A prevention intervention

13 April 2010

Dr Philip Davies, Director General of the European Cervical Cancer Association, urges organised implementation of cancer screening programmes to reduce current healthcare inequalities in Europe

Cancer is one of the greatest public health challenges facing Europe today. Every year, 3.2 million Europeans are diagnosed with cancer, which is the second most common cause of death in Europe, accounting for 29% of deaths in men and 23% of deaths in women in 2006. Within this, cervical cancer remains an important component, with 60,000 new cases and 30,000 deaths every year. However, while these numbers are cause for concern in their own right, one of the greatest tragedies with cervical cancer is that we already have the tools available to prevent almost every case of this disease, and yet they are not readily available to all European women.

It has been clearly established that cervical cancer screening programmes can prevent up to 80% of cases of this disease. However, these substantial reductions in cervical cancer rates can only be achieved by population-based, organised screening programmes that comply with the requirements of the European Guidelines for Quality Assurance in Cervical Cancer Screening¹. In addition, we now also have two vaccines that have both been shown to be highly effective in preventing infection with two of the most common cancer causing types of the Human Papillomavirus (HPV types 16 and 18) that are responsible for the development of 7 out of 10 cervical cancers. While these vaccines still need to be used in conjunction with cervical cancer screening programmes to protect women against cancers arising from other HPV types, and to protect women who have not been vaccinated, the combination of screening with vaccination will be more effective than either on its own, and this now offers the opportunity to virtually eliminate cervical cancer in Europe. However, notwithstanding the amazing potential of these programmes that effectively combine cervical cancer screening with HPV vaccination, the situation in Europe shows a wide variation in their implementation.

For cervical cancer screening, only eight EU member states have implemented proper nationwide, population-based, organised cervical screening programmes (Denmark, Finland, Hungary, Ireland, Netherlands, Slovenia, Sweden and the United Kingdom), which together cover about 25% of EU women aged 30-60 years (the minimum age range recommended for cervical screening). Progress is being made, with new nationwide programmes being implemented in Estonia, Italy, Latvia and Poland, and some of these in the late stages of implementation. But even when these additional programmes are fully operational, they will still cover only around half of the 109 million women aged 30-60 living in the EU, with the rest left to rely on opportunistic screening or no screening at all.

Opportunistic screening is when women are screened when they go to the doctor for other reasons, usually for an annual check-up, and this can produce substantial reductions in cervical cancer rates in countries where the annual check-up is widely practised. However, even in these countries, opportunistic screening will not achieve the high levels seen with population-based, organised programmes, and it has been demonstrated to over-screen the wealthy and well educated who go regularly to the doctor, while under-screening the lower socio-economic groups and minorities who do not². As a result, opportunistic screening is less effective and efficient, wastes scarce healthcare resources³, and promotes health inequalities, none of which can be justified in 21st Century Europe.

The benefits of organised screening programmes compared to opportunistic screening have been clearly set out in the research literature⁴, and they have been recognised by the Council of Europe in its recommendation on cancer screening from 2nd December 2003 (2003/878/EC)⁵, which states that all member states should implement population-based organised screening programmes for cervical, breast and colorectal cancers. Further, the European Parliament, in its resolution of 10th April 2008 (P6_TA/2008/0121)⁶ on combating cancer in the enlarged European Union, reinforced this message by calling on all member states that have not yet done so to follow the council recommendation and set up population-based screening programmes in accordance with European Guide­lines for Quality Assurance in Cervical Cancer Screening.

The situation with HPV vaccination is also less than satisfactory. Data presented by the European Cervical Cancer Association in the European Parliament on 27th January 2010 show that HPV vaccination has so far been preferentially deployed in the Western European countries that already have population-based, organised cervical cancer screening programmes or extensive opportunistic screening, and therefore the lower cervical cancer rates. Meanwhile, the Eastern European countries with the higher cervical cancer rates have yet to move forward with the implementation of this effective tool to reduce cervical cancer risk.

Unfortunately, the differences in the implementation of cervical cancer prevention programmes across Europe are mirrored by differences in cervical cancer rates, which show a wide variation from country to country but with an increasing clear trend as you move from the EU-15 member states to the new member states and neighbouring countries to the East.

As illustrated in Fig. 1, there is a five to sixfold difference in both cervical cancer incidence, as well as mortality between countries with low rates such as Finland or Italy, and those with the highest rates such as Bulgaria, Lithuania and Romania. In practical terms, this means that a woman living in Romania where they do not have effective cervical cancer prevention has a five to six times greater risk of developing and dying from cervical cancer than a woman living in Finland, where they have a highly effective cervical cancer screening programme. As such, it is clear that the implementation of population-based, organised cervical cancer prevention programmes in the countries that currently do not have them would inevitably help to bring down their cervical cancer rates while simultaneously reducing or eliminating this obvious area of health inequality.

The EU was founded on principles of solidarity, social and economic cohesion, human rights and equality of opportunity. Health is an obvious area of disparity between the countries of Europe and these disparities have been acknowledged by the European Commission in its communication of 20th October 2009 entitled 'Solidarity on Healthcare: Reducing Health Inequalities in the EU'. This communication states: 'The health inequalities between people living in different parts of the EU and between socially advantaged and disadvant­aged EU citizens is a challenge to the EU's commitments to solidarity, social and economic cohesion, human rights and equality of opportunity. There­fore, the Commission is determined to support and complement member states and other stakeholders in their efforts to tackle them.'

In terms of cervical cancer, this statement is particularly relevant as we already know exactly what we have to do to resolve the disparity in rates across Europe, and this is to implement the population-based cervical cancer prevention programmes that we know will work. Over the past six years, since the publication of the European Council Resolution on cancer screening, we can see that progress has been made. However, much of this progress had been made during the economic boom, and the current economic crisis and the need to reduce public sector debt will inevitably slow or stop this progress, particularly in Eastern Europe, where the countries that have among the highest cervical cancer rates are also among those that have the hardest economic hit. This is therefore the perfect time for the European institutions to combine economic stimulus together with targeted funding through the structural funds and use this to support the achievement of their other stated objectives for implementing population-based cancer screening programmes and reducing health inequalities across the EU.

1 European Guidelines for Quality Assurance in Cervical Cancer Screening
2 Arblaster L, Lambert M, Entwistle V et al (1996) 'A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health', J. Health. Serv. Res. Policy. 1 (2), 93-103
3 IARC (2005) 'Cervix Cancer Screening', IARC Handbooks of Cancer Prevention, vol. 10, Lyon: IARCPress, p. 1-302
4 Ibid
5 Council of the European Union. Council recommendation of 2 December 2003 on cancer screening. Off J Eur Union 2003;878:34-8
6 www.europarl.europa.eu/sides/getDoc.do?pubRef=-//EP//TEXT+TA+P6-TA-2008-0121+0+DOC+XML+V0//EN, accessed 10th February 2010