6 7
Cad. Saúde Púb lic a, Rio d e Jane iro , 14(Sup. 3):67-75, 1998 A RTIGO A RT I C L E
P roposal t o instit ut ionalize criteria
and quality standards for cervical cancer
s c reening within a health care system
P ro p o sta d e re g ulame ntaç ão d e c rité rio s
e p ad rõ e s d e q ualid ade p ara rastre ame nto
d e c ânc e r d e c o lo ute rino e m um siste ma
d e ate nç ão à saúd e
1 Unidad de In ve s t i g a c i ó n Epidemiológica y en Se rv i c i o s de S alud, Ce n t ro Médico Nacional Siglo XXI, In s t i t u t o Mexicano del Se g u ro Social. Av. Cuahutemoc 330, Un i d a d de Congresos Bloque B, 4op i s o, M é x i c o, D. F. C . P. 0 6 7 2 0 ,M é x i c o. 2 Ce n t ro de In ve s t i g a c i o n e s en Salud Po b l a c i o n a l , Instituto Nacional de Salud Pública. Av. Un i versidad 655, C o l . St a . Ma . Ah u a c a t i t l á n . C . P. 6 2 5 0 8 . Cu e r n a va c a , Mo re l o s ,M é x i c o. 3 Je f a t u ra de En s e ñ a n z a , Delegación Mo re l o s , Ce n t ro Médico Na c i o n a l Siglo XXI, Instituto Mex i c a n o del Se g u ro Social.
Av. Cuahutemoc 330, Unidad de Congresos Bloque B, 4op i s o, M é x i c o, D. F. 0 6 7 2 0 ,M é x i c o.
Jorge Salmerón-Ca s t ro 1
Ed u a rdo César La zcano Ponce 2
R i c a rdo Pérez Cu e vas 1
Iliana del Río Gómez 2
Irene To r res Torija 3
Mauricio Hernández Avila 2
Abstract The uterine cervix is the most common cancer site for females. Ap p roximately 52,000 n ew cases occur annually in Latin Am e r i c a , thus the need to improve efficiency and effective n e s s of Ce rvical Cancer Screening Pro g rams (CCSP) is mandatory to decrease the unnecessary suffer-ing women must bear. This paper is addresssuffer-ing essential issues to re vamp the CCSP as pro p o s e d by the Mexican official norm. A general fra m ew o rk for institutionaling CCSP is outlined. Fu r-t h e r m o re , s r-t rar-tegies r-to sr-trengr-then CCSP performance r-through managerial sr-trar-tegies and qualir-ty a s s u rance activities are described. The focus is on the following activities: 1) improving cove ra g e ; 2) implementing smear-taking quality contro l ; 3) improving quality in interpretation of Pa p t e s t ; 4) guaranteeing treatment for women for whom abnormalities are detected; 5) improv i n g f o l l ow - u p ; 6) development of quality control measures and 7) development of monitoring and epidemiological surveillance information systems. Changes within the screening on cerv i c a l cancer may be advocated as new technologies present themselves and shortcomings in the ex i s t-ing pro g ram appear. It is crucial that these changes should be measured through careful eva l u a-tion in order to tally up potential benefits.
Key words Ce rvix Ne o p l a s m s ; Di a g n o s i s ; Pa p i l l o m a v i r u s ; Quality Contro l
Resumo O colo uterino é a localização tumoral mais importante em mulheres na América La t i-n a , o c o r rei-ndo aproximadamei-nte 52 mil i-novos casos ai-nualmei-nte i-na re g i ã o. As s i m , a i-necessidade de melhorar a eficiência e efetividade dos pro g ramas de ra s t reamento de câncer de colo uterino ( P RCC) é fundamental para que ocorra o decréscimo do sofrimento desnecessário ex p e r i m e n t a-do por essas mulhere s . Este trabalho aborda questões essenciais para revitalizar o PRC C , tal co-mo proposto pela regulamentação oficial no México. Um marco teórico para institucionalização do PRCC é delineado, seguindo-se a apresentação de estra t é g i a s , visando fortalecer seu desempe-nho por meio de medidas organizacionais capazes de assegurar a qualidade da assistência pre s-t a d a . O s-trabalho focaliza as as-tividades seguins-tes: 1) melhora da cobers-t u ra ; 2) implemens-tação no c o n t role de qualidade da obtenção de amostras para ex a m e ; 3) melhoria na qualidade de inter-p retação do exame de Pa inter-p a n i c o l a u ; 4) garantia de tratamento na inter-presença de anomalias detec-t a d a s ; 5) melhoria do seguimendetec-to; 6) desenvolvimendetec-to de medidas de condetec-trole da qualidade e 7) d e s e n volvimento de sistemas de monitoramento e de informação em vigilância epidemiológica.
Cad. Saúde Púb lica , Rio de Jane iro , 14(Sup . 3):67-75, 1998 I n t ro d u c t i o n
New measures have been taken in Mexico to i m p rove the effectiveness of the National Ce r-vical Cancer Screening Pro g ram (CCSP), as stated in the recently updated Official Me x i c a n No rm for Detection, Diagnosis and Tre a t m e n t of Ce rvical Cancer (Se c retaría de Salud, 1997). Fo l l owing this initiative, the different Me x i c a n health care systems, particularly public and so-cial security health care systems have been w o rking to re o rg a n i ze their institutional CC S P policies holding close to the revised new offi-cial norm. This trend has fueled the process of planning and re s t ru c t u ring specific facilities to run the pro g ram in the most efficient way.
The Mexican Social Se c u rity In s t i t u t e (IMSS), which is the biggest health care tion in Me x i c o, has been re o rd e ring its institu-tional pro g ram. This does not mean to design a p ro g ram with new objectives or specific goals but to re o rg a n i ze activities and optimally re d i s-t ribus-te available re s o u rc e s. The uls-timas-te goal is to run a high quality cervical cancer- s c re e n i n g p ro g ram. To achieve this goal, seve ral field tri-als have been developed. An example of this e ff o rt is an ongoing CCSP field trial, which is taking place in the Mexican State of Mo re l o s ( Sa l m e r ó n - Ca s t ro et al., 1997). This study is c a refully evaluating concrete altern a t i ves to g u a rantee the pro g ra m’s efficiency, and to d e m o n s t rate the feasibility of the working pro-c e d u res established in the new Offipro-cial No rm . In addition, this study is evaluating different al-t e rn a al-t i ves al-to improve al-the pro g ram al-thro u g h p romoting quality assurance stra t e g i e s.
Quality assurance aims to maintain mini-mum standards while encouraging the contin-ued striving for exc e l l e n c e. To establish a quali-ty assurance system within a CC S P, it is essen-tial to clearly set a series of cri t e ria and quality s t a n d a rds for eve ry step invo l ved in the pro-g ram. The process of quality assurance must e n s u re that quality systems are in place and a set of standards is met (He r b e rt, 1995a; Sa l m e-r ó n - Ca s t e-ro et al., 1 9 9 6 ) .
Taking advantage of the cervical scre e n i n g i n t e rnational recommendations and accord i n g to the pre l i m i n a ry experience gained at the IMSS field trial, our aim is to propose a set of s t a n d a rds and to outline an ove rall quality f ra m e w o rk. Within a general administra t i ve or-ganization of a health care system, it is possi-ble to institutionalize a set of CCSP standard s. In this paper, we are proposing a set of stra t e-gies and techniques to strengthen, maintain, and monitor achievements of the CC S P. T h e underlying assumptions are that these
stan-d a rstan-ds can be fulfillestan-d by any CCSP run by an o rg a n i zed health care system.
General framework for instit utionalizing CCSP
Co n s i d e ring the suggestions and managing recommendations stated by international con-sensus among countries with we l l - e s t a b l i s h e d CCSP (Coleman et al., 1993; Sa l m e r ó n - Ca s t ro et al., 1997; Pa rkin & Mo s s, 1998), initiative launched by the Mexican Gove rnment thro u g h the official norm (Se c retaría de Salud, 1997), it is ruling out seve ral stra t e g i e s. At first, the aim is to facilitate a close cervical cancer epidemio-logical surveillance and to ease the long term m o n i t o ring of the CCSP activities. The national p ro g ram recommends to subdivide or decen-t ra l i ze decen-the opera decen-t i ve organizadecen-tion in regions or well-defined catchment areas within the are a of influence of each health care institution. These regions should pre f e rentially cover no m o re than 250,000 women at risk for optimal a d m i n i s t ra t i ve efficiency (Laara et al., 1987).
Each region should count with a compre-h e n s i ve register tcompre-he target population tcompre-hat should include all women with active sexual life or aged 25-65 ye a r s. This register should al-so provide data on geographical and age distri-bution for monitoring the regional CCSP im-pact (He r b e rt, 1995b).
As the updated Official No rm establishes, e ve ry health care center within each catch-ment area, must have a strictly re s e rved are a for cervical smear taking. Mo re ove r, each re-gion must rely on a single Cytology Re a d i n g Center as part of a pathology labora t o ry, as we l l as a Co l p o s c o py Center to attend women with a b n o rmal Pap smear results (Sa l m e r ó n - Ca s t ro et al., 1997; Se c retaría de Salud, 1997).
S c reening re c ruit ment and coverage
To effectively decrease the incidence of inva-s i ve cervical cancer, all women aged 25-65 years must be examined at least once eve ry t h ree years and the pro g ra m’s ove rall cove ra g e should be over 85% of the target population ( He r b e rt, 1995b).
ade-Cad . Saúde Púb lic a, Rio de Jane iro , 14(Sup. 3):67-75, 1998 quate information about screening pro c e d u re s
to the target population. Health care prov i d e r s should promote and stimulate the pro g ra m’s utilization by means of individual counseling and community health promotion activities. Specific strategies should exist to encoura g e family physicians to improve re c ruitment, such as training courses, use of special guidelines for cervical screening, as well as clinical re c o rd s labeling as a way of reminding the clinicians about CCSP re c ruitment (He r b e rt, 1995b; Sa l-m e r ó n - Ca s t ro et al., 1997).
Ap a rt from the medical re f e r ral effort s, campaigns to sensitize the population must ex-ist on a regular bases to increase the aware n e s s among the target population about the bene-fits of participating in cervical cancer scre e n-ing activities. Altern a t i ves addressed directly to potential users must be established such as p romotional posters, seminars and mass me-dia communications. To increase compliance, the population should gain a basic under-standing of the nature of cervical cancer, the aim of screening, where it is ava i l a b l e, how the p ro c e d u re is perf o rmed, what is the meaning of results and the potential treatment altern a-t i ve s. Communia-ty para-ticipaa-tion in ru ral are a s in all phases of the pro g ram is essential in gen-e rating community accgen-eptancgen-e (Dignan gen-et al., 1996; Hodge et al., 1996; Matsunaga et al., 1996; Me g e vand et al., 1996). Implementing selective dissemination of information about the cerv i-cal cancer screening pro g ram in different con-texts (ru ral, urban, suburban and border are a s ) may be needed. Altern a t i ve strategies for re-c ruiting re-can be used for spere-cifire-cally targ e t i n g women with persistent non-responses to re g u-lar re p o rting pro c e d u re s, such as personally a d d ressed mailed invitations (Coleman et al., 1993; Crombie et al., 1994; He r b e rt, 1995b), or home visitations by social work e r s.
For a long time, Pap smear testing has been c o n s i d e red the gold standard pro c e d u re for c e rvical cancer screening. Howe ve r, during the last few ye a r s, sensitive pro c e d u res for cerv i c a l cancer screening have been tested. Fu rt h e r-m o re, acceptable pro c e d u res for sar-mple col-lection other than the pelvic examination, which is re q u i red for Pap smears have been un-der scru t i n y.
The well-documented role of HPV infec-tion in cervical cancer causality has give n new insights on the development of better technologies for improving sensitivity on cer-vical screening pro c e d u re s. HPV testing has gained increased attention as an altern a t i ve or as an adjunct for identifying pre - i n va s i ve and inva s i ve cancer. A careful evaluation of
C E RVICAL CANCER 6 9
these new technologies should provide highly valuable information to improve the CSP ef-f e c t i ve n e s s.
Q uality control of cervical smear t aking centers
Each medical unit must count on we l l - t ra i n e d personnel in charge of smear taking. T h e s e personnel should be responsible for Pap smear sample collection and gathering general infor-mation for re g i s t ration purposes. Smear takers must periodically complete training curses to g u a rantee the quality of these pro c e d u re s. St a n d a rd i zed protocols for cervical sampling, slides pre p a ration, material identification and safety tra n s p o rtation should be further deve l-o p e d .
A permanent and systematic quality eva l u-ation of Pap smear sample collection pro c e-d u res must exist. Pe rioe-dic re p o rts (pre f e ra b l e monthly) of smear quality should be issued by the Cytology Ce n t e r; these re p o rts must in-clude information on indicators of tra n s f o rm a-tion zone sampling and sample condia-tions ( Lu n d b e rg, 1989; Chu et al., 1991). This infor-mation should help to identify centers with high rates of low quality smears, as well as per-sonnel responsible for these deviations. In this w a y, it would be possible to address tra i n i n g p ro c e d u res and quality assurance strategies to be ove rcome through a problem-solving ap-p roach to the deficiencies.
Table 1 is showing the main objectives and quality standards re g a rding Pap smear- c o l l e c-tion. Ab n o rmal or unsatisfactory smears can occur in the presence of inva s i ve carc i n o m a ; t h u s, a clinical suspicion of inva s i ve cancer should ove r rule a regular cytological re p o rt . Patients with these findings should be re f e r re d d i rectly to the Co l p o s c o py Ce n t e r.
Q ualit y cont rol of cytology-reading c e n t e r
The Cytology Reading Center must concentra t e all smears from the catchment area. In order to g u a rantee that technicians could be exposed to a reasonable amount of abnormal smears. T h e center should read 35,000 samples annually as a minimum and each technician should re a d 40 to 60 smears a day.
C ad. Saúde Púb lica , Rio de Jane iro , 14(Sup. 3):67-75, 1998
addition, periodic training courses should be p rovided to update and increase diagnosis ac-c u ra ac-c y.
Ac c o rding to well-defined Pap smears ex-amination pro c e d u res a cytological diagnosis should be stated following internationally ac-cepted classification. Table 2 is showing two commonly used diagnosis cri t e ria. In t e rn a l quality control pro c e d u re s, including intero b-s e rver agreement, falb-se pob-sitive and falb-se nega-t i ve ra nega-t e s, should be assessed on a re g u l a r bases: a technician’s double reading and per-manent reexamination of all positive smears and part of negatives should be perf o rmed by a responsible pathologist. The Center must count on an external quality control of smear readings through routine assessment of accu-racy diagnose perf o rmance by means of
peri-odic external evaluation. The set of cri t e ria and s t a n d a rds that we propose for quality contro l of the Cytology Center are presented in Table 3. All abnormal smears should be kept in the l a b o ra t o ry as re f e rence material for teaching and training purposes, as well as 2-5 % of nor-mal smears for long term cytological diagno-sis quality control pro c e d u re s. Ca r rying out a d o uble screening pro c e d u re is desirable to im-p rove quality control systems and scre e n i n g a c c u ra c y. Automated reading equipment c o u l d be used (e.g. PAPNET or Ne o Path) for conve n-tional Pap smear samples or special monolay-er p re p a rations to facilitate electronic image analysis (Wied, 1993; Bi rdsong, 1996).
If CCSP we re using cytomorphological cri-t e ria, icri-t could be more effeccri-tive if cri-the scre e n i n g we re to include objective individual risk factors
Tab le 1
Pap sme ars’ c o lle c tio n q uality assuranc e activitie s.
O b j e c t i v e P ro c e d u re Ta rg e t s
Wa rrant the q uality o f Training c o urse s 100% o f sme ar take rs must cre d it the sample training c o urse s e ve ry ye ar
Ke e p ing and im pro ving skills Ke e p a minimal o f sme ars take n > 8 daily sme ars b y e ac h sme ar take r e v e ry d ay
O p timal co nd itio ns o f sam ple s S u p e rvisio n and mo nito ring o f the 100 % p re se nce o f e nd o ce rv i c a l q uality o f the samp le s o r me tap lastic c e lls
Assuring transfo rm a t i o n Maintaining sme ar c o nd itio ns
Zo ne samp ling Co unting fo r e xc e ssive b lo o d c e lls < 20 (le uko c yte s o r e ry t h ro c y t e s )
b adly d istrib ute d < 3% b adly fixe d < 3%
Use rs’ satisfactio n and pe rce p tio n Ro utine use rs’ inte rv i e w i n g 95% satisfie d with care ab o ut q uality o f c are
Tab le 2
Classific atio n o f c yto lo g ical d iag no sis.
N IC (W HO ) B E T H E S D A
N o rm a l N o rm a l
C o n d i l o m a Atypic al g landular ce lls o f und e te rmine d sig nificanc e (AGUS) NIC I Atypic al sq uamo us c e lls o f und e te rmine d sig nificanc e (ASC US) NIC II Lo w-g rad e sq uamo us intrae p ithe lial le sio n (LG SIL)
NIC III Hig h-g rad e sq uamo us intrae pithe lial le sio n (HG SIL) M i c ro invasive CA A d e n o c a rc i n o m a
C E RVICAL CANCER 7 1
Cad . Saúd e Púb lic a, Rio de Jane iro , 14(Sup. 3):67-75, 1998 for women with normal cytology, such as a test
for high risk of HPV. Previous re p o rts support the view that the interval between successive smears in CC screening can be increased con-s i d e rably for women with cytomorphologically n o rmal and high-risk HPV- n e g a t i ve cerv i c a l smears (Schneider, 1996). Be f o re screening for high risk HPVs can be generally re c o m m e n d e d , H P V-testing has to be carefully evaluated in l a rge epidemiological studies (Schneider & Zahm, 1996).
Follow-up pro c e d u re s
Ever catchment area must have a set of specif-ic p ro c e d u res to ensure follow-up of women with Pap abnorm a l i t i e s. A general guideline for these pro c e d u res could be as follow s :
1) All women must be informed about their re s u l t s, within 3-4 weeks after the Pap smear collection. The health providers in charge of sample collection at Pap smear-taking centers should mainly perf o rm this. In addition, family physicians must have these results at the same time to give additional information to the pa-t i e n pa-t s.
2) Women with Pap smear abnorm a l i t i e s (atypical squamous cells of undetermined sig-nificance (ASCUS); atypical glandular cells of u n d e t e rmined significance (AGUS); low - g ra d e squamous intraepithelial lesions (LGSIL); high-grade squamous intraepithelial lesions ( H G S I L ) ; and inva s i ve cancer, must be re f e r red to the
Re-gional Co l p o s c o py Center for further eva l u a-tion (Fi g u re 1). W h e n e ver it is possible, with a p re-scheduled appointment specifying date and hour.
3) If after six weeks of Pap smear collec-tion, any woman with an abnormal Pap smear who has not been scheduled for colposcopy would re c e i ve a mandatory communique f ro m the Social Wo rker De p a rtment by telephone, t e l e g ram or home visit. The aim is to inform them about the need of attending the Co l-p o s c o l-py Center for final diagnosis and/or re-c e i ve appro p riate tre a t m e n t .
4) Women who have re c e i ved their (posi-t i ve) resul(posi-ts bu(posi-t have no(posi-t a(posi-t(posi-tended Co l p o s c o py Clinics (within 6 weeks) have to be contacted and encouraged by the Social Wo rker De p a rt-ment to attend, and a new appointrt-ment date should be offere d .
Q uality control for colposcopy centers
Management of patients with abnormal smear results will depend on the degree of abnorm a l-i t y. A general gul-idell-ine proposal to manage a n d f o l l ow-up women with abnormal Pap smears is p resented in Fi g u re 2.
The colposcopy pro c e d u res must be re p o rt-ed in specially designrt-ed re s u l t s - re p o rting for-m a t s. These re p o rts should contain the infor-mation on colposcopy findings, treatment pro-vided, and the follow-up re c o m m e n d a t i o n s m a d e. At the end of the diagnose and tre a
t-Tab le 3
Crite ria and stand ard s o f q uality c o ntro l fo r the re g io nal c yto lo g y ce nte r.
O b j e c t i v e P ro c e d u re Ta rg e t s
Wa rrant the p ro d uc tivity and Use d / che cke d fo r the annual sme ars’ re a d i n g s re e ning b y:
1) Ce nte r < 3 5000 sme ars a ye ar 2) Te c h n i c i a n s > 40 sme ars/ d ay/ te c hnician
Wa rrante e o f the q uality Se nsib ility o f the initial re ad ing in > 8 5% cyto lo g ic al d iag no sis re g a rd to the final re p o rt afte r a
fast c he c k
C o n f i rmatio n c ito lo g y d iag no sis Re -e xaminatio n b y a cyto p atho lo g ist 1 to 5 % o f no rmal and all p o sitive s m e a r s
Time line fo r re sults re p o rt i n g Wo m e n who re ce ive the ir re sults > 85% within fo ur we e ks afte r scre e n i n g
Cad. Saúde Púb lica , Rio de Jane iro , 14(Sup . 3):67-75, 1998
N o rm a l
No t o the r d ata
N e w sme ar in 3 ye ars
A b n o rm a l
I n f l a m a t o ry ( i n f e c t i o u s )
v
v
I n a d e q u a t e
P a p
Spe c ific tre a t m e n t fam. p hysician
Re p e at sm e ar s a m p l i n g
C o l p o s c o p y c e nte r re f e re n c e
•HPV Infe c tio n
•A S C U S
•A G U S
•L G S I L
•H G S I L
•I n v a s i v e - C a
v v
v
v v
F i g u re 1
R e f e rral p ro c e d u re s fo r sp e cific p ap sme ar re s u l t s .
ment pro c e d u res all patients must be inform e d about the results and re c e i ve follow-up re c o m-m e n d a t i o n s. A com-mpre h e n s i ve re p o rt of diag-nostic and/or perf o rmed therapeutic pro c e-d u res shoule-d be provie-dee-d to the patient’s fami-ly physician. This will assist the physician in giving additional information to the patient and to further comply with the thera p e u t i c p ro c e d u res that are needed. Cases re f e r red to gynecology or oncology services should be closely followed to warrantee compliance to the re q u i red therapeutic pro c e d u re s. For noni n va s noni ve cancer, combnoninnoning appro p rnoniate follow -up and outpatient thera py methods such as c ryo t h e ra py and the loop electro s u rgical exc i-sion pro c e d u re (LEEP), should be encoura g e d because of their effective n e s s, lack of side ef-f e c t s, simplicity, and low cost (Bishop et al., 1 9 9 6 ) .
A system to monitor the quality of care at the Co l p o s c o py Center must be established to e valuate the service perf o rmance in a perm a-nent way. This must be done through paire d e valuations of colposcopy diagnose, manageri-al evmanageri-aluations and by established qumanageri-ality con-t rol indicacon-tors ( Table 4). The combinacon-tion of cytology and cerv i c o g raphy can decrease the number of re c a l l s, biopsies, and unnecessary t re a t m e n t s, while reducing costs. Dow n - s t a
g-ing inva s i ve cancer by visual inspection seems a cost-effective altern a t i ve to the cytology in c o u n t ries with limited health facilities. Ot h e r methods such as laser-induced fluore s c e n c e, c o m p u t e ri zed digital imaging colposcopy or computer imaging have a potential to be used for future triaging. Howe ve r, there is insuffi-cient data available to evaluate the cost-effec-t i veness of cost-effec-these cost-effec-techniques (Cohen, 1996).
M onitoring and epidemiological s u rveillance information system
Register system
The reading centers should have computer technical personnel in charge of the re g i s t e ri n g s y s t e m s. All information should be captured in s p e c i a l i zed software to create a reliable Ep i-demiological Su rveillance Sy s t e m .
C E RVICAL CANCER 7 3
Cad. Saúd e Púb lic a, Rio d e Jane iro , 14(Sup. 3):67-75, 1998
(+ ) Marg i n s s t ro mal no t invasive
I n v a s i o n
C o l p o s c o p y B i o p s y E C L
v
(-) M arg ins m i c ro invasio n L-V space s no t invasive
Cone b iopsy and ECL
(+ ) Le sio n
All ne g ative s
v
v
F re e marg i n s no t invasive
(-) Le sio n
v
PAP e ve ry/ 6 m. fo r 2 ye ars ( c o l p o s c o p y )
v
A b n o rmal PA P
v
Co mp le te p a r i t y
v
Inc o mp le te p a r i t y
v
Co mp le te p a r i t y
v
Inc o mp le te p a r i t y
v v
D e m u rr a g e
v
Tre a t m e n t
PAP c o ntro l 6 mo nths
v
Anc ial PA P
v
C o l p o s c o p y
v
Re p e at co nizatio n o r CD L
v
2 ye ars f o l l o w - u p
v
Re p e at c o n i z a t i o n
v
C D L
v
Fo llo w-up e v e ry 6m. d uring 2 ye ars (sp e cial c ase s)
v
F i g u re 2
Po ste rio r hand ling to c o ne .
EC L = e nd o ce rvic al tre a t m e n t CD L = co nizatio n with d iathe rmic lo o p
be re c o rded in an independent re p o rt and cap-t u red. All cap-this dacap-ta will feed incap-to cap-the Mo n i cap-t o r-ing and Epidemiological Su rveillance Sy s t e m ( Mi l l e r, 1992).
Establishing an automated monitoring sys-tem will help supervise specific pro g ram pro-c e d u res and goals: pro-cove ra g e, re s u l t s - re p o rt i n g i n t e rva l s, smears quality, follow-up and tre a t-ment compliance.
With the aim of monitoring the CC S P, com-p re h e n s i ve, com-periodical re com-p o rts including nec-e s s a ry information to nec-evaluatnec-e thnec-e pro g ra m
should be generated, to assess specific pro c e-d u res ane-d its impact over the main compo-nents of the pro g ram. This will also correct de-viations and facilitate constant improve m e n t s in the pro g ram. A Special Regional Qu a l i t y Co n t rol Committee should carefully eva l u a t e this inform a t i o n .
An automated Ce rvical Cancer Ep i d e m i o-logical Su rveillance System should create ag-g reag-gated charts of reag-gional cervical cancer be-h a v i o r, occurrence of pre - i n va s i ve lesions, can-cer and mortality ra t e s, as well as the use of
v v
v v v
Cad . Saúde Púb lic a, Rio de Jane iro , 14(Sup. 3):67-75, 1998
Tab le 5
C e rvic al canc e r sc re e ning re g io nal e p id e mio lo g ical surve illanc e (o utp uts and o utco me indic ato rs).
O utput indicat ors Out come and impact indicat ors
Use o f he alth se rvic e s (e ve ry ye ar) Mo rb idity – mo rtality
a) Cyto lo g ie s Anual (inc id e nc e rate s)
b ) C o lp o sc o p y – c e ntral P re c e d ing le sio ns NIC tre atme nts (lo o p d iathe rm y, co nizatio n) In situ c anc e r
Invasive canc e r
c) Re fe rrals to o nco lo g y-g yne co lo g ical se rvic e s (hyste re c t o m y, M o rtality d ue to ce rvic al c ance r
s u rg ic al tre atme nt, rad io the rap y &/ o r q uim o the rapy Numb e r o f ave rte d c ase s o f invasive canc e r Num be r o f ave rte d d e aths
d) Be d / d ays due to ce rvic al cance r care (se co nd Q A LYs and D ALYs g aine d afte r tre a t m e n t and third le ve l)
Tab le 4
Q uality c o ntro l o f d ysp lasia ce nte r targ e t .
Qualit y control indicat ors*of dysp lasia cent er perf o rm a n c e
1) O c curre nce o f c e rvical b le e d ing afte r inte rv e n t i o n
2) O cc urre nce o f wo me n with c e rvic al e ste no sis afte r inte rv e n t i o n 3) P re se nc e o f the e sc amo co lumnar junc tio n afte r inte rv e n t i o n
4) Pe rsiste nc e o f p o sitive marg ins afte r inte rve ntio n (c ry o t h e r a p y, lo o p d iathe rm y ) 5) Pe rsiste nc e o f c e rvical ne o p lasia afte r inte rv e n t i o n
6) De te rminatio n o f the sp e c im e n’s hysto lo g y q uality 7) De te rminatio n o f the spe c ime n’s cyto lo g y q uality take n. 8) Co rre latio n stud ie s o f c yto -hysto lo g y-c o lp o sco p y.
* Indic ato rs and b e nc hmarking sho uld b e tailo re d ac c o rd ing to the c harac te ristics o f the dysp lasia ce nte r.
health services due to cervical cancer in each region. This information should allow the as-sessment of medium and long term cerv i c a l cancer behavior at regional leve l s. Available in-f o rmation oin-f pre i n va s i ve-lesions incidence as well as cervical cancer and mortality ra t e s should permit an analysis of the cost-effective-ness of the screening pro g ram: costs per life year gained or cancer free life year gained (Ra f-f l e, 1996).
Table 5 is highlighting main output and outcome indicators that could be used to mea-s u re impact and effectivenemea-smea-s of the CC S P.
C o m m e n t
C E RVICAL CANCER 7 5
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