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Almukhamedova Barno Gulmukhamatovna, Tashkent city branch of RSSPMCO&R, Alieva Dilfuza Akmalevna, RSSPMCO&R Yusupov Behruz Dilmuratovich, The women's Wellness center, Orzikulov Sunnatulla Doniyorovich, TUIT for Al-Horezmiy Ruzibaev Ortik Bakhtiyorovich, E-mail: [email protected]
THE PROBLEMS OF CERVICAL CANCER SCREENING IN UZBEKISTAN
Abstract: this article attempts to research main existing problems of cervical cancer screening in Uzbekistan within the scope of the methodological framework and implementation, also provides insight information on how it can be organized screening information system, in order to succeed and insure the high quality measures.
Keywords: cervical cancer, screening, methodological approach, information system.
Алмухамедова Б. Г., Ташкентский городской филиал РСНПМЦОиР
к.м.н. Алиева Д. А., РСНПМЦОиР,
Юсупов Б. Д., Центр здоровья женщин, Орзикулов С. Д., ТУИТ им. Аль-Хорезмий Рузибаев О. Б., ТУИТ им. Аль-Хорезмий E-mail: [email protected]
ПРОБЛЕМЫ СКРИНИНГА РАКА ШЕЙКИ МАТКИ В УЗБЕКИСТАНЕ
Аннотация: В данной статье изучены основные проблемы, имеющиеся в настоящее время в плане проведения скрининга рака шейки матки в Узбекистане, также приведены предпринимаемые меры для правильной методологии его организации, с созданием информационной системы обеспечивающей поддержку и успешность его проведения.
Ключевые слова: рак шейки матки, скрининг, методологические подходы, информационная система.
The problem of cervical cancer (CC) does not cease ity and neglect. It should be noted, that this situation is to remain relevant, given the high incidence of morbid- typical for many countries, including Uzbekistan.
Studies of cervical epidemiology, risk assessment, territorial features are in demand and necessary for the formation of targeted prevention programs, early diagnosis and screening activities [1, 58-71; 4, 30-44; 5, 275-289].
Purpose: to study the possibility of conducting screening studies at the population level in the Republic of Uzbekistan.
Cervical cancer occupies the third position, after breast cancer and stomach cancer, in the structure of morbidity of malignant neoplasms (MN) among all nosonomies. Cervical cancer ranks second, after breast cancer, in the structure of MN among the female population, the incidence rate, which in Uzbekistan is 4.6 and deaths 2.5 per 100 thousand of population, remains high.
The cervical cancer has a long period of development (on average, up to 10 years): the disease can be diagnosed in the preclinical phase, with effective treatment; there are opportunities for a screening test.
Theoretically, the program of cytological screening of cervical cancer was formed in the 1940s of the last century. During this period it was already known that methods of early diagnosis and prevention can help improve the situation, i.e. lead to a decrease in morbidity and mortality.
To date, three morphological classifications of cervical smears have been widely used: the Papanicolaou test (Pap test, Pap smear, cervical smear, or smear test) [6, 153-159; 9, 202-215; 12, 115-132], WHO, Bethes-da System [11, 191; 12, 115-132].
According to the classification of Papanicolaou, there are 5 classes of gynecological smears: I class - normal cells; II class - inflammatory type of smear; III class-dyskaryosis, morphological changes in epithelial cells; IV class - atypical cells, suspicious for malignancy; V class - malignant cell changes.
In the WHO classification (Cervical intraepithelial Neoplasia), the following degrees are distinguished:
• IN I - mild cervical dysplasia;
• CIN II - moderate dysplasia;
• CIN III - severe dysplasia;
• Cancer in situ.
In 1988, in Bethesda City, Bethesda Terminology System was developed (Terminology Bethesda System, TBS) [2, 66-73; 11, 191]. Its main terminological characteristics include:
• ASC (Atypical glandular cells) - atypical glandular (glandular) cells;
• ASC (Atypicals squamous cells) - atypical squamous cells of flat epithelium;
• ASC-US (Atypicals squamous cells underter-mined significance) -atypical flat epithelial cells of undertermined significance;
• ASC-H (Atypicals squamous cells cannot exclude HSIL (high grade squamous intraepithelial lesion)) - atypical cells of the flat epithelium, which do not allow to exclude the defeat of the epithelium of severe degree;
• CIN I, II, III (Cervical intraepithelial neoplasia I, II, III) - cervical intraepithelial neoplasia of I, II and III degree;
• CIS (Carcinoma in situ) -cancer in situ
• HSIL (High grade squamous cells intraepithelial lesion) -high degree of squamous cells intraepi-thelial lesion;
• LSIL - (Low grade squamous cells intraepithe-lial lesion) - low degree of squamous cells in-traepithelial lesion;
• NILM (Negative for intraepithelial lesionor malignancy) -negative for intraepithelial lesionor malignancy;
• NOS (Not other wise specified) - not other wise specified.
According to the literature, the sensitivity of the cytological examination ranges from 66% to 83%, but, at the same time, in 70-90% there are cases that cause false-negative responses due to poor material intake, 10-30% are erroneous interpretation.
The effectiveness and results of cytological screening are as follows:
- detection of premalignant diseases;
- identification of early stages of cancer;
- detection of cancer in situ;
- treatment in time.
With the proper methodology and implementation of cervical cancer screening, it is possible to achieve results in changing the structure of cervical cancer incidence, by identifying the number of patients in the early stages and reducing common and neglected forms; death rates and one-year mortality, and the reduction of disabled patients. To achieve this, it is necessary to ensure continuity in the work of primary health care (family
clinics, RMC, women's clinics) and specialized centers that provide assistance to cancer patients.
Currently, two systems of cytological screening of cervical cancer are accentuated: organized (systematic) screening and unorganized (sporadic) screening. When screening is organized, a definition of groups of women that are subject to screening is carried out, for which they are actively invited to participate in the survey. In case of sporadic screening, women are examined for treatment in connection with the presence of complaints for any pathology.
According to the data [1, 58-71; 3, 16-19; 6, 153-159; 8, 2649-2658] the effectiveness of organized screening is higher than that of unorganized screening.
Screening of cervical cancer involves three stages:
- Stage I (population screening) - division into subgroups is healthy / sick on the basis ofvisual examinations;
- Stage II (diagnostic screening) - division into subgroups according to the degree of cancer risk on the basis ofpre-examination data: background diseases, pre-cancer, cancer;
- Stage III - formation of dispensary observation groups for monitoring and correction according to the nosological principle.
Early detection of cervical cancer requires extensive coverage of the female population by cytological screening, which can lead to changes in the structure of morbidity and the stabilization of mortality by identifying early stages and reducing neglect. The informative value of the cytological method is 50-87%, in connection with which it is necessary to search for modern methods with increased sensitivity and specificity.
Given the high role of the human papillomavirus (HPV) in cervical cancer, one of the methods of early diagnosis is HPV testing, which is currently carried out in private clinics in our republic, just as the cost of this method is expensive. Despite this, the need to introduce modern approaches in the early diagnosis of cervical cancer, and screening programs is obvious.
In our republic, on April 4, 2017, a resolution and the President's state program on improving the provision of specialized care for cancer patients were adopted, within the framework of which screening programs for various diseases of the MN, including cervical cancer, are envisaged.
In this regard, population-based screening studies have been initiated at the family clinic of the Yakkasaray district of Tashkent, with the assistance of the private clinic "Women's Health Center", in which HPV testing will be carried out. To this end, the distribution of women, who will participate in a screening program with cytological testing and HPV testing, across all areas of the clinic's service area was conducted.
To optimize the implementation and conduct of screening studies, an information system (IS) is being developed, which will include questionnaires and questions to determine the risk factors for the development of cervical cancer, which will subsequently be a database of women, who underwent a screening study with further monitoring.
The existing problem of a high incidence rate, despite the availability of organ visualization, is apparently due to the destruction of the earlier existing system, which provides for the presence of observation rooms separate for the male and female population, the inability and low quality of inadequate preventive examinations, the lack of methodological bases for conducting screening studies and programs, which is currently being developed.
In this regard, the modern strategies and measures taken in this direction require integration and friendly work on the implementation of methodologically tested screening programs in conjunction with the regional centers of oncology and radiology, which will be developed on the basis of current trends in cervical cancer development, taking into account the risk factors of this disease separately for of each territory.
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