PROJECT Situation analysis and cost-effectiveness analysis of cervical cancer screening in Russia

1. PROJECTSituation analysis and cost-effectiveness analysis of cervical cancer screening in Russia Coordinator of the project: N. Koroleva

2. PURPOSE To undertake a situation analysis in relation of existing cervical cancer screening programs in Russia, supplemented by an economic analysis of various options to systematize and extend coverage, so as to be able to recommend an effective and acceptable method of population screening Cost-effectiveness of cervical cancer screening programs for Russia

3. GENERAL OBJECTIVES • To describe the epidemiology of cervical cancer in Russia • To describe the current policy of the MoH on screening for cervical cancer • To understand and explain the existing infrastructure and resources available • To identify factors that affect screening uptake in Russia • To carry out a cost-effectiveness analysis of existing and potential screening protocols using data specified to the Russian context • To make evidence-based recommendations to the Government of Russia and non-governmental organizations on options for implementation of cervical cancer screening in Russia

4. PILOT REGIONS • Tver • St-Petersburg • Nalchik • Tula

5. MAJOR FINDINGS 1. Epidemiology of cervical cancer in Russia • Cervical cancer is a second cause of cancer related death among women in Russia • Average age of cervical cancer is 45.6 years • Russia has one of the highest (7 per 100000 women) SDR among European countries • 70% of all cervical cancer cases are diagnosed at an advanced, incurable stages • 5-years survival rate is: 92% for local, 49% regional, 15% distant • Stage distribution in %: CIS – 6.6, I - 8.8, II – 28, III – 36.7, IV – 19.9 • Source of information: Russian State Statistics Committee, 2002

8. MAJOR FINDINGS 2. Description of the current policy of the Russian Ministry of Health on screening for cervical cancer The current policy of the Russian Ministry of Health in relation to the screening for cervical cancer is consistent to the international standards such as proposed by WHO and EU

9. MAJOR FINDINGS 3. Existing infrastructure and resources available Review of the medical equipment condition in the hospitals and gynecological consultations showed that equipment has been 80% depreciated Some types of medical equipment have been exploited for 15-20 years Requirements of the hospitals and policlinics with medical equipment are satisfied to 30-40%

11. MAJOR FINDINGS 4. To identify factors that affect screening uptake in Russia 1) Knowledge, attitudes, beliefs and practices of medical personnel and women in relation to cervical cancer Methods: a face-to-face interviews of 400 randomly selected women were conducted at home by family physicians using a structured questionnaire

12. MAJOR FINDINGS Screening Coverage: 30% of women reported ever having PAP test • About2/3 of them had it more than once • About 2/3 of them had it less than two years ago AGE GROUPS • 69,6% of them at age 35-64 years (p ≤ 0.001) • 22,7% at age 15-34

13. MAJOR FINDINGS Knowledge of women about Pap smear • 42% of interviewed have never heard about screening as a method of cervical cancer prevention, PAP smear • 1/3 of those who know about PAP smear aware that test is used to diagnose CANCER (rather than CIN) Fear to go to the physician Sources of information • Most of those who know about screening reported that they received an information about cervical cancer from physicians (gynecologists)

14. MAJOR FINDINGS Results: • Most of women recognized age as a risk factor At the same time • 1/3 of interviewed reported that cervical cancer is not curable and there is no method to prevent or influence the disease outcome • Only few women were aware that cervical cancer is one of the most commonly occurring among Russian women • Heredity is the main factor for cervical cancer and the are not at risk as they have a “good heredity”

15. MAJOR FINDINGS Role of physicians • The lack of physicians recommendations came up spontaneously from all pilot regions • 25% of women who ever had Pap smear reported that they were not informed about results of the analysis • Most of women said that doctors don’t encourage them to have screening

16. MAJOR FINDINGS Role of physicians Almost all women reported that they want to have more information on what tests they are having, the reasons for these tests and the results but if they express any interest and ask doctors what is it used for the most common answer they receive is : you don’t need to know it

17. MAJOR FINDINGS 5. Results of cost-effectiveness analysis: CEA of 3 screening policies (depending on model of screening design, guidelines of follow up of women with detected CIN, interval of screening) Cost-effectiveness of cervical cancer screening programs for Russia

19. Cost-Effectiveness Analysis - Validity of Screening tests Validity of screening tests makes a great influence on the results of cost-effectiveness analysis. There is no data on validity of screening tests in Russia Therefore, 84 schemes (depending on the validity of screening test)

21. Cost and LYS for 84 screening alternatives Cost-effectiveness of cervical cancer screening programs for Russia

22. Efficient screening combinations(as the World Bank proposed we used GNP per capita in 2002 as a cut-off-point below which the program is not effective)

23. MAJOR FINDINGS • Results of cost-effectiveness analysis: • Results: • 12 efficient screening policies (i.e., no alternativepolicy exists that results in more life-years gained for lowercosts). • For the efficient policies,the predicted gain in life expectancy ranged from 2.04 to 2.45 life-year saved per 1000 women per year of screening depending on the screening strategy • The total cost of screening program varies between 2950 and 4100$ US per 1000 women per year of screening • In the whole of Russia it is result in total 2.8-3.8 billion rubles (from 93 to 127 mln dollars US) in the frame of 12 effective strategies varies between Cost-effectiveness of cervical cancer screening programs for Russia

24. CONCLUSION The current screening program is not effective in reaching the majority of population A major negative factor of low test currency was low educational level. With few exceptions, beliefs and attitudes were not very important barriers Lack of recommendations coming from physicians Negligence, absence of medical problem, fear, lack of knowledge were the main reasons given for not being screened Validity of screening tests - crucial

25. References: • Dorte Gyrd-Hansen, Berit Hund, Per Andersen. A cost-effectiveness analysis of cervical cancer: • health policy implications. J. Health Policy 1995; 34: 35-51. • Cuzick J, Sasieni P, Davies P, Adams J, Normand C, Frater A. A systematic review of the role of human papilloma virus • (HPV) testing within a cervical screening programme:summary and conclusions. British Journal of Cancer 2000; 83(5): 561–565. • van Ballegooijen, E. et a:l Overview of important cervical cancer screening process values in European Union (EU) countries, • and tentative predictions of the corresponding effectiveness and cost-effectiveness. European Journal of Cancer 2000; 36: 2177- 2188. • Cuzick J. Human Papillomavirus in Cervical Screening. FIGO 2000, Conference Coverage Washington D.C., USA • Allison P. Hawkes, et al Cervical Cancer Screening: American College of Preventive Medicine Practice Policy Statement. • American Journal of Preventive MedicineSeptember 1996 October;12(5):342-44. • Zoorov R, Anderson R, Cefalu C, Sidani M. Am Fam Physician 2001;63:1101-12. • Goldie, S J; Kuhn, L; Denny, L; Pollack, A; Wright, T C Policy analysis of cervical cancer screening strategies in • low-resource settings: clinical benefits and cost-effectiveness. JAMA 2001 June 285(24): 3107-3115. • Brown AD and Garber AM, Cost-effectiveness of 3 Methods to Enhance the Sensitivity of Papanicolaou Testing, • JAMA 1999, 81 (4); • Spitzer M. Cervical screening adjuncts: recent advances. Am J Obstet Gynecol 1998;179:544-56. • European Guidelines for Quality Assurance in Cervical Cancer Screening, 2001. • .Brown AD, Garber AMCost-effectiveness of 3 methods toenhance the sensitivity of Papanicolaou testing; • JAMA 1999 Jan 27;281(4):347-53.

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