Present state and possibilities for improvement of cancer prevention and early detection in the Osijek-Baranya county

Cancer morbidity and mortality are on a steady increase in Croatia. Technologic possibilities for appropriate management are available for four cancer sites, i.e. cancer of the breast, cervix uteri, colorectum and prostate, and include cancer prevention and early detection in individuals yet free from manifest signs of the disease. The magnitude of the problem, the experience acquired to date, health care personnel available, and additional resources required to launch a systematic program of early detection of the disease are presented. The program should be initially launched in a county with greatest experience in early detection of cancer, where health care service is ready to immediately start its implementation. The role of family physician, gynecologic service at primary health care level, and polyclinic-consultation hospital service in program implementation is described. The following three possible options for early detection of cancer are analyzed and proposed: minimal program (early detection every 3 years), medium program (the same individuals examined every 2 years), and optimal program proposed by the American Cancer Society and other national and international organizations.     

Tissue banking training courses: Polish experience

Personnel directly involved in the donation, procurement, testing, processing, preservation, storage and distribution of human tissues and cells should be appropriately qualified and provided with timely and relevant training according to EU directives. In the time of new tissue and cells regulations implementation such a training system existed in Poland only at a local level. The first training programme outlines for various groups of health professionals engaged in tissue banking practice was created in co-operation with the Institute for LifeLong Learning at University of Barcelona in 2006. This initial training courses were financially supported by EU Transition Facility Programme 2004. Then, starting from 2006, based on previous experience, system of advanced training courses was created. This training programme was financially supported by the National Programme for the Development of Transplantation Medicine 2006–2009—POLGRAFT financed by Polish Ministry of Health. During 2006 and 2007 first set of tissue banking initial training courses were provided according to TF 2004 project. Over 200 pathologists, forensic medicine specialists and other medical doctors responsible for donor screening and classification, medical directors of tissue establishments, technical staff; tissue graft users: orthopaedic surgeons, neurosurgeons, cardiosurgeons and ophthalmologists were trained. Between 2006 and 2009 there were organized 8 advanced tissue banking training courses according to POLGRAFT programme. There were organized both theoretical and practical courses on various aspects of tissue for over 350 persons. We present our experience in organisation of international and national tissue banking training courses.     

Implications of gynaecological abnormalities in pre-selection criteria for cervical screening: preliminary evaluation of 3602 subjects in South India

Early detection and eradication of cervical cancer and its precursor lesions through organized mass cytological screening programmes have recently gained considerable attention in developing countries. Strategies for both cost saving and effective implementation are however required for mass cervical screening in developing countries. In an early cancer detection programme conducted in South India, we analysed cytological abnormalities in 3602 women and correlated the results with other factors, including age, gynaecological complaints, number of years of married life and parity to see if pre-selection for cytologic screening was possible. Only lower grades of dysplasia were found in asymptomatic women below the age of 40 years. In asymptomatic women, malignancy and higher grades of dysplasia were confined to women with a clinically abnormal cervix only. Univariate analysis also revealed that subjects with a parity of more than 3 and a married life of more than 20 years had a significantly higher number of cytological abnormalities. However, on a multivariate analysis the increased number of marital years was not found to be an independent variable. These results suggest that asymptomatic women below the age of 40 years with a married life of less than 20 years and parity below 3, may be excluded from screening campaigns, and that pre-selection for cytologic screening is possible by introducing a programme of clinical and speculum examination of the cervix.     

HPV testing for cervical cancer screening in Croatia

Opportunistic screening based on the Pap smear has been undertaken in Croatia since 1953. However, cervical cancer remains an important health problem in Croatia when compared to European countries with organised screening programmes. In Croatia, in addition to screening based on well established cytology, Human papillomavirus (HPV) testing is widely used as secondary test as a triage to borderline cytology and as a follow-up after treatment of severe cervical lesions. Many different approaches for HPV testing arose in Croatia over the last decade depending on the needs of each medical institution involved. Presently, there is an urgent need for better networking between the laboratories, the implementation of quality assessment and the adaptation of a uniform system of referring to and reporting of HPV testing. In conclusion, the best possible organisation for HPV testing would be essential for implementation of HPV testing as primary screening test in Croatia, an thus ultimately and hopefully, the more successful cervical cancer control.     

Cancer: improving early detection and prevention. A community practice randomised trial.

OBJECTIVE--To test the impact of physician education and facilitator assisted office system interventions on cancer early detection and preventive services. DESIGN--A randomised trial of two interventions alone and in combination. SETTING AND SUBJECTS--Physicians in 98 ambulatory care practices in the United States. INTERVENTIONS--The education intervention consisted of a day long physician meeting directed at improving knowledge, attitudes, and skills relevant to cancer prevention and early detection. The office system intervention consisted of assistance from a project facilitator in establishing routines for providing needed services. These routines included division of responsibilities for providing services among physicians and their staff and the use of medical record flow sheets. MAIN OUTCOME MEASURES--The proportions of patients provided the cancer prevention and early detection services indicated annually according to the US National Cancer Institute. RESULTS--Based on cross sectional patient surveys, the office system intervention was associated with an increase in mammography, the recommendation to do breast self examination, clinical breast examination, faecal occult blood testing, advice to quit smoking, and the recommendation to decrease dietary fat. Education was associated only with an increase in mammography. Record review for a patient cohort confirmed cross sectional survey findings regarding the office system for mammography and faecal occult blood testing. CONCLUSION--Community practices assisted by a facilitator in the development and implementation of an office system can substantially improve provision of cancer early detection and preventive services.     

Cervical cancer in Croatia: state of the art and possibilities for prevention

In Croatia, there are about 355 incident cases and about 100 deaths from cervical cancer every year. The aim of this study is to present the trends of cervical cancer incidence and mortality and to propose preventive strategies for cervical cancer in Croatia. Age-standardised and age-specific cervical cancer incidence rates were calculated for the period 1985-2004. For cervical cancer mortality data, the WHO Mortality Database was used. After an early decrease of cervical cancer incidence and mortality following the introduction of opportunistic screening in Croatia, no further decrease has been observed since the 1990s. An increase in incidence over the last 20 years was observed in the age-groups 40-44 and 45-49 years. To reduce cervical cancer rates, an organised cervical cancer screening programme is essential. In addition, HPV vaccination should be introduced in the school vaccination programme to achieve further reductions in cervical cancer incidence in the future.     

The use of bacterial larvicides in mosquito and black fly control programmes in Brazil

Bacillus spp. based larvicides are increasingly replacing, with numerous advantages, chemical insecticides in programmes for controlling black fly and mosquito populations. Brazil was among the pioneers in adopting Bacillus thuringiensis israelensis (B.t.i) to control black flies. However, the major current mosquito control programme in Brazil, the Programme for Eradication of Aedes aegypti launched in 1997, only recently decided to replace temephos by B.t.i based larvicides, in the State of Rio de Janeiro. In the last decade, works developed by research groups in Brazilian institutions have generated a significant contribution to this subject through the isolation of B. sphaericus new strains, the development of new products and the implementation of field trials of Bacillus efficacy against mosquito species under different environmental conditions.     

Scaling Up Paediatric HIV Care with an Integrated,Family-Centred Approach: An Observational Case Study from Uganda

Family-centred HIV care models have emerged as an approach to better target children and their caregivers for HIV testing and care, and further provide integrated health services for the family unit’s range of care needs. While there is significant international interest in family-centred approaches, there is a dearth of research on operational experiences in implementation and scale-up. Our retrospective case study examined best practices and enabling factors during scale-up of family-centred care in ten health facilities and ten community clinics supported by a non-governmental organization, Mildmay, in Central Uganda. Methods included key informant interviews with programme management and families, and a desk review of hospital management information systems (HMIS) uptake data. In the 84 months following the scale-up of the family-centred approach in HIV care, Mildmay experienced a 50-fold increase of family units registered in HIV care, a 40-fold increase of children enrolled in HIV care, and nearly universal coverage of paediatric cotrimoxazole prophylaxis. The Mildmay experience emphasizes the importance of streamlining care to maximize paediatric capture. This includes integrated service provision, incentivizing care-seeking as a family, creating child-friendly service environments, and minimizing missed paediatric testing opportunities by institutionalizing early infant diagnosis and provider-initiated testing and counselling. Task-shifting towards nurse-led clinics with community outreach support enabled rapid scale-up, as did an active management structure that allowed for real-time review and corrective action. The Mildmay experience suggests that family-centred approaches are operationally feasible, produce strong coverage outcomes, and can be well-managed during rapid scale-up.     

赣州市结核病防治规划实施情况分析

目的详细了解赣州市结核病防治规划实施情况,为今后结核病防治工作提供依据。方法由赣州市疾病预防控制中心执行卫生部统一制定下发的《全国结核病防治规划(2001-2010年)终期评估方案》和《终期评估调查表》,进行单位自查与市级组织检查验收。通过验收的《终期评估调查表》全部录入计算机,进行资料分析。结果《规划》期间全市投入用于结核病防治的各种费用总计4 517.04万元。登记活动性肺结核63 427例,其中涂阳患者33 339例(初阳27 621例、复阳5 718例),涂阴27 408例,完成初治涂阳任务指标平均达到99.64%,治愈率平均达到91.11%。结论经实施《全国结核病防治规划(2001-2010年)》,赣州市结核病的防控措施无论是软件还是硬件都得以完善,并且病人及时得到发现与有效治疗。     

Cervical screening in the UK and laboratory quality control in the context of the 2007 European guidelines

The first part of this article will provide an overview of cervical cancer screening in the UK during the years before, during and after the introduction of a highly successful centrally organised cervical screening programme in 1988: since then the incidence of invasive cervical cancer has fallen by more than 40%. Screening was introduced in a background of opportunistic screening with poor quality control during a period of time when risk of disease was increasing, which will be demonstrated by national registrations of carcinoma in situ as well as invasive cancer. The programme is still facing new challenges and has recently recorded falling screening coverage in younger women, the causes of which have yet to be established. Liquid-based cytology is in the process of being rolled out nationally but high-risk human papillomavirus testing has yet to be introduced into the National Health Service (NHS) programme. Lessons from our experience may be relevant to countries introducing and maintaining organised programmes elsewhere under similar circumstances. The second part of the article will consider laboratory quality control as practiced in the UK and as recommended in the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. These evidence-based guidelines provide recommendations for organising and monitoring quality control as well as for introducing new technology and standardising terminology, which are equally relevant for new and existing programmes. Invasive cancer audit may highlight areas where procedures could be improved in any programme but also can also demonstrate the effectiveness of screening.     

Did the first Global Fund grant (2003-2006) contribute to malaria control and health system strengthening in Timor-Leste?

ABSTRACT: BACKGROUND: In 2003, Timor-Leste successfully obtained its first Global Fund grant for a three-year programme for malaria control. The grant aimed to reduce malaria-related morbidity and mortality by 30 % by the end of the implementation. METHODS: A mixed-methods approach was used to assess the impact of the grant implementation. Fiftyeight in-depth interviews, eight group interviews, 16 focus group discussions, and on-site observations were used. Morbidity data reported to the Ministry of Health were also examined to assess trends. RESULTS: The National Malaria Programme with funding support from the Global Fund grant and other development partners contributed considerably to strengthening malaria control and the general health system. It also brought direct and indirect benefits to pregnant women and to the community at large. However, it failed to achieve the stated objective of reducing malaria morbidity and mortality by 30 %. The implementation was hampered by inadequate human resources, the rigidity of Global Fund rules, weak project management and coordination, and inadequate support from external stakeholders. CONCLUSION: Despite limitations, the grant was implemented until the agreed closing date. Considerable contributions to malaria control, health system, and the community have been made and the malaria programme was sustained.     

Calling sample mix-ups in cancer population studies

Sample tracking errors have been and always will be a part of the practical implementation of large experiments. It has recently been proposed that expression quantitative trait loci (eQTLs) and their associated effects could be used to identify sample mix-ups and this approach has been applied to a number of large population genomics studies to illustrate the prevalence of the problem. We had adopted a similar approach, termed 'BADGER', in the METABRIC project. METABRIC is a large breast cancer study that may have been the first in which eQTL-based detection of mismatches was used during the study, rather than after the event, to aid quality assurance. We report here on the particular issues associated with large cancer studies performed using historical samples, which complicate the interpretation of such approaches. In particular we identify the complications of using tumour samples, of considering cellularity and RNA quality, of distinct subgroups existing in the study population (including family structures), and of choosing eQTLs to use. We also present some results regarding the design of experiments given consideration of these matters. The eQTL-based approach to identifying sample tracking errors is seen to be of value to these studies, but requiring care in its implementation.     

WHO's special programmes: undermining from above.

Despite the World Health Organisation''s spoken commitment to developing integrated primary health care, its most visible and successful activities are not integrated within countries; they are its disease specific intervention programmes, such as the Global Programme on AIDS and the programmes for the control of diarrhoeal and acute respiratory diseases. The 10 or so special programmes, all but one of which (the onchocerciasis control programme) are based in Geneva, have found increasing favour among donors, but critics say that they undermine WHO''s attempts to integrate its activities at country level and discourage countries from developing their own capacity.     

Onderwijs in het Nationaal Programma Ouderenzorg

The Netherlands Organisation of Health Research and Development started in 2008 the Dutch National Care for the Elderly Programme (in Dutch abbreviated as NPO) with the aim to improve the quality of life for the frail older people through better quality of care (health, social, community) which is tailored to the needs and wants of older people. The delivery of good care is related with competent professional behaviour which is inextricably linked to the education of professionals. This article presents an overview of 32 educational programmes developed within the NPO. Within the NPO different educational programmes were developed on relevant themes to improve elderly care. However, the programmes focused mainly on professionals in health care, especially those working in primary care. For nurses and nursing assistants and more or less for physicians also different educational programmes were developed. Educational programmes for paramedics or professionals working in social care, housing or in the municipalities were scarce. This is also the case for specific themes in elderly care like loneliness or (domestic) violence. Moreover, none of the experiments focused on older people or informal care givers. Although 22 of the 32 projects developed educational programmes for different groups, multi – or interdisciplinary education is rare in these programmes. Based on the overview we advise the development of more educational programmes on: target groups which were less or not addressed in the NPO, like professionals in social care and paramedics; multi- or interdisciplinary collaboration; and themes, like loneliness in older people and elder abuse.     

Microcalcifications in breast cancer: From pathophysiology to diagnosis and prognosis

The implementation of mammographic screening programmes in many countries has been linked to a marked increase in early detection and improved prognosis for breast cancer patients. Breast tumours can be detected by assessing several features in mammographic images but one of the most common are the presence of small deposits of calcium known as microcalcifications, which in many cases may be the only detectable sign of a breast tumour. In addition to their efficacy in the detection of breast cancer, the presence of microcalcifications within a breast tumour may also convey useful prognostic information. Breast tumours with associated calcifications display an increased rate of HER2 overexpression as well as decreased survival, increased risk of recurrence, high tumour grade and increased likelihood of spread to the lymph nodes. Clearly, the presence of microcalcifications in a tumour is a clinically significant finding, suggesting that a detailed understanding of their formation may improve our knowledge of the early stages of breast tumourigenesis, yet there are no reports which attempt to bring together recent basic science research findings and current knowledge of the clinical significance of microcalcifications. This review will summarise the most current understanding of the formation of calcifications within breast tissue and explore their associated clinical features and prognostic value.     

National Health Service breast screening programme results for 1991-2.

OBJECTIVES--To report the results of the NHS breast screening programme for the year March 1991 to April 1992. DESIGN--A report of statistics was derived from Körner (K62) returns and from the radiology quality assurance programme. MAIN OUTCOME MEASURES--Detection rates for breast cancer and small (< or = 10 mm diameter) invasive cancer, benign biopsy rates, and recall and acceptance rates. RESULTS--The acceptance rate for screening across the United Kingdom was 71.3%. The referral rate for further investigation was 6.2% (regional 4.3-9.0%). The breast cancer detection rate was 6.2 cancers per 1000 women screened (5.1-9.0) and the detection rate of invasive cancers < or = 10 mm was 1.4/1000 (1.0-2.3). 72% of screening programmes reached the target 70% acceptance rate, and 95% of programmes achieved a recall rate of less than 10%. 75% of programmes had a cancer detection rate of more than 5/1000, but only 32% had a detection rate for invasive cancers < or = 10 mm of more than 1.5/1000. CONCLUSIONS--Overall, the results of the screening programme for the year 1991-2 can be regarded as extremely satisfactory, given the size and complexity of the operation.     

Implementing and managing self-management skills training within primary care organisations: a national survey of the expert patients programme within its pilot phase

A key element of the United Kingdom (UK) health policy reform in relation to chronic disease management is the introduction of a national programme seeking to promote self-care from within the National Health Service (NHS). The mainstay of the Expert Patients Programme (EPP) is a six-week training course that provides the opportunity for anyone with a long-term condition to develop new skills to manage their condition better on a day-to-day basis. The course forms part of the NHS self-care support programme, is administered by Primary Care Trusts (PCTs) and delivered by people who have personal experience of living with a long-term condition. The NHS' official Expert Patients Programme website presently states that, "Pilot EPP courses began at 26 NHS PCT sites across England in May 2002, and by May 2004 approximately 300 PCTs had either actively implemented pilot courses or had committed to joining. The majority of PCTs are now coming to the end of the pilot phase, with many implementing plans to make EPP sustainable for the long-term." The NHS website heralds the pilot "a success." A national, postal survey of PCT EPP Leads was undertaken in order to examine both the evolvement of EPP during its pilot stage and future plans for the programme. A questionnaire was sent out to the 299 PCTs known to have committed to the EPP pilot, and an excellent 100% response rate was obtained over a 3-month period (April-July 2005). One marker of success of the Expert Patients Programme implementation is the actual running of courses by the Primary Care Trusts. This paper explores the extent to which the implementation of the pilot can indeed be viewed as a "success," primarily in terms of the number of courses run, and considers the extent to which PCTs have carried out all that they were committed to do. Findings suggest that the more time an EPP Lead dedicates to the Programme, the more likely it is that EPP has run successfully in the past, and the more likely it is that it will continue to run successfully in the future. Other factors indicating future EPP success include collaborating across PCTs to share co-ordinators, tutors, and funding.     

Effectiveness of home care programmes for patients with incurable cancer on their quality of life and time spent in hospital: systematic review

Objective: To investigate whether for patients with incurable cancer comprehensive home care programmes are more effective than standard care in maintaining the patients’ quality of life and reducing their “readmission time” (percentage of days spent in hospital from start of care till death). Design: Systematic review. Methods: A computer aided search was conducted using the databases of Medline, Embase, CancerLit, and PsychLit. The search for studies and the assessment of the methodological quality of the relevant studies were performed by two investigators, blinded from each other. Prospective, controlled studies investigating the effects of a home care intervention programme on patients’ quality of life or on readmission time were included in the analyses. Results: Only 9 prospective controlled studies were found; eight were performed in the United States and 1 in the United Kingdom. Their methodological quality was judged to be moderate (median rating 62 on a 100 point scale). None of the studies showed a negative influence of home care interventions on quality of life. A significantly positive influence on the outcome measures was seen in 2 out of the 5 studies measuring patients’ satisfaction with care, in 3/7 studies measuring physical dimensions of quality of life, in 1/6 studies measuring psychosocial dimensions, and in 2/5 studies measuring readmission time. The incorporation of team members’ visits to patients at home or regular multidisciplinary team meetings into the intervention programme seemed to be related to positive results. Conclusions: The effectiveness of comprehensive home care programmes remains unclear. Given the enormity of the problems faced by society in caring for patients with terminal cancer, further research is urgently needed.

Key messages

• Only nine controlled prospective studies have compared the effects of home care intervention programmes for patients with terminal cancer with those of standard care, in relation to patients’ quality of life and time spent in hospital between start of care and death
• The methodological quality of these studies seemed to be moderate
• Home care programmes did not have a negative influence on quality of life or time spent in hospital; some studies observed positive effects on these outcome measures
• Enabling team members to visit patients at home and holding regular multidisciplinary team meetings seem important elements for obtaining favourable results
• The general belief that home care programmes are effective for patients with terminal cancer is not supported scientifically