22. 200720062005 NMean10 centile 90 centile NMean10 centile 90 centile NMean10 centile 90 centile 1162.4%1.0%4.4%1152.3%1.0%3.9%1072.3%0.8%4.4% Referral rate to colposcoy

23. 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.

24. Reason for Referral to colposcopy by Region

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

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

28. 200720062005 NMean10 centile 90 centile NMean10 centile 90 centile NMedia10 centile 90 centile 1032.91.04.81002.80.74.8962.70.64.0 CIN2+ Detection Rate

29. Detection rates of CIN2+ lesions by Region

30. 200720062005 NMean10 centile 90 centile NMean10 centile 90 centile NMean10 centile 90 centile 10316.0%6.0%29.4%10316.1%5.4 %32.4%9216.8% 5.7%36.3% VPP of cytology ASCUS+ for histologically confirmed CIN2+

31. Conclusion (1) Cervical Cancer is almost a preventable cancer by a regular pap testing Almost 75%-80% of Italian women aged 25-64 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

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

33. 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).