Launch of screening for breast and colon cancer

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The MoH of Slovenia decided to support the introduction of two new organised screening programmes for cancer, one for breast and the other for colon cancer in 2005. After the idea had been proposed, the Health Council analysed and supported the concepts. Preparations took one year and in the course of 2008 both programmes are expected to be launched. Regionally gradual screening for breast cancer was launched in April 2008, while the nationwide screening for colon cancer starts later this year.

Purpose of health policy or idea

The main objective of the introduction of the two organised screening programmes is in reducing mortality due to breast cancer and colon cancer. In both cases, Slovenia underperforms when compared to the best performing countries in Europe. In the case of mammography screening, which is at present opportunistic, the actual number of mammographs is high. But as it is not performed in an organised fashion and dedicated to the specific age groups, the outcomes do not match the infrastructure invested. In contrast, colon cancer is the cancer with the highest rise in incidence, partly as a result of risk factors and partly due to ageing.

Both screening programmes will be performed through a central system, which will support inivtations to screening and steer also the next steps in the process of disease management when necessary. There will be specific financing provided for the carrying out of the screening and for the further management, which will be independent from the present financing of curative services for both diseases. The necessary investments will be made out of the national budget and will cover the new infrastructure for mammographies and a central laboratory for stool occult blood testing. Providers will be refunded for all services in the disease management that will be necessary for the follow-up treatment of the patients identified with one of the two diseases.

There should be benefits in reduced mortality for the target populations (50-69) for breast cancer and for colon cancer, provided response rates reach at least 70% of the target populations.

 

Main points

Main objectives

The main objective of the two screening programmes is to reduce mortality for the respective cancers. This should be achieved through organised screening programmes intended for specific target populations, where benefits can be greatest. For this purpose, epidemiologic data were analysed and both, in the case of breast as well as colon cancer, the age group 50 to 69 years was identified as the target population.

In breast cancer screening, called DORA, women aged 50 to 69 will be invited to screening, which will be carried out in either of the two main centres (Ljubljana, Maribor) or in one of the mobile centres. It started in April 2008 in the largest region of Ljubljana and it will be spread throughout Slovenia by June 2010. The programme is based on the latest international experience in breast cancer screening. There has been a specially intense co-operation with the University Hospital in Heidelberg, which provided some additional training and knowledge transfer. Women in the target age group will be called by a letter of invitation to undergo a screening mammography every two years. If found suspicious or marginal, they will be scheduled for diagnostic cf. therapeutic procedures by the respective centre. After the establishment of clinical diagnosis they will follow the same process of care as in the period of opportunistic screening.

In the case of colon cancer (the programme is called SVIT) every person in the target age group will receive a package for sending of two independent stool samples. These are going to be sent to a special centralised laboratory, which will process all samples, using the immunohistochemical method. If found positive, the person will be scheduled for a diagnostic/therapuetic colonoscopy at the nearest regional centre. After that the process will be the standard clinical treatment and follow-up. Invitation for stool samples will regularly follow every two years within the age group, regardless of the fact if the last test was negative.

Type of incentives

The entire setting of the two screening programmes is defined as two self-contained and centrally managed programmes with specially allocated resources and its own structure for quality assurance and follow up.

Groups affected

Population aged 50 to 69 years, Health care providers, Health insurance institute of Slovenia

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

DORA and SVIT

The two programmes, DORA (breast cancer) and SVIT (colon cancer) had been prepared for several years and were not particularly influenced by any specific general or political circumstance.

The fact that Slovenia chose cancer as the main topic of its presidency to the Council of the EU helped in creating a positive environment at the political level and to push for the last necessary decisions to be taken in dedicating the required resources. This was important both in view of the specific requirements defined by each of the two programmes, as well as in giving a good example in complying with the common European positions and guidelines on cancer management and the respective screening programmes.

Even if Slovenia still does not have a specific national cancer plan (it is under preparation and it is, hopefully, going to be ready for adoption by the end of this year), it decided to make a move forward in two of the most important cancers for its population. It is important even more so, because of the insufficient performance of existing/previous opportunistic initiatives, which have not yielded the desired outcomes.

The recognition of the DORA programme by the Health Council in March 2007 and of SVIT programme in December 2006 marked the launch of the two remaining, currently internationally recognised and validated organised screening programmes to reduce the burden of cancer in Slovenia.

Complies with

Guidelines for screening for cervical, breast and colon cancer

Change based on an overall national health policy statement

Draft national cancer plan (in preparation)

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The idea was generated in the cancer and public health communities and had two background reasons. Both of these were founded in the developments of the epidemiological situation. One of them was in the fact that survival of breast cancer patients kept lagging behind the best performing countries, in spite of the quickly growing number advancing points of mammography screening. This was carried out in an unorganised, opportunistic fashion, not ensuring comparability of diagnostic standards and thus also the outcomes.

The other reason lied with the developments in colon cancer epidemiology. This is one of the most rapidly growing cancers in Slovenia, which is partly due to the risk factor distribution and developments and partly, due to the ageing of Slovenia's population. This in combination with the decline in the share of early diagnosed colon cancer cases led to the initiative to launch an organised screening programme.

What is common to both initiatives is the fact that they are both internationally recognised and validated and that they both apply to the same population age group. The initiative for organised breast cancer screening has been supported for many years by the EuropaDonna movement in Slovenia, which also raised significant funds for some of the necessary preparatory activities.

Initiators of idea/main actors

• Government

• Payers

• Patients, Consumers

• Civil Society

• Scientific Community

Approach of idea

The approach of the idea is described as:
renewed: Breastcancer screening based on the German experience, colon cancer screening based on experience and approaches from Finland and France

Stakeholder positions

There was general agreement about the usefulness and the benefits of the two screening programmes and there were few limited reservations, such as the concern over the available capacity to manage and treat all the new patients in the first two or three years of the respective programmes.

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Payers
Health Insurance Institute of Slovenia	very supportive		strongly opposed
Patients, Consumers
Patient groups	very supportive		strongly opposed
Civil Society
Europa Donna association	very supportive		strongly opposed
CINDI Slovenija	very supportive		strongly opposed
Scientific Community
Institute of Oncology	very supportive		strongly opposed
Cancer registry	very supportive		strongly opposed

Influences in policy making and legislation

The two programmes were proposed to the Health Council, which is the advisory body to the Ministry of Health in the issues of scientific validation of new programmes and of health economics. Both were assessed according to the standard protocols and were adopted under the standard procedures, breast cancer screening programme in March 2007 and colon cancer screening programme in December 2006.

Legislative outcome

success

Actors and influence

Government
Ministry of Health	very strong		none
Payers
Health Insurance Institute of Slovenia	very strong		none
Patients, Consumers
Patient groups	very strong		none
Civil Society
Europa Donna association	very strong		none
CINDI Slovenija	very strong		none
Scientific Community
Institute of Oncology	very strong		none
Cancer registry	very strong		none

Positions and Influences at a glance

Monitoring and evaluation

There will be an ongoing process of monitoring and evaluation in the case of both programmes.

1. Epidemiologic monitoring and evaluation will be performed by the Cancer registry of Slovenia and will ensure data on survival, clinical outcomes and changed disease management practices.
2. Quality assurance processes will be applied to both programmes, specifically in breast cancer screening there will be a three-level quality assurance mechanism, providing peer-control, supervisory national roles and international reference supervision. In the case of colon cancer screening the same will be assured through the standardisation of the laboratory practices and their centralisation in one single laboratory.

Expected outcome

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

References

Sources of Information

1. Project DORA for breast cancer screening at: http://dora.onko-i.si
2. Programme SVIT for colon cancer screening at: http://www.zd-lj.si/zdlj/content/view/282/244/ 
3. Documentation - conclusions and minutes of the Health Council at the Ministry of Health (http://www.mz.gov.si )

Author/s and/or contributors to this survey

Tit Albreht

Suggested citation for this online article

Tit Albreht. "Launch of screening for breast and colon cancer". Health Policy Monitor, April 2008. Available at http://www.hpm.org/survey/si/a11/2