EUROCHIP ACTIVITY IN BULGARIA

1. EUROCHIP ACTIVITY IN BULGARIA Cervical cancer screening problems and barriers in Bulgaria

2. Action of the Bulgarian group One of the main tasks of the Bulgarian action under EUROCHIP-II project is to assess the information level and the readiness for implementation of organized population–based cervical cancer screening in the country. For that purpose we start interviewing health consumers, health experts and devoted specialists of local and national level, who are currently engaged in the cervical cancer secondary prevention and women’s reproductive health on a general basis.

3. Main problems of cervical cancer in Bulgaria • 1097 new diagnosed cases in the year 2004 (7.6% of all cancer cases in females; 4th place, after breast cancer, non-melanoma skin cancer and corpus uteri cancer). • 55% increasing of the new cases in the age group 30 - 44 years in 2004 compared to 1984. • Increasing of the incidence and mortality rates over time. In the age group 30 - 44 years age-specific incidence rate is 11.52 (1984) vs. 41.17 (2004) per 100 000 females. The same mortality rates increase 3 times, from 3.46 (1984) to 10.13 (2004).

4. Main problems of cervical cancer in Bulgaria • Ca in situ of the cervix uteri is only 20.4%, and invasive cervix uteri cancer is 79.6% in the year 2004. More than 30% of the new cases are in III + IV stage (UICC, 1998) and it doesn’t changed during the last 20 years. • Estimated age-standardized mortality rates (European standard), 2006 for Uterus (C53-55) are 14.4 (Bulgaria), 6.8 (EU25), and 9.3 (Europe) per 100 000 (Ferlay J., et al public. Estimates of the cancer incidence and mortality in Europe in 2006. Annals of Oncology, 2007).

5. Methodology and Sampling The study was conducted using a structured questionnaire of 15 questions, developed by the Health Psychology Research Center and consulted by leading specialists in cervical cancer prevention. The sample was consisted of 46 respondents (43.5% men and 56.5% women)

6. Methodology and Sampling They were affiliated with the following institutions and organizations: The Ministry of Health, The National Health Insurance Fund, The National Center for Public Health, The Medical Universities of Sofia, Varna and Plovdiv, The National Oncological Hospital, The Bulgarian Association of Obstetrics and Gynecology, The Military Medical Academy, Oncological Dispensaries of Sofia and Plovdiv, Non-profit organizations (NGO) They included health managers, heads of clinics, professors, research scientists, oncologists and gynecologists.

7. Prevalence, Priority & Programs for Preventionof Cervical Cancer • Prevalence: About 60 % of respondents ranked Bulgaria among the countries with highest levels of cervical cancer in Europe. About 30% believe that Bulgaria is among countries with medium morbidity and mortality from cervical cancer in Europe. The majority of them are affiliated with the Ministry of Health and the National Health Insurance Fund. No one believed that Bulgaria is among countries with the lowest morbidity and mortality. About 10 percent of participants had no knowledge about the issue.

8. Prevalence, Priority & Programs for Preventionof Cervical Cancer • Priority*: About 30% stated that cervical cancer is treated as a real priority; 30% stated that it is not considered a priority at all and 37% believe that cervical cancer screening should be a real priority, but this is not reflected anywhere in the currently enacted regulations. • Programs for Prevention:The results show that there is no clear view on the ongoing programs for cervical cancer prevention in Bulgaria. *More than one answer was possible.

9. Obstacle . 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Barriers to screening The insufficient number of cytological laboratories The insufficient number of specialists Difficulties in covering all women eligible for screening The unwillingness of women to be screened The absence of a screening register Insufficient financing The absence of knowledge regarding the effectiveness of SPs The absence of organized mass screening The absence of a health policy regarding screening

10. Responsibility Which institutions should be involved in the organization of CCS in Bulgaria?* • 91% of respondents identified the Ministry of Health as having to take on the main responsibility. • Other institutions, that could have an important input in the organization of cervical cancer screening - Local authorities – 20%; The National Oncological Hospital – 35%; The National Center of Public Health – 37%; NGOs - 35% ). Who should finance the organized population-based CCS?* • For 67% the main responsibility for funding should go to the Ministry of Health through the national budget; • About 1/2 of respondents foresaw the National Health Insurance Fund as having responsibility for funding. It was not uncommon for both options to be marked by the same participant. • 24% think that there should be special funds allocated for screening programs • no one believes that women should pay out of pocket for screening. Specialists who should be performing the cervical smears for screening * • 90% - Specialists of obstetrics, gynecology and reproductive medicine. • 35% - General Practitioners • 17% - midwifes *More than one answer was possible.

11. Most effective approach and health system’s ability to cope Which is the most effective approach for CC prevention?* • For 80% that is the organized population-based screening; • 48% believed that effectiveness could be achieved by enforcing screening through mandatory preventive check ups. • Very few of respondents selected voluntary preventive check ups or selective screening as options. Is the current health system in Bulgaria capable to organize and implement organized CC screening? • 61 % - stated that the system has no capability to cope • 33 % - believe that it does * More than one answer was possible

12. Evaluation of the standards in the cytological laboratories in Bulgaria • The evaluation of cytological laboratories and improvement of work’s quality demands introduction of widely accepted standards of organization of work and keep to the technical requirements in the routine work. • They include: minimal capacity of work load, staff and technical equipment, follow regulations of smears’ preparation, reporting system and data storage. • The assessment of standards is made of two investigated laboratories (of National Oncological Hospital, Sofia and Oncological Dispensary, Plovdiv).

13. Evaluation of the standards in the cytological laboratories • On the basis of the analysis and comparison of the standards in the laboratories under study and international standards the conclusion can be drawn that the required minimum for laboratory cytological diagnostics is available. • Unfortunately, the performance of effective screening activities require the introduction of more conditions such as: • Development of a system of continuing training and evaluation • Introducing and implementing of unified terminology for reporting results • Development of a computerized laboratory register • Implementation and respect of the European standards for the activities of screening laboratory • Connection with the national screening register

14. Conclusions • Health authorities consider cervical cancer screening as real health priority. However, many of them do not have clear vision on the ongoing preventive programs. • The Ministry of Health is the main structure that should be involved in the organization and the implementation of the screening program. NGOs are perceived as important participant, especially for public health campaigns (same as breast cancer activities).

15. Conclusions • Screening program should be financed by the National/State budget. The role of the National Health Insurance Fund (NHIF) is not clear. • Population-based screening is recognized as the best way for cervical cancer prevention. • Many specialists doubt if the current health system is able to cope with organizing and carrying out an effective screening program. • The majority of respondents evaluate the pre-1989 screening system as good and the current situation as poor.