The experience of Cervical Cancer screening program in

The experience of Cervical Cancer screening program in Kazakhstan Dilyara Kaidarova, MD, Ph. D, Professor President of the Kazakh Cancer Society, Director of Kaz. IOR

Quick facts about Kazakhstan §Territory 2 724, 900 square kilometers § Population 18 146 156 people (2017) § Location: Eurasia §Average life expectancy 72 year (2017) § Borders: China, Kyrgyzstan, Russia, Turkmenistan, Uzbekistan § 131 ethnic groups, 46 religions

Kazakhstan Cancer Morbidity and Mortality Data 1999 -2017 235 185 135 34 499 1 st place: Breast cancer 27 047 195. 9 197. 3 Morbidity 194. 1 194. 2 192. 6 191. 7 186. 8 183. 7 180. 7 181. 9 181. 3 181. 2 136. 5 133. 4 130. 4 124. 9 120. 5 20 373 190. 7 193. 9 198. 8 207. 7 206. 8 Mortality 114. 4 113. 7 111. 2 105. 1 107 85 195. 2 7 838 104 101. 5 100. 4 99. 5 94 89. 8 211, 0 per 100 000 84. 9 1 st place: Lung cancer 20 16 20 15 20 14 20 13 20 12 20 11 20 10 20 09 20 08 20 07 20 06 20 05 20 04 20 03 20 02 20 01 20 00 20 99 17 44. 4 35 19 270, 5 per 100 000

Cancer Incidence and Mortality in Kazakhstan for 2017, % Oesophagus Ovary Corpus uteri Stomach Hemoblastosis Colorectal Prostate Сervix uteri Lung Breast 0 5 10 15 Mortality 20 25 Incidence 30 35 40 45 50

Mortality of Women in Fertile Age in Kazakhstan, 2017 CERVICAL CANCER ALL CANCERS Age groups Half of women with cervical cancer are dying in fertile age Mortality . . . 23% of women with all types of cancer are die in fertile age

SCREENING PROGRAMMS IN KAZAKHSTAN History Current programs 2013 -2017 Endoscopy 50 -60 years every 2 years Since 2008 PAP smear 30 -70 years every 4 years 2013 -2017 PCA 50 -66 years every 4 years Since 2011 Hemoccult-test 50 -70 years every 2 years 2013 -2017 AFP+Ultra. Sound Patients with Liver Cirrhosis every 2 years Since 2008 Mammography 40 -70 years every 2 years

HISTORICAL OVERVIEW CERVICAL CANCER SCREENING IN KAZAKHSTAN Started among women aged 35 -60, every 5 years, PAP-test Expansion of age groups to 30 -60. 2008 Interpretation by Bethesda system Development of National cancer guidelines 2011 2012 2011 Switching to liquidbased cytology (LBC) 2013 -2014 Expanding age to 30 -70 years and period of screening to 4 year Introducing HPV screening for cervical cancer 2018 2019 -2020

Cervical Cancer in Kazakhstan before screening 18. 00 16. 00 14. 5 14. 9 15. 8 15. 3 15. 5 14. 00 12. 00 40 10. 00 35 8. 00 7 25. 9 15 2008 28. 1 8. 7 10 5 Mortality 0. 4 0. 6 80 60 40 67. 2 68. 6 68. 4 73. 6 77. 0 2004 2005 2006 2007 2008 20 0 I-II St IV St Age-related incidence rate as per 100, 000 women of corresponding age group, average from 2004 -2008 70+ 65 -69 60 -64 55 -59 50 -54 45 -49 100 40 -44 0 0 -14 Incidence 2007 25 -29 2006 20 -24 0. 00 2005 30. 1 16. 9 20 2. 00 2004 31. 3 25 4. 00 35 -39 7. 3 30 7. 7 30 -34 7. 3 7. 5 15 -19 6. 00 27. 9 35. 2 34. 3 34. 4

CYTOLOGICAL SCREENING COVERAGE Coverage, in absolute numbers 60 50 49. 1 48 44. 8 47. 3 48. 3 2015 2014 2013 2008 2016 2015 2014 2013 2012 2011 2010 2009 2008 0 2012 300, 000 67. 7 49. 5 2011 376, 552 76. 8 72. 9 2010 80. 0 70. 0 60. 0 50. 0 40. 0 30. 0 20. 0 10. 0 45. 9 2016 583, 638 2009 554, 283 Coverage by the Population Registry, % 48. 5 48. 1 47. 2 49. 2 47. 5 47. 7 48. 3 40 42. 4 47. 5 26. 4 30 20 Coverage by regions in 2016, % Almaty c. Astana c. East Kaz North Kaz Pavlodar South Kaz Mangistau Kostanay Karaganda Zhambyl West Kaz Atyrau Almaty obl Aktobe Akmola 10 Kyzylorda 600, 000

SCREENING RESULTS CANCER AND PRE-CANCER DETECTION 263 250 200 150 168 151 118 194 190 211 60 189 104 42. 8 2011 2012 50. 8 30 20 50 10 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 Cervical Cancer Incidences in absolute numbers 0. 06 0. 05 0. 04 0. 02 41. 7 48. 9 56. 9 40 100 0. 03 50 52. 5 0. 03 0. 02 0. 01 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 CC detection: % of examined women 0 2013 2014 2015 2016 Proportion of screen-detected cancers that are stage I, % 0. 8 0. 7 0. 6 0. 5 0. 4 0. 3 0. 2 0. 1 0 0. 673 0. 236 0. 323 0. 379 0. 322 0. 136 2011 2012 2013 2014 2015 2016 Pre-cancer detection (ASC-H + HSIL): % of examined women

CERVICAL CANCER IN KAZAKHSTAN Early detection (I and II stages) – 84, 8% (2017) 25 19. 9 20 18. 7 16. 4 16. 2 20. 1 III 12 % 19. 7 18. 5 17. 9 16. 9 IV, 2, 4 % I 36, 1 % 15 10 8. 20 7. 5 7. 7 7. 2 6. 9 7. 8 7. 2 7. 1 6. 2 II 49, 6 % 5 0 2009 2010 2011 2012 2013 Incidence 2014 2015 Mortality 2016 2017: Number of СС patients – 1827 • through self initiated visits to cancer clinics – 1102 (60, 3%) • through medical examination visits – 527 (28, 8%) • through screening program – 198 (10, 8%)

5 -year survival among cancer patients 200 7 201 7 months 5 -year survival 95% CI 52. 505 50. 7 -52. 2 Cervical Cancer– 88, 9% 45, 8% 52. 5% Cervical Cancer – 52, 5%

Cervical cancer screening problems Poor-quality sampling and conservation of biomaterial Violations in the screening algorithm Inadequate software Delayed delivery of consumables for screening High level of cervical cancer detection

Im. PACT MISSION (NOVEMBER, 2016) The program was initiated by the Ministry of Health of the Republic of Kazakhstan Strengthening of monitoring for patient with precancerous pathology. Implementation of HPV screening Increasing of coverage THE MINISTRY OF HEALTHCARE OF THE REPUBLIC OF KAZAKHSTAN

THE MINISTRY OF HEALTHCARE OF THE REPUBLIC OF KAZAKHSTAN RECOMMENDATIONS Expanding of target age PAP smear+ LBC Software improvement

Results of Im. PACT MISSION IN 2018 PRECANCEROUS PATHOLOGY HPV SCREENING Age expansion 30 -70 years TRAINING of CYTOLOGISTS AND GYNECOLOGISTS PILOT project 2019 -2020 Interval reduction to 4 years CONTROL BY KAZIOR TURKISH MODEL OF HPV SCREENING COVERAGE

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