Quality assured implementation of the Slovenian breast cancer screening programme.

SETTING: The organised, population-based breast cancer screening programme in Slovenia began providing biennial mammography screening for women aged 50-69 in 2008. The programme has taken a comprehensive approach to quality assurance as recommended by the European guidelines for quality assurance in breast cancer screening and diagnosis (4th edition), including centralized assessment, training and supervision, and proactive monitoring of performance indicators. This report describes the progress of implementation and rollout from 2003 through 2019. METHODS: The screening protocol and key quality assurance procedures initiated during the planning from 2003 and rollout from 2008 of the screening programme, including training of the professional staff, are described. The organisational structure, gradual geographical rollout, and coverage by invitation and examination are presented. RESULTS: The nationwide programme was up and running in all screening regions by the end of 2017, at which time the nationwide coverage by invitation and examination had reached 70% and 50%, respectively. Nationwide rollout of the population-based programme was complete by the end of 2019. By this time, coverage by invitation and examination had reached 98% and 76%, respectively. The participation rates consistently exceeded 70% from 2014 to 2019. CONCLUSIONS: The successful implementation of the screening programme can be attributed to an independent central management, external guidance, and strict adherence to quality assurance procedures, all of which contributed to increasing governmental and popular support. The benefits of quality assurance have influenced all aspects of breast care and have provided a successful model for multidisciplinary management of other diseases.

Cervical cancer screening in Europe: Quality assurance and organisation of programmes.

BACKGROUND: Cervical screening programmes have reduced cervical cancer incidence and mortality but the level of success is highly variable between countries. Organisation of programmes is essential for equity and cost-effectiveness. However, there are differences in effectiveness, also among organised programmes. In order to identify the key organisational components that determine effectiveness, we performed a Europe-wide survey on the current status of organisation and organised quality assurance (QA) measures in cervical cancer prevention programmes, as well as organisation-associated costs. METHODS: A comprehensive questionnaire was developed through systematic review of literature and existing guidelines. The survey was sent to programme organisers, Ministries of Health and experts in 34 European Union (EU) and European Free Trade Agreement (EFTA) countries. Detailed aspects of programme organisation, quality assurance, monitoring, evaluation and corresponding line-item costs were recorded. Documentation of programme guidelines, protocols and publications was requested. RESULTS: Twenty-nine of 34 countries responded. The results showed that organised efforts for QA, monitoring and evaluation were carried out to a differing extent and were not standardised, making it difficult to compare the cost-effectiveness of organisation and QA strategies. Most countries found it hard to estimate the costs associated with launching and operating the organised programme. CONCLUSIONS: To our knowledge, this is the first questionnaire to request detailed information on the actual organisation and QA of programmes. The results of this survey can be used as a basis for further development of standardised guidelines on organisation and QA of cervical cancer screening programmes in Europe.

Towards better implementation of cancer screening in Europe through improved monitoring and evaluation and greater engagement of cancer registries.

Proposals to improve implementation, monitoring and evaluation of breast, cervical and colorectal cancer screening programmes have been developed in a European project involving scientists and professionals experienced in cancer registration (EUROCOURSE). They call for a clear and more active role for cancer registries through better interfaces with cancer screening programmes and adapting data contents of cancer registries for evaluation purposes. Cancer registries are recognised as essential for adequate evaluation of cancer screening programmes, but they are not involved in screening evaluation in several European countries. This is a key barrier to improving the effectiveness of programmes across Europe. The variation in Europe in the implementation of cancer screening offers a unique opportunity to learn from best practices in collaboration between cancer registries and screening programmes. Population-based cancer registries have experience and tools in collecting and analysing relevant data, e.g. for diagnostic and therapeutic determinants of mortality. In order to accelerate improvements in cancer control we argue that cancer registries should take co-responsibility in promoting effective screening evaluation in Europe. Additional investments are vital to further development of infrastructures and activities for screening evaluation and monitoring in the national settings and also at the pan-European level. The EUROCOURSE project also aimed to harmonise implementation of the European quality assurance guidelines for cancer screening programmes across Europe through standardising routine data collection and analysis, and definitions for key performance indicators for screening registers. Data linkage between cancer and screening registers and other repositories of demographic data and cause of death and where available clinical registers is key to implementing the European screening standards and thereby reducing the burden of disease through early detection. Greater engagement of cancer registries in this collaborative effort is also essential to develop adequate evaluation of innovations in cancer prevention and care.

Prevention strategies for gastric cancer: a global perspective.

Despite the substantial burden of gastric cancer worldwide, population strategies for primary prevention have not been introduced in any country. Recognizing the causal role of Helicobacter pylori infection, there is increasing interest in population-based programs to eradicate the infection to prevent gastric cancer. Nonetheless, the paucity of available evidence on feasibility and effectiveness has prevented implementation of this approach. There are very few secondary prevention programs based on screening with endoscopy or radiography, notably in the Republic of Korea and Japan, two of the countries with the highest incidence rates of gastric cancer. In Korea, where the organized screening program is in place, survival rate of gastric cancer is as high as 67%. More research is needed to quantify the specific contribution of the screening program to observed declines in mortality rates. Gastric cancer screening is unlikely to be feasible in many Low-Middle Income Countries where the gastric cancer burden is high. Prevention strategies are still under development and the optimal approach may differ depending on local conditions and societal values. The present review gives an overview of the etiology and burden of the disease, and possible prevention strategies for countries and regions confronted with a significant burden of disease.

Quality criteria for health checks: development of a European consensus agreement.

OBJECTIVE: Health checks may empower individuals to take better care of their health, but they may incorporate risks of incorrect test results, overdiagnosis and overtreatment as well. Some health checks are strictly regulated, such as in many of the national screening programs, but the ones offered outside such programs and in the commercial domain, are not. We developed a European consensus agreement for quality criteria. METHOD: Quality criteria were developed with the contribution of 43 experts from 16 European countries and 8 European organizations. A working group drafted a proposal, which was revised in several rounds of internal and external review by a multidisciplinary group of experts. RESULT: The quality criteria address the provision of information, communication and informed consent, predictive ability and utility of the test, and quality assurance. CONCLUSION: The consensus agreement on the quality of health checks aim to enhance informed decision making in clients and protects the affordability of the health care system. The criteria can be developed further into a formal standard and regulation if such authority is warranted.

Development and implementation of guidelines for quality assurance in breast cancer screening: the European experience.

In Europe, as in many other regions of the world, breast cancer is a major cause of suffering and death. Early detection of breast cancer by systematic mammography screening can find lesions for which treatment is more effective and generally more favourable for quality of life. Comprehensive quality assurance guidelines for breast cancer screening based on mammography have been developed in the Europe Against Cancer programme with the aim of maximising screening benefits while minimising adverse effects, such as unnecessary examination or treatment resulting from false-positive screening tests. The present report provides an overview of the European experience in developing and implementing quality assurance guidelines for breast cancer screening. It highlights implications relevant to those regions of the world in which the burden of breast cancer in the coming years will make population-based screening an option for cancer control.

Development and implementation of guidelines for quality assurance in breast cancer screening: The European experience / Desarrollo e implementación de guías para el aseguramiento de la calidad en el tamizaje de cáncer de mama: la experiencia europea

In Europe, as in many other regions of the world, breast cancer is a major cause of suffering and death. Early detection of breast cancer by systematic mammography screening can find lesions for which treatment is more effective and generally more favourable for quality of life. Comprehensive quality assurance guidelines for breast cancer screening based on mammography have been developed in the Europe Against Cancer programme with the aim of maximising screening benefits while minimising adverse effects, such as unnecessary examination or treatment resulting from false-positive screening tests. The present report provides an overview of the European experience in developing and implementing quality assurance guidelines for breast cancer screening. It highlights implications relevant to those regions of the world in which the burden of breast cancer in the coming years will make population-based screening an option for cancer control.

En Europa, como en muchas otras regiones del mundo, el cáncer de mama es una causa importante de sufrimiento y muerte. La detección temprana del cáncer de mama a través de un programa de tamizaje organizado mediante la mamografía sirve para encontrar lesiones cuyo tratamiento es más efectivo y generalmente más favorable para la calidad de vida. En el programa Europa contra el Cáncer se han desarrollado guías integrales de garantía de calidad para el tamizaje del cáncer de mama basado en la mamografía, con el fin de maximizar los beneficios del tamizaje y minimizar sus efectos adversos, que pueden resultar en resultados falsos positivos. El presente trabajo ofrece una visión general de la experiencia europea en el desarrollo y aplicación de las guías de control de calidad para el tamizaje del cáncer de mama. En él se destacan las implicaciones relevantes para las regiones del mundo en las que la incidencia del cáncer de mama en los próximos años hará del tamizaje poblacional una opción para el control del cáncer.

Mammographic screening programmes in Europe: organization, coverage and participation.

OBJECTIVES: To summarize participation and coverage rates in population mammographic screening programmes for breast cancer in Europe. METHODS: We used the European Network for Information on Cancer (EUNICE), a web-based data warehouse (EUNICE Breast Cancer Screening Monitoring, EBCSM) for breast cancer screening, to obtain information on programme characteristics, coverage and participation from its initial application in 10 national and 16 regional programmes in 18 European countries. RESULTS: The total population targeted by the screening programme services covered in the report comprised 26.9 million women predominantly aged 50-69. Most of the collected data relates to 2005, 2006 and/or 2007. The average participation rate across all programmes was 53.4% (range 19.4-88.9% of personally invited); or 66.4% excluding Poland, a large programme that initiated personal invitations in 2007. Thirteen of the 26 programmes achieved the European Union benchmark of acceptable participation (>70%), nine achieved the desirable level (>75%). Despite considerable invitation coverage across all programmes (79.3%, range 50.9-115.2%) only 48.2% (range 28.4-92.1%) of the target population were actually screened. The overall invitation and examination coverage excluding Poland was 70.9% and 50.3%, respectively. CONCLUSIONS: The results demonstrate the feasibility of European-wide screening monitoring using the EBCSM data warehouse, although further efforts to refine the system and to harmonize standards and data collection practices will be required, to fully integrate all European countries. The more than three-fold difference in the examination coverage should be taken into account in the evaluation of service screening programmes.

Cancer screening and health system resilience: keys to protecting and bolstering preventive services during a financial crisis.

The aim of this paper is to elucidate the rationale for sustaining and expanding cost-effective, population-based screening services for breast, cervical and colorectal cancers in the context of the current financial crisis. Our objective is not only to promote optimal delivery of high-quality secondary cancer prevention services, but also to underline the importance of strengthening comprehensive cancer control, and with it, health system response to the complex care challenges posed by all chronic diseases. We focus primarily on issues surrounding planning, organisation, implementation and resources, arguing that given the growing cancer burden, policymakers have ample justification for establishing and expanding population-based programmes that are well-organised, well-resourced and well-executed. In a broader economic context of rescue packages, deficits and cutbacks to government entitlements, health professionals must intensify their advocacy for the protection of vital preventive health services by fighting for quality services with clear benefits for population health outcomes.

Determinants of successful implementation of population-based cancer screening programmes.

To facilitate the future implementation of population-based cancer screening programmes in European countries, we summarised the experience gained from existing programmes across Europe. We listed points that citizens, advocacy groups, politicians, health planners, and health professionals should consider when planning, implementing and running population based cancer screening programmes. The list is general and is applicable to breast, cervical and colorectal cancer screening. It is based on evidence presented in the three European Union guidelines on quality assurance in cancer screening and diagnosis, supplemented with other literature and expert experience presented at a European Science Advisory Network for Health workshop. The implementation of a cancer screening programme should be divided into the following seven phases: (1) before planning, (2) planning, (3) feasibility testing, (4) piloting or trial implementation, (5) scaling up from pilot to service, (6) running of full-scale programme, and (7) sustainability. For each phase, a substantial number of specified conditions have to be met. Successful implementation of a cancer screening programme requires societal acceptance and local ownership along with the best evidence-based practise and verification of adequate performance in each phase of implementation.

Annex to Quirke et al. Quality assurance in pathology in colorectal cancer screening and diagnosis: annotations of colorectal lesions.

Multidisciplinary, evidence-based European Guidelines for quality assurance in colorectal cancer screening and diagnosis have recently been developed by experts in a pan-European project coordinated by the International Agency for Research on Cancer. The full guideline document includes a chapter on pathology with pan-European recommendations which take into account the diversity and heterogeneity of health care systems across the EU. The present paper is based on the annex to the pathology chapter which attempts to describe in greater depth some of the issues raised in the chapter in greater depth, particularly details of special interest to pathologists. It is presented here to make the relevant discussion known to a wider scientific audience.

Quality assurance in pathology in colorectal cancer screening and diagnosis­European recommendations.

In Europe, colorectal cancer is the most common newly diagnosed cancer and the second most common cause of cancer deaths, accounting for approximately 436,000 incident cases and 212,000 deaths in 2008. The potential of high-quality screening to improve control of the disease has been recognized by the Council of the European Union who issued a recommendation on cancer screening in 2003. Multidisciplinary, evidence-based European Guidelines for quality assurance in colorectal cancer screening and diagnosis have recently been developed by experts in a pan-European project coordinated by the International Agency for Research on Cancer. The full guideline document consists of ten chapters and an extensive evidence base. The content of the chapter dealing with pathology in colorectal cancer screening and diagnosis is presented here in order to promote international discussion and collaboration leading to improvements in colorectal cancer screening and diagnosis by making the principles and standards recommended in the new EU Guidelines known to a wider scientific community.

Cervical cancer screening policies and coverage in Europe.

The aim of the study was to compare current policy, organisation and coverage of cervical cancer screening programmes in the European Union (EU) member states with European and other international recommendations. According to the questionnaire-based survey, there are large variations in cervical cancer screening policies and inadequacies in the key organisational elements of the programme such as registration and monitoring required for quality-assurance and fail-safe mechanisms. Based on data from available screening registers, coverage of the screening test taken within the population-based programme was below 80% in all programmes, ranging from 10% to 79%. The screening capacity is satisfactory in most EU member states, however, and there is even over-capacity in several countries. There are also countries which do not have an acceptable capacity yet. Control of proper capacity along with education, training and communication among women, medical professionals and authorities are required, accordingly. The study indicates that, despite substantial efforts, the recommendations of the Council of the EU on organised population-based screening for cervical cancer are not yet fulfilled. Decision-makers and health service providers should consider stronger measures or incentives in order to improve cervical cancer control in Europe.

Report on the 2007 International Workshop on Human Papillomaviruses and Consensus Recommendations for Cervical Cancer Prevention.

National and international experts in cervical cancer prevention met at the International Workshop on Human Papillomaviruses and Consensus Recommendations for Cervical Cancer Prevention to review the current evidence and assess the potential for improvement in cervical cancer prevention and to develop plans for implementation of cervical cancer prevention programmes in Croatia. Key recommendations were developed and adopted during the course of the meeting. The process of bringing national experts together with internationally recognized experts in an open forum for the development of consensus recommendations could serve as a model for other countries seeking to implement or improve cervical cancer prevention programmes.

The burden of cervical cancer in south-east Europe at the beginning of the 21st century.

The situation of cervical cancer prevention in South-East Europe is hardly documented, in spite of the fact that it encloses the most affected countries of Europe. We estimated the number of cases of cervical cancer, the number of deaths from this malignancy and the corresponding rates for 11 countries located in South-East Europe, in the period 2002-2004. Each year, approximately 9,000 women develop cervical cancer and about 4,600 die from the disease in this subcontinent. The most affected country is Romania with almost 3,500 cases and more than 2,000 deaths per year High world-age standardised mortality rates (> 7.5 [expressed per 100,000 women-years]) are observed in 7 countries: FYROM (7.6), Moldova (7.8), Bulgaria (8.0), Bosnia & Herzegovina (8.0), Albania (9.8), Serbia & Montenegro (10.1) and Romania (13.0). A matter of concern is the increasing mortality rate, in younger women, in the countries with the highest burden of cervical cancer. Thus, appropriate cervical cancer prevention programmes should be set up without delay in this part of Europe.