1、ACCP Evidence base: Implications for policy and practice,R. Sankaranarayanan MD Head, Screening Group World Health Organization (WHO) International Agency for Research on Cancer (IARC) Lyon, France http:/screening.iarc.fr,ACCP Evidence Base,Test characteristics Efficacy of treatment of CIN Effective
2、ness of reducing disease burden Cost effectiveness issues Acceptability of participation determinants,Reduced frequency of screening: one or twice a life time Reducing the number of visits and improving adherence to treatment screen and treat (1 or 2 visits)* screen, see (colposcopy), and treat (1 t
3、o 2 visits) (with a posteriori histological confirmation)*,ALTERNATIVE PROGRAMMATIC APPROACHES:,*RTCOG/ JHPIEGO Lancet, 2003; 361: 814-20 * Sankaranarayanan et al., Int J Cancer, 2004; 109: 461-7 * Denny et al., 2005 JAMA 294: 2173-81,Accuracy of screening tests in developing countries: range in sen
4、sitivity and specificity,RESULTS OF TREATMENT OF CIN,Women,SAFETY, ACCEPTABILITY, AND FEASIBILITY OF A SINGLE-VISIT APPROACH TO CERVICAL CANCER PREVENTION IN RURAL THAILAND,Acceptability of Cryotherapy Treatment,Lancet 2003; 361:814-820,RANDOMISED CONTROLLED TRIAL OF SCREEN AND TREAT APPROACH FOR CE
5、RVICAL CANCER PREVENTION IN SOUTH AFRICA,Denny et al., JAMA 2005; 294: 2173-81,Cluster Randomised Controlled Trial of VIA Screening, Dindigul District, India,Christian Fellowship Community Health Centre (CFCHC), Ambillikai, India PSG Institute of Medical Sciences and Research (PSGIMSR), Coimbatore,
6、India Cancer Institute (WIA), Chennai, India World Health Organization-International Agency for Research Cancer (WHO-IARC), Lyon, France,Supported by the Bill & Melinda Gates Foundation through the ACCP,Study design,113 Village clusters 79 372 eligible women aged 30-59 years,Allocated to single roun
7、d VIA screening by nurses, 57 clusters, 48 225 women,Colposcopy/directed biopsy for screen +ve women Cryotherapy/LEEP/conization for CIN,Follow-up of women for cervical cancer incidence and deaths,Comparison of cervical cancer incidence and deaths in the VIA and Control Groups,Diagnosis & treatment
8、of invasive cancer,Diagnosis & treatment of invasive cancer,Allocated to usual care control group health education, 56 clusters, 30167 women,Interim results,VIA Group, 48 225 women 32 340 (67%) received VIA screening 3 088 (9.5%) women screened positive 1 882 (5.8%) had CIN 1 lesions 278 (8.6%) had
9、biopsy 239 (0.7%) had CIN 2 & 3 lesions 75% with CIN received treatment Follow-up for cervical cancer incidence and mortality continuingControl Group, 30 167 women Follow-up for cervical cancer incidence and mortality continuingAn interim analysis of final outcomes at the end of 2006,Cost-Effectiven
10、ess of Cervical Cancer Screening in Five Developing Countries,The most cost-effective strategies were those that required the fewest visits, resulting in improved follow-up testing and treatment. Screening women once in their lifetime, at age 35, with a one- or two-visit screening strategy involving
11、 visual inspection of the cervix with acetic acid or DNA testing for human papillomavirus (HPV) in cervical cell samples, reduced the lifetime risk of cancer by approximately 25 - 36 %, and cost less than $500 per year of life saved. Relative cancer risk declined by an additional 40 % with two scree
12、nings (at ages 35 and 40), resulting in a cost per year of life saved that was less than each countrys per capita gross domestic product a very cost-effective result, according to the Commission on Macroeconomics and Health.,Goldie et al., 2005 N Engl J Med 353; 20: 2158-68,Comparative efficacy of v
13、isual inspection with acetic acid, HPV testing and conventional cytology in cervical cancer screening: a randomized intervention trial in Maharashtra State, India,Tata Memorial Centre (TMC), Mumbai, India Nargis Dutt Memorial Cancer Hospital (NCMCH), Barshi, India International Agency for Research C
14、ancer (WHO-IARC), Lyon, France,Supported by the Bill & Melinda Gates Foundation through the ACCP,Primary Objectives,To evaluate the reduction in cervical cancer incidence and mortality associated with a single round of screening with visual inspection with acetic acid (VIA) or cytology or HPV testing, as compared to a control group with no screeningTo evaluate the cost-effectiveness (CE) of the above three approaches,FLOW CHART OF THE STUDY DESIGN AND FINDINGS,Collaboration with Tata Memorial Centre, Mumbai and NDMCH, Barshi,Stage of disease by group and detection mode,
