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Description
Cancer is a major public health problem in Romania. Malignant tumors account for two out of 10 deaths recorded in Romania, ranking second place among the main causes of death after cardiovascular diseases. Among EU member states, Romania has the highest incidence of cervical cancer (13.1/100,000 Romania compared to an average of 3.29/100,000 in EU). One of the causes of this unusually large incidence of cervical cancer in Romania is the deficiency of the medical system in early detecting the HPV persistent infection and cervical precancerous lesions which, treated, prevents cancer.
The project proposed to improve the quality of integrated preventive and curative medical services related to cervical cancer prevention among the disadvantaged population at risk living in communities from remote areas. The main project results are: 7,000 preventive cancer screening tests for vulnerable women, 1.000 vaccinations against Human papillomavirus (HPV), 1500 women treated with a mobile unit or in ambulatory care, 30000 women informed on cervical cancer prevention by the door to door campaign, 1 post-doctoral study and policy recommendations related on cervical cancer screening and quality assurance.
The project is implemented by Oncology Institute Cluj-Napoca in partnership with Norwegian Cancer Registry. The partnership will support the exchange of experience for the implementation of effective screening programs and also the achievement of the technical quality conditions of screening programs to be performed in Romania. Also, the Norwegian partner will conduct a study using participatory action research (PAR) aiming to bring out knowledge about how the Romanian health care system can make robust solutions that facilitate women''s participation, and ensure adequate follow-up and treatment of women when needed. Guidelines for screening testing and follow-up must also be addressed and amended.
Summary of project results
Cancer is a major public health problem in Romania. Malignant tumors account for two out of every 10 deaths registered in Romania, ranking second among the main causes of death after cardiovascular diseases. Due to the high impact of the disease on the population, limited resources and the high expenses required to care for patients diagnosed with cancer, both for the family and for society, cancer has become a social problem of major importance in Romania. Therefore, it requires a firm commitment of all relevant actors in the control of this disease in establishing the priorities of public health interventions in the allocation of resources, in order to maintain an efficient control of the cost, the health of the individual and the community to which he belongs.
Cancer is a major public health challenge, responsible for 25% of deaths, representing the second cause of death after cardiovascular diseases and the leading cause of death in people aged 45 to 64. A recent report by IARC (International Agency for Research on Cancer, Lyon, France) mentioned, worldwide, a total of 14,068,000 new cases; the number of deaths was 8,202,000. In the European Union (EU), in the same year, the incidence was 2,612,000, and the mortality was 1,263,000. In Romania, the incidence was 78,760, and the mortality: 48,252. It was estimated that for Europe, including Romania, the situation will become even more critical as the European population ages.
Among EU Member States, Romania has the highest incidence of cervical cancer (13.1/100,000 Romania compared to an average of 3.29/100,000 in the EU). One of the causes of this unusually high incidence of cervical cancer in Romania is the deficiency of the medical system in the early detection of persistent HPV infection and precancerous lesions of the cervix which, if treated, can prevent cancer.
The National Health Strategy 2014-2020 envisaged that Romania would achieve suboptimal prevention effectiveness, including early detection of cervical cancer, with mortality from this disease increasing or at least stable, except in the North-West Region with a new established downward trend. The national cervical cancer screening program requires a long implementation period, sustained funding, an increase in performance in accordance with specific standards before the first significant signs with a stable impact on mortality. The high morbidity and mortality rates make primary prevention of cervical cancer, through vaccination against the HPV virus, an extremely relevant and necessary intervention in Romania, especially since HPV strains 16 and 18 are responsible for approximately 70% of the diseases, and the benefits of vaccination are well documented. Approximately 4343 new cases of cervical cancer are diagnosed annually in Romania. Cervical cancer ranks as the third leading cause of female cancer in Romania. Cervical cancer is the second most common cancer in women aged 15 to 44 in Romania.
The ambitious objective set by the European Commission on combating cancer: "The European Partnership is to reduce cancer incidence by 15% by 2020". Early detection of cervical cancer has already proven effective in reducing the burden of disease in these locations. Starting in 2003 and subsequently in 2008, the Council of the EU recommends that EU Member States develop public policies and population-based screening programmes, in accordance with technical guidelines intended to support this process with the aim of a coherent and firm national and European policy in this area. Also, the European Code Against Cancer, promoted by the World Health Organization, recommends 12 ways to reduce the occurrence of cancer in terms of the organization of individual lifestyle. Each of these measures is supported and validated by scientific data.
The National Health Strategy 2014-2020 shows that one of the essential categories of determinants of health (together with socio-economic condition/poverty and environmental and occupational factors) is the individual lifestyle (smoking, alcohol consumption, diet/obesity and physical inactivity, etc.). This project aims precisely to cover this gap and to stimulate the future adoption of a systematic public health policy in this regard, targeting communities with disadvantaged groups of women at risk of cancer, especially cervical, but also generally providing information from the European Code Against Cancer.
Screening tests are offered as part of a project according to the European Guidelines on quality assurance of cervical cancer screening programs, following the 2003 European Council recommendations on cancer screening.
In order to reduce the incidence and mortality rate of cervical cancer in Romania, it is not enough to identify barriers and perform screening tests with the help of mobile units, women living in rural areas. On the contrary, for a screening program to be active, several entities of different types must be mobilized and act together. At the heart of this mobilization are women in the age group at risk, adequate testing equipment and specialists who perform the tests. This collective must be associated with: a safe transport environment so that the test is safely stored before analysis, a sample transport service, a laboratory capable of evaluating the samples, a feedback mechanism to inform women about the test results, a Cancer Registry to monitor the screening history of women to ensure appropriate and correct treatment and finally, a follow-up service to allow appropriate medical measures to be taken when precancerous changes are detected.
In this context, Latour (2007) refers to a “network of actors” made up of all human and non-human factors. Moreover, this is a network of actors that act and continuously interconnect to keep the screening program active.
The following activities were implemented within the project, and the results were obtained as follows:
Activity 1. HPV and Babeș-Papanicolaou vaccination and testing in disadvantaged communities
A door-to-door information campaign targeting particularly disadvantaged groups (Roma and other ethnic groups) in isolated rural areas was carried out in 100 communities in 7 counties with the involvement of 20 trained community experts (medical assistants and mediators). Local community experts (medical assistants and mediators) were the key community points for information on cancer prevention, mobilization for screening testing, smear collection in mobile units and in family doctors'' offices and HPV self-collection.
In the sensitized communities, contracted local community experts were mainly involved in disseminating information and secondarily to take smears or to propose and offer self-collection of samples.
The contracted local community experts also ensured the distribution of relevant information on cervical cancer prevention, included in the European Code Against Cancer (to a minimum of 30,000 people). Also, the local community experts (medical assistants and mediators) ensured access to tests for the informed population, both by scheduling women at mobile units, through self-collection, in proximity outpatient clinics and access to follow-up of positive results in the project''s mobile or outpatient units.
A media campaign was also carried out to raise awareness and mobilize the target population.
Results:
• 1 door-to-door information campaign, piloting the use of 20 local community experts (mediators and nurses) from disadvantaged groups (including Roma and other ethnic groups) in 7 pre-established counties from 100 communities, which benefited 30,000 women informed about the risk of cervical cancer
• 1 media campaign - estimated audience: 100,000 views.
• of vaccinations performed (including Roma and other ethnic groups) in 7 pre-established counties
• 7,000 preventive tests performed (including Roma and other ethnic groups) in 7 pre-established counties
Activity 2. CEDICROM 2 follow-up component for the treatment of cervical lesions found in the CEDICROM 1 and CEDICROM 2 projects
This activity ensured the follow-up of cervical lesions identified in both the CEDICROM 1 and CEDICROM 2 projects, using the infrastructure acquired under the CEDICROM 1 project (the special mobile treatment unit) and the equipment that was acquired in the present project. The medical services targeted the positive results from both the CEDICROM 1 and CEDICROM 2 projects. The follow-up activities covered the uninsured women to be treated in both CEDICROM projects. Outpatient consultations were performed to verify all follow-up actions of the women found positive in CEDICROM 1.
Also, in this activity, the Norwegian partner, the Oslo Cancer Registry, Norway, provided assistance for the research methodology and guideline development, including public policy proposals in the field of cervical cancer screening. The proposals were based on the results of CEDICROM 1.
Results:
• 200 cases treated on-site out of 1,000 people in CEDICROM 1
• 500 cases treated out of CEDICROM 2
• 1,500 women consulted in outpatient clinics from both projects
• 1 Study and public policy document on cervical cancer screening and quality assurance
The implementation of the project contributed to the improvement of policies and services for disease prevention, namely the percentage of 100% of women who were examined within the CEDICROM1 project and who received follow-up treatment with a mobile unit in the CEDICROM2 project, as well as the percentage of 100% of women examined within the CEDICROM2 project who received treatment using the mobile unit.
The project results also contributed to the indicator Primary and community care services provided to vulnerable groups by performing 7,041 preventive cancer screening tests performed for women from vulnerable groups in the beneficiary counties, by performing 1,245 HPV vaccines in women (young girls and Human Papilloma Virus - HPV recovery campaigns), as well as carrying out the "door-to-door" information campaign on cervical cancer prevention that benefited 30,000 women.