Group of experts assess prevention and treatment of cervical cancer in Romania

WHO

At the invitation of the Romanian Ministry of Health, cancer experts from WHO and the International Agency for Research on Cancer (IARC) visited Romania in June 2017 to assess the prevention and treatment of cervical cancer in the country.

During their visit, Dr Maribel Almonte (IARC), Dr Marilys Corbex (WHO/Europe) and Dr Rolando Herrero (IARC) presented evidence-based cervical cancer prevention strategies, reviewed local cervical cancer prevention activities with a special focus on screening, and provided key recommendations.

Romania has the highest incidence of cervical cancer and the highest associated mortality in the WHO European Region. In 2012, the number of new cases per year was 28.6 per 100 000 inhabitants and the number of deaths per year was 10.8 per 100 000 inhabitants (1).

Yet cervical cancer is a highly preventable disease thanks to both primary and secondary prevention. Primary prevention principally entails human papillomavirus (HPV) vaccination of girls (preferably before the beginning of sexual activity). Secondary prevention requires implementation of an effective screening programme for detecting and treating precancerous lesions.

Focus on screening programme and HPV vaccination

The screening programme in Romania started in 2012, and uses Pap smear testing with a 5-year screening interval. It targets women between the ages of 25 and 64 – a total of 5.4 million women in the country.

In their review and analysis, the group of experts observed some key limitations and highlighted that the programme needs to be strengthened substantially. In particular, the group found that:

  • coverage has remained low, with no more than 10% of the target population benefitting from screening;
  • the follow-up of women screened positive is not fully part of the programme;
  • no real quality assurance process is in place for screening, diagnosis and treatment of screened women; and
  • some key indicators are missing for monitoring and evaluation of the programme.

The experts highlighted that cervical screening programmes without strong quality control have limited impact, and can even cause more harm than benefit. Quality control is therefore a must.

The experts also observed that while the HPV vaccination was rolled out between 2008 and 2010, it was unsuccessful and subsequently stopped. This failed attempt to vaccinate has contributed to public resistance against vaccination. Currently, the HPV vaccine can only be purchased in the private sector at high cost (approximately US$ 350 for the required 3-dose course). HPV vaccination coverage therefore remains low.

Key recommendations

The experts made the following recommendations:

  • Reintroduce HPV vaccination in the routine immunization programme. This should be treated as a public health priority in Romania, given the high incidence of cervical cancer.
  • Ensure adequate follow-up of all women with a positive (that is, abnormal) screening test as part of the national screening programme.
  • Increase screening coverage.
  • Develop a strong quality assurance system for the screening programme.

They also provided details and practical advice on how to implement these recommendations.

One of the visit’s outcomes was the proposal that WHO organize training on cervical cancer prevention. This would cover basic epidemiological concepts, cancer prevention strategies and evidence-based approaches, principles of screening, information systems for screening programmes, quality assurance, and use of cancer registries in screening programmes. This initiative, however, is subject to availability of funding.