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

1. Ministero della Salute Centro Nazionale per la Prevenzione e il Controllo delle Malattie Conferenza del Presidenti delle Regioni e delle Province Autonome 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

2. The Italian context • 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.

3. 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

4. National Centre for Screening Monitoring (Osservatorio Nazionale Screening)  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

5. Aims 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

6. Monitoring : Data Collection 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

7. The questionnaire • 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)

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

9. www.osservatorionazionalescreening.it

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

11. Cervical Screening Calabria Region : Referral Rate to colposcopy by programme ONS 2008

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 - 194 cases No previous pap Pap > 5 years ago Courtesy of A. Iossa, P. Mantellini, E.Paci, C.Visioli

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. Compliance to invitation

17. Compliance to invitation by 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)

18. % of recommandation to repeat smear

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

20. Compliance to Recommendation to repeat citology

21. Compliance to recommendation to repeat smear by Region 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)

22. 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. CIN2+ Detection Rate

29. Detection rates of CIN2+ lesions by Region

30. 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).