Czech National Cancer Screening Programmes in 2010

Overview

Backgrounds:
All three cancer screening programmes recommended by the Council of the EU are available to defined target age groups in the Czech Republic. Organized programmes for screening of breast, colorectal and cervical cancer have been initiated in the last decade.

Materials and Methods:
A system for information support, as an essential component of organized screening programmes, has been implemented in all screening programmes. It comprises the Czech National Cancer Registry to monitor the cancer burden and population impact of the programmes, the National Reference Centre as a provider of nationwide insurance claims data, and the specialised databases of all three programmes, which collect information on screening, diagnostics and final diagnoses.

Results:
Early diagnostics of malignant neoplasms and progress in therapy have helped to stabilize mortality, even in diagnoses with increasing incidence. The coverage of the Czech screening programmes has constantly been rising; however, it is still insufficient: 51.2%, 17.9% and 48.4% of the target population was covered at the end of 2008 in breast, colorectal and cervical screening programmes, respectively. In 2008, a total of 468,419 women underwent screening mammography and 2,128 tumours were detected (4.5 per 1,000 screened). According to the screening colonoscopy registry, more than 13,000 men and women underwent preventive colonoscopy in 2009, 4,085 patients were diagnosed with adenoma and 619 with colorectal cancer, mostly in the early stages. The information system for cervical screening was implemented in 2009 and has been running in pilot mode; the first results are expected at the end of 2010.

Conclusion:
The system for information support within organised cancer screening programmes enables monitoring of the performance of screening and diagnostic centres and thus helps to maintain continuous quality improvements, which are a necessary presumption for replicating the promising results of clinical trials. To achieve a substantial impact on population incidence and mortality, a large increase in test coverage in target populations will be necessary. The programmes should be transformed to a population-based form, which involves inviting all people in the target population to be screened.

Key words:
cancer screening – malignant neoplasms – information system

Backgrounds

With regards to evidence from clinical and epidemiological studies, the Council of the European Union recommends cervical cancer, breast cancer and colorectal cancer screening to be offered to citizens of the European Union by its member states [1].

Breast cancer screening with mammography can decrease breast cancer mortality in target population by 25– 30% [2], as demonstrated in randomised controlled trials in the United States and Europe and in several meta analyses; the results were successfully replicated in many European programmes: Denmark [3], Finland [4], Iceland [5], Italy [6], the Netherlands [7], Spain [8], Sweden [9,10] and United Kingdom [11].

Colorectal cancer (CRC) screening with annual guaiac faecal occult blood test (gFOBT) was demonstrated to decrease the CRC mortality by 33 percent in U.S. randomized trial [12]. European trials showed reduction of the CRC mortality by 15% [13] and 18% [14] with biennial gFOBT. The reduction persisted after 9 rounds and reached 43% in all rounds participants [15], emphasising importance of regular attendance by participants. Including also the unpublished results of the Göteborg trial, the mortality reduction of 16% was estimated in Cochrane systematic review [16]. Annual or biennial FOBT screening also significantly decreases CRC incidence [17]. Immunochemical faecal occult blood test (iFOBT) seems to have even better performance than gFOBT [18,19] and first promising results from randomized trials have been published [20]. Colono­scopy seems to be a powerful screening tool, with estimated decrease of CRC incidence up to 90% [21– 24]; however, direct evidence is necessary to estimate its effectiveness [25]. The low risk of CRC after colonoscopy persists for more than 10 years [26– 28], which potentially en­ables a long interval between screening examinations.

Screening for cervical cancer based on cytology was not evaluated using randomized controlled trial assessing decrease in the disease mortality and evidence was derived from cohort and case  control studies [29]. Nevertheless, these observational studies showed outstanding decrease in cervical cancer incidence by up to 80% [30]. Decrease in mortality ranging from 25– 80% was confirmed in the subsequent international study [31]. This study also confirmed that unorganized cervical cancer screening may completely fail to show the outlined benefit. Finnish case control study comparing organised and spontaneous pap  smear screening concluded that the latter is less effective, costs more and results in more harm in screened women [32].

Organization is equally important in breast and colorectal cancer screening as well. IARC Handbooks of cancer prevention [29,33] state six characteristics of organised screening programme: a policy specifying target population, screening method and interval; a defined target population; a team responsible for overseeing screening centres; a decision structure and responsibility for health care management; a quality assurance system utilizing relevant data; and a monitoring of cancer occurrence in target population.

Cancer screening programmes have been implemented in most countriesof the European Union [34]. In the Czech Republic, recommended screening modalities were offered to target population even before publication of the Council Recommendation. However, large efforts to organize the screening programmes have been undertaken just recently and led to complete offer of screening modalities, as recommended by the Council, and proper monitoring of the screening process (Tab. 1, Fig. 1– 3).

This article summarizes the status and latest results of all three cancer screening programmes in the Czech Republic and outlines potential future improvement. The results are generated from unified information system, which is implemented in all screening programmes.

Material and methods

The system for information support is a vital part of organized screening programmes. Czech system for the information support facilitates effective configuration and monitoring of screening process and outcomes. Its components include monitoring of cancer epidemiology, performance monitoring of screening centres and monitoring of screening programme using administrative data (Fig. 4). The system is operated by an independent academic body –  Institute of Biostatistics and Analyses of Masaryk University in Brno, Czech Republic.

The Czech National Cancer Registry (CNCR) is an essential source of cancer burden data. Registration of cancer cases is obligatory and stipulated by the legislation; the registry therefore covers the entire population of the Czech Republic since 1976. CNCR can be combined with demographic data and with Death Records Database, provided by the Czech Statistical Office, and thus enables to estimate disease incidence and mortality, monitor distribution of clinical stages, cancer treatment, survival, etc. Information on cancer epidemiology are available on line for wide public at http:/ / www.svod.cz [35].

The system of mammodiagnostic scree-ning centres was established in 2002 [36],at the same time when the programme started. These centres regularly send data to the Breast Cancer Screening Registry. This database includes information on screening mammography, additional imaging or invasive diagnostic procedures and final diagnosis. Reporting of screening performance indicators according to European Guidelines [37] is provided to ensure high quality and efficiency of the programme.

After pilot studies on colorectal cancer screening feasibility performed in the Czech Republic both before [38] and after fall of the communist regime in 1989, organized service screening programme was initiated in 2000 [39,40] using biennial FOBT as a screening test. Starting from 2009, primary screening colono­scopy has been introduced as a screening test [41]. Therefore, persons aged over 55 years can now attend a gastroenterologist directly to obtain their colonoscopy, without need for prior positive FOBT test.

A pilot organized collection of records on screening colonoscopy examination after positive FOBT was initiated in 2007. The data collected in the Screening Colonoscopy Registry include information on macroscopic and microscopic results of colonoscopy, final diagnosis and information on adverse events during the procedure. Monitoring of screening performance was proposed in colorectal cancer screening [42]. U.S. review prioritized two performance measures in colonoscopy: caecal intubation rate and adenoma detection rate [43], which are measurable, apart from many others, in the Screening Colonoscopy Registry. Adenoma detection rate has been recently proven to directly affect interval cancer rate, and therefore programme sensitivity [44].

Pilot collection of records on screening cervical cytology was initiated in 2009 by establishing the Cervical Cancer Screening Registry (CCSR). The collected data include information on screening examination, its results and results of indicated histopathology examination. Such data should provide a basis for performance evaluation according to the European Guidelines [45].

In the Czech Republic, most of the medical procedures relevant to secondary cancer prevention are reimbursed within public health insurance. After aggregation of the data by the National Reference Centre (NRC), it is possible to use these health insurance data in monitoring of the screening programmes. The breast cancer screening programme can use the data for verification of information obtained by its own information system. Besides that, data can be extracted to credibly estimate prevalence of opportunistic screening examinations. Health insurance data contains information on all faecal occult blood tests performed. Therefore, this data source can reliably supplement individual information systems to obtain complete picture of the screening process. In a similar fashion, health insurance data can be employed in cervical cancer screening as well.

Incidence of invasive breast cancer has been rising in the Czech Republic since the early 1990s and peaked in 2003, when prevalent round of breast cancer screening occurred (Fig. 5). Breast cancer is an example of cancer diagnosis with successfully improving early detection (Fig. 6). Further improvement occurred after initiation of breast cancer screening programme. Coverage by screening mammography gradually increased in 2002– 2008 and recently exceeds 50% for two year period 2007– 2008 (Fig. 7). However, no decreasing trend is observable in breast cancer mortality, which remains stable over 1990s and 2000s (Fig. 8).

The Breast Cancer Screening Registry allows the monitoring of the screen­ing process using key performance indicators. Total of 468,419 women underwent screening examination in 2008. Breast cancer detection rate (number of breast cancer cases detected per 1,000 women screened) is an indirect indicator of mammography sensitivity. In 2008, 6.1 breast cancers were detected in 1,000 women initially screened. This number decreases in women attending their subsequent screening examination: 3.7 breast cancers were found per 1,000 screened women. Over 70% of tumours detected in the screening programme are in situ cases or invasive cases smaller than 2 cm (pT1). Further assessment rate (proportion of women undergoing additional diagnostic examination after positive result of screening test) is rather decreasing in initially and subsequently screened women, showing improving specificity of the screening test and therefore better efficiency of the programme; however, it still remains high compared to organised programmes abroad (Tab. 2).

Despite operation of the organized screening programme, the incidence and mortality of colorectal cancer has been very stable in recent years (Fig. 5, 8). Reason for the lack of effect on population cancer burden is certainly a low participation of the target population at the screening examination (Fig. 7) –  only 18% proportion of the target population was screened in 2007– 2008. Screening colonoscopy registry, however, shows very promising development in number of screening and primary screen­ing colonoscopies in the target population (Tab. 3). The number of men and women undergoing colonoscopy almost doubled in 2009 compared to previous year. Caecal intubation rate constantly increases and reaches 95.6% in 2010. During period 2006– 2010 (preliminary results), 12,822 patients were diagnosed with adenoma and 2,090 with colorectal cancer. One half of the adenoma patients were diagnosed and treated for advanced adenoma, which would have significant risk of progression to colorectal cancer if untreated. About 20% of patients with colorectal cancer are diagnosed with advanced stage III– IV disease, compared to about 50% in population cancer registry. Screening programme is therefore able to detect colorectal cancer earlier or even to prevent the disease in patients through removing high risk adenomas.

Despite the long time utilization of preventive cervical cytology examinations, incidence and mortality of cervical cancer has not been changing in the Czech Republic. Incidence rate of approximately 20 cases per 100,000 women has been observed for almost 30 years (Fig. 5). No time trend is observable in mortality rate (Fig. 8). About 50% of the woman target population attends regular annual gynaecological check  up with collection and cytological examination of cervical smear (Fig. 7). Comprehensive results from Cervical Cancer Screening Registry on performance of screening cytology will be available at the end of 2010. Thorough monitoring will hopefully help to improve screening performance with more apparent impact on cervical cancer burden.

Discussion

The Czech Republic ranks among countries with highest cancer burden in the world. Latest IARC database [46] even shows the Czech Republic to have the highest male colorectal cancer incidence worldwide. During 1990s and 2000s, the incidence of breast and colorectal cancer was constantly increasing. Apart from apparent ageing of the Czech population, this increase could be probably attributed to transition towards ‘westernized’ lifestyle, e. g. changes in reproductive behaviour (breast cancer), increased consumption of sugar, red meat or decreased physical activity (colorectal cancer) [47]. Absence of organized, population based cervical cancer screening programme precluded significant decrease in cervical cancer incidence and mortality similar to Scandinavian countries [31,48].

System for information support was developed to facilitate monitoring of performance measures, as recommended by the EU Council [1], IARC [29,33] and the European Commission in official Guidelines [37,45]. Adhering to common definitions of process measures enables comparison to guideline targets and reports published on performance of organized screening programmes abroad (e. g. [49– 51]). Similarly, the screening performance, as measured by defined indicators, is a necessary prerequisite to replicate promising results of randomized controlled trials in preventing death from cancer [52].

In addition to data based monitoring of well organized screening programmes, controlled in the network of accredited screening centres, the attendance of target population is the most important task.

To increase coverage by breast cancer screening, the pilot project for centralized invitation of non attendees was undertaken in the Czech Republic in 2007– 2008 by the General Health Insurance Company. Although the overall participation rate after invitation was rather low, this project helped the mammography coverage to exceed 50% level in 2007– 2008. The coverage improved particularly in elder age groups of women and confirmed that transformation to population based programme inviting every eligible person will be necessary to increase participation to 70% or more, as it is usual in successful programmes in western and northern Europe [49,53,54].

Women over 70 years of age were also invited during the pilot project in order to assess characteristics of screening process in this age group. High rates of detection and low further assessment rates were observed in women over 70 years of age, promising high quality and good effectiveness of performed examinations. Following progress in the Netherlands [55], where the upper age limit for invitation to breast cancer screening was set to 75 years, and in England, where women can continue to request routine mammography every three years after they reach 70 years of age, the Czech Republic has extended the upper age limit for access to screening mammography since 2010.

Not all colorectal cancer screening tests are acceptable for all men and women and it is therefore important for improving uptake to consider patients’ preference [56]. Accordingly, starting in January 2009, primary screening colonoscopy and annual FOBT were offered to the Czech target population. Improved participation could be also expected with wider use of iFOBT instead of gFOBT [57] and with involvement of gynaecologists to recruit women, starting in 2009.

Information strategy and dissemination of information on cancer risk and potential benefits of screening are equally important. As a principal source of information on breast, colorectal and cervical cancer prevention, national web portals www.mamo.cz, www.kolorektum.cz and www.cervix.cz were launched to enable communication with wide public and also health professionals offering cancer screening examinations. Combining direct invitation with mass media campaigns seems to be the most successful strategy to improve attendance in cancer screening programmes [58], celebrity promotional campaign can also help to substantially improve participation [59].

Conclusion

All three cancer screening programmes with evidence on effectiveness are available in the Czech Republic. Programmes are organized, with strictly defined screening test, interval and target population, and with nominated network of screening centres based on quality assurance. Data on screening tests and outcome diagnoses are collected in the system for information support, which thoroughly monitors the screening process and maps cancer burden and impact of the prevention. This system ensures quality comparable to clinical trials, which is necessary to achieve effectiveness observed in successful screening programmes abroad. To achieve substantial impact, significant increase in attendance is necessary. This should be facilitated by transformation to population based programmes with centralised invitation of target population, along with effective mass  media campaigns.

Acknowledgements and funding

The authors want to thank all screening centres of the organised screening programmes, Institute for Health Informatics and Statistics (administrator of the Czech National Cancer Registry) and public health insurance companies for devoted cooperation in system for information support.

This work was supported by the Grant Agency of the Czech Ministry of Health Care (grant no. 10650-3).
Práce vznikla za podpory grantu č. 10650-3 GA AV ČR MZ ČR.

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.
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The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.
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Assoc. Prof. MUDr. Ladislav Dušek, Ph.D.
Institute of Biostatistics and Analyses
Masaryk University in BrnoFaculty of Medicine and Faculty of Science
Kamenice 126/3
625 00 Brno
Czech Republic
e-mail: dusek@iba.muni.cz