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Cervical Cancer Screening in Latvia: Cervical Cancer Screening in Latvia: Present, Problems and FuturePresent, Problems and Future

Ilze Viberga, MD, PhD, Ob/Gyn Ilze Viberga, MD, PhD, Ob/Gyn

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Demographics of the Latvian PopulationDemographics of the Latvian Population

19961996 20022002

Total population (millions)Total population (millions) 2.52.5 2.32.3

Men (%)Men (%) 4646 5454

Women (%)Women (%) 4646 5454

Natural population growthNatural population growth - 5.9- 5.9 -5.3-5.3

National budget expenses for health National budget expenses for health

(% of total national spending)(% of total national spending)

10.310.3 11.111.1

3

Structure of Cancer Incidence in Latvia 2002 – Structure of Cancer Incidence in Latvia 2002 – 2004 (per 100 000 Women)2004 (per 100 000 Women)

74,8

72,70

79,60

30,7

30,8

30,4

22,4

23,4

22,1

16,5

16

18,3

0,0 20,0 40,0 60,0 80,0 100,0

2002

2003

2004

year

Colli uteri

Ovarii

Corporis uteri

Breast

4

Ca Colli Uteri III-IVCa Colli Uteri III-IV 1995 – 2004 (%) 1995 – 2004 (%)

42,8

40,3

43,3

44,6 44,7

43,2

46,9 46,6

43,5

48,2

36

38

40

42

44

46

48

50

%

1995 1997 1999 2001 2003

Ca colliuteri

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Primary Health CarePrimary Health Care

► tthere are three groups of practitioners in Latvia that are here are three groups of practitioners in Latvia that are working as primary care practitioners since health care working as primary care practitioners since health care reforms has come into forcereforms has come into force: : FFamily doctorsamily doctors (GP) (GP), , IInternists nternists and and PPaediatriciansaediatricians (paid for mostly by HCISA or also only (paid for mostly by HCISA or also only privately)privately)

► tthe outpatient service is provided by he outpatient service is provided by Specialists Specialists that has that has

private practiceprivate practice (directly paid for by HCISA or only (directly paid for by HCISA or only privately)privately) or are working in the outpatient clinics or are working in the outpatient clinics in the in the contract with GP paid for by HCISAcontract with GP paid for by HCISA

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Preventive Examinations for Women (1) Preventive Examinations for Women (1)

► Survey Survey Reproductive health of the population Reproductive health of the population (2003) – (2003) – 1251 1251 ♀ aged 15 to 49♀ aged 15 to 49 63% of women go for a preventive gynecological 63% of women go for a preventive gynecological

examination at least once a yearexamination at least once a year 18% do the same once every 2-3 years18% do the same once every 2-3 years less frequently, never, no answer – 19%less frequently, never, no answer – 19% despite recent health care reforms, the most popular despite recent health care reforms, the most popular

doctor for this kind of examination is a gynecologistdoctor for this kind of examination is a gynecologist why do women not attend preventive visits to a why do women not attend preventive visits to a

gynecologist:gynecologist:► I do not have any gynecological complaints: 61%I do not have any gynecological complaints: 61%► I do not like gynecological examination: 36%I do not like gynecological examination: 36%► I do not have time: 17%I do not have time: 17%►Nobody has actively invited me to go for the examination: 16%Nobody has actively invited me to go for the examination: 16%►The visit to doctor costs too much: 14%The visit to doctor costs too much: 14%

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Preventive Examinations for Women (2)Preventive Examinations for Women (2)

► Choice of specialist:Choice of specialist: despite health care reforms that aim at driving health care despite health care reforms that aim at driving health care

to GPs, women still consider the GYN to be the best to GPs, women still consider the GYN to be the best specialist for preventive gynecological examinationsspecialist for preventive gynecological examinations

76% of women felt that they could not trust their GP to 76% of women felt that they could not trust their GP to perform a preventive gynecological examination: women perform a preventive gynecological examination: women with a higher education had the most objections against with a higher education had the most objections against services rendered by a GPservices rendered by a GP

► selection of services paid by HCISA and privately paid selection of services paid by HCISA and privately paid services:services: 35% of all women who had used the services of a GYN 35% of all women who had used the services of a GYN

went to a doctor paid for by HCISA, thereby only needing went to a doctor paid for by HCISA, thereby only needing to co-pay services renderedto co-pay services rendered

on the other hand, women are often referred to GYN paid on the other hand, women are often referred to GYN paid for by HCISA in order to receive a preventive for by HCISA in order to receive a preventive examination or need certificateexamination or need certificate

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Preventive examinations of women (3)Preventive examinations of women (3)

173941

152 605

153249

150268

151177

2000

2001

2002

2003

2004

year

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Preventive examinations of women (4)Preventive examinations of women (4)

2053

1536

2024

797

626

742

196

186

209

112

85

69

2002

2003

2004

year

Ca colli uteri

CIN III

CIN II

CIN I

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Cervical Cancer ScreeningCervical Cancer Screening► Preventive examination program December 2004 Preventive examination program December 2004

(corrections November 2005)(corrections November 2005)

► the preventive gynecological examination, including breasts the preventive gynecological examination, including breasts examination, and PAP smear examination has to be done one examination, and PAP smear examination has to be done one time per year initially and, if the results of examination are time per year initially and, if the results of examination are without the pathological findings, a repeated preventive without the pathological findings, a repeated preventive examination follows one time per three years in 20 – 35 years examination follows one time per three years in 20 – 35 years age group age group

► in age group 35 – 70 years, the preventive gynecological and in age group 35 – 70 years, the preventive gynecological and PAP smear examination has to be done one time per year PAP smear examination has to be done one time per year

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ProblemsProblems► how to implement the announced screening:how to implement the announced screening:

who is going to invite woman for the preventive gynecological who is going to invite woman for the preventive gynecological examination and how examination and how

training of GPs in taking of PAP smearstraining of GPs in taking of PAP smears who is going to control the level of examinations and practices of GPswho is going to control the level of examinations and practices of GPs majority of women consider the GYN to be the best specialist for majority of women consider the GYN to be the best specialist for

preventive gynecological examination preventive gynecological examination

► the preventive gynecological examination and PAP smear as the preventive gynecological examination and PAP smear as the screening program is paid for by HCISA:the screening program is paid for by HCISA: if woman selects privately paid services, how about registration and if woman selects privately paid services, how about registration and

data collection from this sector data collection from this sector

► who is going to treat and monitoring CIN I and CIN II and who is going to treat and monitoring CIN I and CIN II and how – no guidelines!!how – no guidelines!! if woman selects privately paid services, how about registration and if woman selects privately paid services, how about registration and

data collection from this sector data collection from this sector !! no good traditions of Colposcopy at all for gynecologists!! no good traditions of Colposcopy at all for gynecologists

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FutureFuture

► the educational aspectthe educational aspect what is the cervical cancerwhat is the cervical cancer what is the screening of cervical cancerwhat is the screening of cervical cancer

► the implementation aspectthe implementation aspect who is ’the main’ specialist in the screeningwho is ’the main’ specialist in the screening who is responsible for the invitation for the screeningwho is responsible for the invitation for the screening how ‘screening money’ follows the woman how ‘screening money’ follows the woman how precise is data collection how precise is data collection

► the quality aspectthe quality aspect► the treatment and monitoring aspectthe treatment and monitoring aspect

ColposcopyColposcopy guidelinesguidelines follow-upfollow-up