Rim Ben Aissa (ONFP), Leila Joudane (UNFPA Co) - Tunisia Program - Working Meeting on Comprehensive Cervical Cancer Prevention and Control

1. WORKING MEETING ON
COMPREHENSIVE CERVICAL CANCER
PREVENTION AND CONTROL
TUNISIA Program
Dr Rim Ben Aissa (ONFP)
Dr Leila Joudane (UNFPA Co)
Antalya, Turkey 18-20 May 2011
CSB/UNFPA

2. MAGNITUDE AND BURDEN
OF CERVICAL CANCER IN TUNISIA
 2nd female cancer in Tunisia after Breast cancer
 According to the North Tunisia cancer registry 2005 ,
incidence of cervical cancer remained stable from 1994 to
2003 , with an annual age-standardized incidence rate of
6 cases per 100,000 women.
 250 new cases per year
 Invasive cancer rare before 35 years ( 2.9% of cases of
cancer)
 Average age of invasive cancer 55 years versus 42.2 years
for carcinoma in situ
 Adenocarcinoma is rare ( 5.3 %)
CSB/UNFPA

3. MAGNITUDE AND BURDEN
OF CERVICAL CANCER IN TUNISIA
Most of women are diagnosed at late stage disease
• carcinoma in situ :7.2:%
• Local extension:13.6%
• Regional extension :52.9%
• Metastasis: 3.9%
CSB/UNFPA

4. CERVICAL CANCER SCREENING
PROGRAMME
• Population of Tunisia is about 10 millions habitants
• Number of women eligible for the program is
about 2millions
 2000 primary health care centers –
 24 reproductive health centers (one /governorate)
offering gynecologyst services/colposcopy
 One cytology unit per region; each region cover
4 governorates
 Referral services (surgery,radiotherapy) available
on the 3 main governorates
CSB/UNFPA

5. CERVICAL CANCER SCREENING
PROGRAM: DESCRIPTION
TARGET:
ONE PAP SMEAR DURING LIFE, AT LEAST, FOR
WOMEN VISITING REPRODUCTIVE HEALTH
CENTERS AND HEALTH CARE CENTERS AND
BETWEEN 35-59 YEARS
1 PAP SMEAR EVERY 3 YEARS: FOR HIGH RISK
WOMEN (WOMEN EXPOSED TO HIGH RISK OF
STI, HAVING MULTIPLE PARTNERS WITHOUT
USING ANY PROTECTION)
CSB/UNFPA

6. CERVICAL CANCER SCREENING
PROGRAMME - DESCRIPTION
 The cervical screening program is based on Pap smears
performed mostly by midwifes (1 mide wife per 800
women from 15-49 years)
 Pap smears are transported to cytology units and readen
by cytologists
 Quality control system : anatomopathologists ensure
second reading of 10% of pap smears at random and all
abnormal pap smears
 Colposcopy performed by gynecologist in the
reproductive health center for every positive pap smear
 Referral for treatment of every cervical cancer
diagnosed
CSB/UNFPA

7. CERVICAL SCREENING
PROGRAMME: RESULTS
• COVERAGE RATE : 14% out of 2 millions target
women was screened in 5 years,
• 54% of pap smears are normal
• 17,5% are inflammatory
• 0,02% high grade
• 0,06% low grade
CSB/UNFPA

8. SCREENING AND TREATMEN PROGRAMME
CHALLENGES AND ACTIONS TAKEN
CHALLENGES ACTIONS TAKEN
 Low rate of coverage (14%) because of the  Sensitize target population especially
limited number of cytologists most at risk women
Delay to deliver result to women: only 50%  Training of health care providers on pap
of women has their results by the end of the smear technical
month
Advocacy for recruiting 45 cytologists to
low knowledge about the program: 20% of cover 60% of eligible population
target population have never heard about the
program  Improve the referral system, M&E system
 Over treatment of low grade lesions
 Delay for treatment
 monitoring and evaluation system weak
Estimation cost of the program to cover
60% of the target population: 10 millions $
CSB/UNFPA

9. SCREENING AND TREATMENT PROGRAMME
WAY FORWARD
 Sensitize target population to screening and STI prevention
 Sensitize health care provider to screening
 Improve health care providers training
 Develop a comprehensive information , monitoring and evaluation
system
 Develop cytology units
Develop HPV testing as primary screening ? Low HPV
prevalence
Make vaccine more affordable ? Low prevalence of HPV
16 & 18
CSB/UNFPA

10. Prévalence de l’ADN des HPVs dans la
population étudiée
Nombre de sujets %
HPV- 94 92
HPV+ 8 7,84
Total 102 100
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11. Types d’HPV observés
Type d’HPV Nombre de virus
Bas risque 5
HPV 6 1
HPV11 3
HPV42 1
CP6108 2
Risque intermédiaire 2 ( 25%)
HPV 56 1
HPV73 1
Haut risque 3
HPV16 3
HPV18 0
HPV31 0
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12. THANKS FOR YOUR ATTENTION
CSB/UNFPA