Canadian Medical Association Journal 1996; 154: 1847-1853
All authors were members of the organizing committee for the Interchange `95 workshop, held in Ottawa Feb. 27 to Mar. 1, 1995.
© 1996 Canadian Medical Association and Minister of National Health and Welfare
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Résumé
Même s'il a été démontré que le dépistage du cancer du col aide à réduire la morbidité et la mortalité causées par cette maladie, et en dépit de nombreux efforts afin d'encourager l'élaboration de programmes provinciaux, aucune province n'avait de programme complet de dépistage du cancer du col en 1995. Les participants à l'atelier Interchange `95 qui a eu lieu à Ottawa en novembre 1995 ont passé en revue les recommandations de l'atelier national tenu en 1989 sur le dépistage du cancer du col et défini les facteurs qui ont nui à leur mise en oeuvre. Les participants ont discuté du besoin de systèmes d'information complets, de contrôle de la qualité et de stratégies afin de recruter davantage de femmes non examinées ou examinées insuffisamment. Ils ont conclu que la création d'un réseau de prévention du cancer du col réunissant des intervenants clés facilitera l'élaboration et la mise
en oeuvre de programmes provinciaux afin d'assurer un dépistage optimal. Ils ont convenu qu'entre-temps, les recommandations destinées aux médecins actifs devraient demeurer les mêmes qu'à la suite de l'atelier de 1989.
In the Health Promotion Survey of 1990 the number of women aged 25 to 44 years who reported that they had never had a Papanicolaou test was double that in the 1985 survey; in the 1990 survey 27% of respondents over 65 years of age reported that they had never been screened.[2] In a study of invasive cancer of the cervix conducted in British Columbia,[3] almost half of newly diagnosed cases fell into the category of "no cytology or cytology longer than 5 years ago." Native women, recent immigrants and women over 60 were disproportionately represented in these statistics, and it was felt by the authors that special efforts were needed to recruit these groups for screening. In a review of the cervical cytology screening history of women in Prince Edward Island diagnosed with squamous cell carcinoma of the cervix, 57% of the study sample had no previous record of screening; 39% of those under 60 years of age and 86% of those over 60 had no record of screening.[4] An analysis of data from the Ontario Health Survey found that factors associated with low utilization of cervical cancer screening were recent immigration, low level of education and not having English or French as a mother tongue.[5] These studies suggest that there are still opportunities to reduce the occurrence of invasive cervical cancer in Canada by targeting those groups least likely to present for screening.
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History of cervical screening
in Canada
As early as 1973 the Conference of Deputy Ministers of Health was exploring the need for comprehensive screening programs for cervical cancer. The resulting Walton Task Force recommended in its 1976 report that health authorities support the development of cervical cancer screening programs and that all women be encouraged to participate.[6] Further recommendations pertained to quality control and efficiency in cytology laboratories, frequency of screening, follow-up mechanisms (including provincial registries) and uniformity of terminology.[6] The primary effect of the report was to stimulate an assessment of current patterns of practice. However, a survey conducted in 1980 to assess the impact of the task force concluded that, by and large, its recommendations were not being implemented at the provincial level.[7] This finding, together with concerns about the significance of new data, changing sociosexual patterns and wide variation in the implementation of the 1976 recommendations,[8] prompted the reconvening of the task force in 1980. Subsequent recommendations, made in 1982, dealt with frequency of screening, laboratory quality control and mechanisms for follow-up. Measures to improve the quality and sensitivity of screening programs, to recruit women never screened and to develop government-sponsored registries were seen as essential components of an effective system and as potentially more effective than attempts to increase the frequency of screening.
On Nov. 27 to 29, 1989, a National Workshop on Screening for Cancer of the Cervix was held in Ottawa to review the 1982 recommendations and propose an integrated screening program within Canada's health care system. The workshop participants recognized that programs in Canada were still not fully effective: not all women at risk were being screened; some physicians had not acquired the necessary skill to obtain satisfactory smears; some laboratories were too small to provide adequate experience for staff and adequate quality control; and some women with detected cytologic abnormalities were receiving inadequate follow-up and management.[9] Conversely, some women were being screened too frequently, resulting in an inappropriate use of resources. Table 1 lists the 27 recommendations made at the workshop; these addressed concerns related to the need for an organized approach, the frequency of screening, the management of abnormalities, information systems, and training and quality-control requirements for laboratories and programs.
The Society of Obstetricians and Gynaecologists of Canada, the Gynaecologic Oncologists of Canada and the Society of Canadian Colposcopists supported the development of formal screening programs and recognized the need for the 1989 recommendations to be considered as a whole and not be implemented in part until such time as comprehensive programs existed in each province. These groups argued that the recommendation that a 3-year screening interval is adequate for women who obtain normal results for two consecutive annual tests was premature in view of the inability of existing systems to ensure that women were recalled at the appropriate time. They also questioned the recommendation that repeat smears be taken without colposcopy for women with low-grade squamous intraepithelial neoplasia, and suggested that, until adequate patient information systems and high-quality laboratory services were in place, annual screening of sexually active women should continue to be standard practice.[10]
In response to renewed concern about the prevalence of cervical cancer among Canadian women, the Interchange `95 workshop was held in Ottawa on Feb. 27 to Mar. 1, 1995, to determine whether the recommendations made in 1989 were still relevant and, if so, to identify the barriers to their implementation and develop an approach through which information and expertise could be shared at the provincial, territorial and national level. The workshop focused on three specific but interrelated components of a comprehensive cervical cancer screening program: information systems, quality improvement and recruitment. Provincial and territorial representatives involved in cervical cancer screening on a clinical or programmatic level were invited to attend the workshop along with policymakers from the provincial and federal governments and other relevant national organizations.
Although the participants at Interchange `95 reaffirmed and validated most of the recommendations of the 1989 workshop, concerns were raised that the recommendations on quality control related only to cytology. It was also felt that the recommendations needed to be updated, particularly with respect to community involvement in policy and program development and to quality improvement processes; it was felt that the latter should incorporate guidelines for smear taking and follow-up of women with abnormal smears, as well as for cytology (to incorporate automated technology), and should reflect new educational approaches. Participants also reiterated the view that the recommendations should be considered as a complete package and deplored the tendency for programs and individual physicians to adopt single recommendations in the absence of appropriate information systems and quality-improvement processes.
Notwithstanding their support for the spirit of the 1989 recommendations, participants identified some major challenges. They noted that although the evidence to support screening programs has existed for over 20 years, little or no progress had been made in terms of program implementation in many provinces. The earliest provincial screening program for the detection of preinvasive cervical cancer in Canada was started in 1949 in British Columbia; today this program incorporates a central laboratory as well as a colposcopy program for the management of preinvasive lesions. In 1991 an organized, accountable provincial screening program was introduced in Nova Scotia in response to the recommendations of the three national task force reports.[11] In recent years, the other provinces and territories have been addressing the issue of cervical cancer control and are at various stages of developing some or all components of an organized program. However, a model of a fully implemented comprehensive organized provincial screening program does not yet exist.
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Components of an organized screening program
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Current provincial activities
In the two provinces with the most advanced programs, British Columbia and Nova Scotia, efforts are being focused on the improvement of information systems to facilitate recruitment and recall as well as on the
enhancement of quality-assurance programs. Both provinces will focus on infrequently screened women, British Columbia giving priority to older women. The Nova Scotia program has a colposcopy database and has cytology, histopathology and colposcopy guidelines in place; linkage between the cytology registry and the colposcopy database is being developed. Both provinces recognize the value added to their programs when reliable information is made available to epidemiologists and other researchers.
To give an example of the value of good information systems, the British Columbia program was able to change the recommended frequency for routine smears from 1 year to 2 years as a result of analysis of their data and the ability to recall women with normal results; the Nova Scotia program intends to review its screening interval when sufficient experience with their system has been acquired. Continuing analysis of information from these databases will allow decisions to be made with respect to the screening interval on the basis of actual experience.
In Ontario a Cervical Cancer Ad Hoc Working Group was formed in October 1993 with representation from the Ontario Medical Association, the Ontario Association of Medical Laboratories and the Ontario Cancer Treatment and Research Foundation to consider ways to improve the present system of cervical screening. The group identified four elements that must be in place before a cervical screening program can be implemented in Ontario: a linkage group of researchers, professional organizations, service providers, funding sources, users and their support groups; a cervical screening information system to integrate patient information and identify women who are infrequently or never screened; continuous quality improvement for all aspects of the program; and a review of existing guidelines regarding the age of women to be screened and the frequency of screening.
Alberta, Saskatchewan, Manitoba, New Brunswick, Prince Edward Island and Newfoundland are at different stages in the development of a collaborative approach to designing and implementing comprehensive screening programs. All have the support of their respective departments of health but differ in the involvement of partners and in the commitment of funding. In some provinces cytology laboratories are being amalgamated to meet the guidelines of the Canadian Society of Cytology for workload and training; in others, laboratories are collaborating on the development of standardized guidelines for cytologic reporting. Most provinces acknowledge the need for information systems. A committee of the Manitoba Cancer Foundation has been convened and, as well as undertaking other activities, will be addressing the issue of public education to increase the participation of women, particularly native women, older women and prostitutes, in cervical cancer screening. Quebec is addressing the issue of breast cancer first in its overall cancer control activities and will address cervical cancer in the near future. In the Northwest Territories most cervical smears are taken by nurse practitioners and are processed, under contract, by the British Columbia Cancer Agency; in the larger urban areas smears are taken by medical practitioners. Guidelines and follow-up procedures are those of the British Columbia Cancer Agency.
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Population health and the role
of the federal government
Health care in Canada is facing a period of reform, and the health care system of the future will likely be grounded in a population health approach. This requires that health care strategies address the entire range of individual and collective factors that determine health and are designed to benefit whole groups or populations of people. In contrast to the population-health approach, traditional health care focuses on risks and clinical factors related to particular diseases and deals with patients on a one-to-one basis, usually after they already have or are at high risk of having a health problem. To be most effective in reducing morbidity and mortality from cervical cancer, both population health and traditional health care approaches are relevant; collaboration, including the active support of the consumer, is the key to success.
The Interchange `95 workshop concluded with suggestions that the federal government continue to encourage and facilitate information exchange between the provinces and to provide some direction and leadership in the area of standards and quality of care. To build on the momentum of current activities in the provinces and of the workshop itself, all provinces and territories were invited to participate in the Cervical Cancer Prevention Network, an informal association of provincial and federal representatives with the relevant clinical professional bodies. Among the clinician groups represented are the College of Family Physicians of Canada, the Canadian Society of Cytology, the Society of Obstetricians and Gynaecologists of Canada, the Gynaecologic Oncologists of Canada and the Society of Canadian Colposcopists; in recognition that nurses play an important role in Papanicolaou testing in some parts of the country, representation from the Canadian Nurses Association will be sought. The network will continue to share information on program development, organization and data at the provincial and national levels as one of the intended outcomes of Interchange `95. Three working groups have been struck to address the issues of information systems, an integrated approach to quality management and the development of recruitment strategies; a coordinating committee will oversee the activities of the working groups and ensure that duplication of effort does not occur. The challenge for the network is to overcome the barriers to the implemention of the 1989 recommendations and for the provinces to emerge with comprehensive, organized programs that use the technologic innovation and advances in knowledge that have occurred since 1989.
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The international scene
Canada is not alone in revisiting the issue of cervical cancer screening at this time; many industrialized countries are reviewing the effectiveness of their cervical cancer screening activities and have recognized the need for organized programs. In 1991 all health ministers in Australia agreed to adopt an organized approach to cervical cancer prevention, as recommended by the Cervical Cancer Screening Evaluation Steering Committee, with the aim of making screening more effective, equitable and cost effective.[13] Under the Europe Against Cancer program, guidelines for quality assurance have been developed with the aim of improving the quality of cervical screening in the European Community.[14] In the United Kingdom, the National Health Service Cervical Screening Programme was developed in recognition of the piecemeal expansion of cervical cancer screening since the 1960s and has succeeded in achieving 83% coverage in the first 5 years of its existence.[15] In the United States the Public Health Service established a National Breast and Cervical Cancer Screening Early Detection Program to bring breast and cervical screening services to underserved women, particularly women with low incomes, those from ethnic minorities and older women.[16]
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Recommendations for current practice
Physicians have an important role in encouraging their patients to have a Papanicolaou test; having a regular source of medical care and a physician's recommendation to undergo screening has been shown to be strongly associated with having the test.[17,18] Until organized screening programs are established in each province the 1989 recommendations for age to commence screening and for screening interval still hold. As suggested by the Society of Obstetricians and Gynaecologists of Canada, the Gynaecologic Oncologists of Canada and the Society of Canadian Colposcopists, annual screening of sexually active women should remain the standard of practice until patient information systems and high-quality laboratory services are in place. The presence of these two elements in British Columbia's screening program has allowed that province to recommend biennial testing.
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The future
Interchange `95 provided a catalyst for the enhancement or development of comprehensive cervical cancer screening programs in the provinces and territories. It is hoped that the Cervical Cancer Prevention Network will continue to facilitate this process and thereby help to reduce the occurrence of this preventable disease among Canadian women. The commitment of all health care professionals involved in the prevention and treatment of cervical cancer is vital if we are to move forward. The initial impetus for the development of screening programs was provided by the Walton report in 1976; the participants at Interchange `95 stated that they would like to continue to share information that will further the prevention and control of cervical cancer. The Cervical Cancer Prevention Network will continue the drive toward organized and comprehensive screening programs in Canada.
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References