Cervical Screening Program in Hong Kong

Cervical Screening Program in Hong Kong

21 November 2002

Outline

Why HK needs a cervical screening program?

How do we bring it about? What is the screening policy? What are the key elements? What are the expected benefits?

Burden of Disease (1999)

Cervical cancer is the fourth commonest cancer in women 436 new cases (4.7% of total cancers) Median age at diagnosis 54 years

Cervical cancer is the seventh leading cause of cancer deaths in women 159 deaths (3.8 % of total cancer deaths)

Trend of Age-standardised Incidence & Mortality Ratesof Cervical Cancer in Hong Kong

2018.7 18.6

16.116.8

15.7 16

14.4 13.9 13.412.7

13.5

11.3 11.2 11.6

9.8

4.6 5 5.1 4.53.8 4 3.9 4.4 3.9 4 3.6 4.1

3.1 3.3 3.2 3.5

23

5.2

2.6

0

5

10

15

20

25

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Year

No.

of n

ew c

ases

and

dea

ths p

er 1

00,0

00 st

anda

rd fe

mal

e po

pula

tion Incidence Rate

Mortality Rate

Sources: Hong Kong Cancer Registry Census and Statistics Department, HKSAR Government

International Comparison

Age-standardized Mortality Rates

0.8

1.2

1.8

1.9

2.3

2.4

2.6

2.6

2.6

2.7

2.9

2.9

4.3

4.3

0.0 1.0 2.0 3.0 4.0 5.0

Italy (1997)

Finland (1998)

The Netherlands (1999)

Australia (1998)

US-White (1995-99)

United Kingdom (1999)

Sweden (1997)

Germany (1999)

Hong Kong (2000)

Ireland (1999)

New Zealand (1998)

European Union (1997)

US-Black (1995-99)

Singapore (1998)

Rates (per 100,000 standard population)

Age-standardized Incidence Rates

3.8

6.5

6.9

7.0

7.4

8.0

8.2

8.5

8.6

9.4

9.8

12.9

14.2

19.1

0.0 5.0 10.0 15.0 20.0 25.0

Finland (1999)

The Netherlands (1997)

Italy (1997)

Australia (1998)

United Kingdom (1998)

Ireland (1997)

European Union (1997)

New Zealand (1998)

Sweden (1997)

Germany (1997)

Hong Kong (1999)

US(SEER)*-Black (1995-99)

Singapore (1993-97)

US(SEER)*-White (1995-99)

Rates (per 100,000 standard population)

Hong Kong (2000)

Hong Kong (1999)

Coverage rate

Women aged 25-49 53% had cervical smear in past 3 years (FPA, 1997)

Women aged 50-64 43% had cervical smear in lifetime (HKU, 1999)

Women aged 65+

18% had cervical smear in lifetime (HKU, 1999)

Countries with organized screening programs: coverage rate 65-85%

Current problems (1)

Opportunistic screening

Variable screening practices

Women not screened according to risk or need

Current problems (2)

Lack of an agreed set of quality management guidelines, indicators, and monitoring mechanism

Lack of central registry for cervical smears

Lack of public-private collaboration

Rationale for screening program Cervical cancer causes significant mortality and

morbidity

Cervical cancer rates are relatively high internationally

Current problems in cervical screening result in low coverage rate

An organized screening program may prevent an estimated 144-183 new cases a year (McGhee, 2002)

Policy initiative

The Policy Address pledged to launch a Cervical Screening Program for women in collaboration with other health services providers in 2003-04

Program goal

To achieve higher and more equitable screening coverage in the target population, thereby reducing incidence and mortality of cervical cancer in Hong Kong

Outline



Cervical Screening Task Force

Professional colleges

Hong Kong College of Family Physicians

Hong Kong College of Obstetrics and Gynecology

Hong Kong College of Pathologists


Professional societies Hong Kong Society for Colposcopy and

Cervical Pathology

Hong Kong Society of Cytology


Universities Chinese University of Hong Kong

Hong Kong University


Service providers

Family Planning Association Hospital Authority Private doctors and laboratories Department of Health


Community and consumer groups

Hong Kong Federation of Women

Hong Kong Cancer Fund

Three Working Groups

Working Group on Recruitment and Education

Working Group on Quality Management

Working Group on Information Systems

Consultative process

Questionnaire surveys to private doctors and laboratories

Field visits to private laboratories and major providers

Women’s focus groups

Outline


How do we bring it about? What is the screening policy? What are the key elements? What are the expected outcomes and

benefits?

Screening Policy Women aged 25-64

Triennial Pap smears after two consecutive yearly negative smears

Women aged 65 and above Two consecutive yearly negative smears, then

discontinue

Women aged below 25 Individual risk profile

Age-specific Incidence Rates for Cervical Cancer, 1983-1999

0

10

20

30

40

50

60

70

80

90

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Year

Rat

e pe

r 10

0,00

0 w

omen

15 - < 25

25 - < 35

35 - < 50

50 - < 65

65+

Age Group

Rationale for starting at 25 Extremely low incidence of cervical cancer below age

25 (only 1 in 436 new cases, 1999)

Regression of cervical dysplasia in younger women

More false positives in women aged<25

In line with international programs (18-30)

Rationale for 3-yearly screen

Very little marginal benefit for more frequently screening 1-yearly screen: 94% reduction 2-yearly screen: 93% reduction 3-yearly screen: 91% reduction

In line with HKCOG recommendation

Target coverage

Interim 60% coverage for women aged 25-64, 3

years after program launch (present estimated coverage: 45%)

Long term

On par with international best practices

Additional smears and colposcopies

If target coverage of 60% is reached, 40% more smears annually (370,000

520,000)

26-45% more colposcopies, to be shared

by public and private sector (estimated by HA)

Outline



Quality Management

Adopt guidelines and standards from local professional organizations

Hong Kong College of Obstetrics and Gynecology:

Guidelines on the management of an abnormal cervical smear

Hong Kong College of Pathologists: Basic Criteria for a Cervical Cytology Screening Laboratory

Quality Management

Adopt guidelines and standards from local professional organizations

Hong Kong Society of Cytology: Cervical

Cytology Practice Guidelines

HKSCCP and HKCOG: Colposcopy Service Provision and Standards

Examples

Both conventional and liquid-based cytology methods are acceptable

Bethesda system recommended

Quality performance indicators, e.g., Report turnaround time Proportion of ASCUS

Training and support for quality Refresher courses in smear taking

e.g., HKCPath/SPACE, CUHK

Training kit for doctors Video, manual, CD-ROM

Training of colposcopists

Requirements being developed by HKSCCP & HKCOG

Supervised on-job training Both clinical and communication skills

Recruitment of women

Prioritized into 3 groups

women aged 50-64 women aged 35-49 women aged 25-34

Specific messages will be developed for each of the 3 groups (e.g., focus group studies)

Rationale for prioritization

Emphasis should go to women who have never been screened women at higher risk of cervical cancer

Better control pace of program

Ensure services not overwhelmed

Methods of recruitment (1)

Personalized invitation letters effective from overseas experience HA Patient Master Index

Women in the 3 prioritized groups will receive invitation letters in a 3-year cycle e.g., first year 50+, second year 35-49,

third year 25-34

Methods of recruitment (2)

Reminder letters for women whose next smear is due

Mass media campaign and publicity materials

Community organizations

Outreach to promote screening

Methods of Recruitment (3)

Provider support, especially private sector Training kits on smear taking Pamphlets for clients Enquiry for smear results Reminder letters Statistical reports Website information

Cervical Screening Information System (CSIS)

Central registry of cervical smear results

Bethesda system for cytology reporting

Cytology-biopsy correlation

Data source

Laboratories performing cytological examination

Major service providers Family Planning Association Hospital Authority Large group practices Department of Health

Minimum data set

Basic items only Patient record

name, HKID, date of birth, etc.

Smear record Smear result, smear taker, date of report, etc.

Follow up record Colposcopy result, histology report, date of report,

etc.

Functions of CSIS (1)

Maintain information on screening history and results

Track utilization and issue reminders

Support quality management and monitoring

Functions of the CSIS (2)

Facilitate record linkage

Program evaluation and research

Ensure data privacy and confidentiality

Data privacy CSIS must comply with Personal Data (Privacy)

Ordinance

Ordinance allows analysis of data in aggregate form

Patient consent may be required for sending individual reminders

Focus groups to find out how women think about privacy of smear results

Outline



What differences the CSP makes (1) Explicit screening policy and target population

Consensus quality management guidelines

and standards

Personalized invitation letters and reminders

Targeted recruitment of women according to risk

What differences the CSP makes (2) Coordinated and sustained education campaigns

Greatly improved provider support and training

Evaluation of program via performance indicators

Cervical Screening Information System

Collaboration and consensus building among various

sectors, including public and private sector

Benefits to the community

Improved overall coverage of the target population not achievable by opportunistic screening

More equitable cervical screening service particularly for women at high risk / not screened before

Better quality assurance in cervical screening service provision

Public health goal achieved

Cervical cancer in Hong Kong

Thank you

Documents

Cervical Screening Program in Hong Kong