Organization of Population-Based Cervical Cancer Screening Program ZORA in Slovenia

Key Contextual Factors

Organization:

• Founded in 2003: Ministry of Health (MoH), Health Insurance Institute of Slovenia (HIIS).
• Central management since 2003: Institute of Oncology Ljubljana (Head of the program, Central coordination unit since 2003 with central Screening registry, Expert Council).
• Screening providers since 2003: gynecological teams (screening and diagnostic, treatment, follow up after treatment), laboratories (cytopathology, histopathology, HPV testing).
• Reimbursement of all costs to screening providers since 2003 by HIS.
• Screening Programs Steering Committee since 2018: MoH; HIIS, Association of Health Institutions of Slovenia, NGOs.

Key Components/Steps

• 1998-2000: Pilot of organized screening in two regions.
• 2003: Roll-out of national organized screening with central screening registry nightly synchronized with Central Population Registry, quality assurance, monitoring and control.
• 2003 (last change in 2019): Legal frame for  implementation of national screening programs for the early detection of precancerous changes and cancer).
• Current developmental projects:

• Renewal of the central information system of the screening programme. Linked to national eHealth, clinical data structured in open Electronic Health Record (EHR)format. A change in the concept of the screening registry: switching from database of copies of all reports, to e-circle among screening providers with real time exchange of original requests, reports and other relevant clinical data.
• Pilot study for the implementation of liquid-based cytology to allow for reflex testing and leave opportunity for different tests and biomarkers in the future.
• Standardization of colposcopy on national level and central registration of structured colposcopy reports.

• Renewal of the screening policy, switching toward HPV screening (preparatory phase).

Main Impacts / Added Value

Since 2003 there has been a successful switch from opportunistic to organized screening:

• Implementation of organized screening within the existing healthcare system (integration).
• Prolongation of the screening interval form one to three years.
• Systematic central registration and monitoring of screening, diagnostic, treatment and follow-up activities (programmed and opportunistic).
• Systematic education of screening providers, implementation of national guidelines for providers, legal framework for the operation of screening programme and screening registry.

The observed benefits were:

• Higher coverage of women in the target age group by a screening test and less excess smears, lower recall rate due to a pathological screening test result (from 16% in 2003 to 5% in recent years), less unsatisfactory smears (from 7% in 2003 to less than 1% in recent years), higher quality of providers’ services, higher detection of precancerous lesions (HSIL/CIN2+) and 50% decrease in cervical cancer incidence.

Results of the screening program:

• Coverage by a screening smear (Source: Screening registry ZORA):

• 72 % (3-year); below 70 % in women aged 50 years and more and in two out of nine regions;
• 82 % (5-year).

• Cervical cancer incidence (ASIR, recorded since 1961) and mortality (ASMR, recorded since 1985) rate per 100.000 women, age standardized, world standard (Source: Cancer registry of Republic of Slovenia (incidence) and National Institute of Public Health (mortality)):

• highest recorded: 27,5 ASIR in 1962, 5,4 ASMR in 1985;
• the lowest ever recorded in 2017: 4,9 ASIR in 2017, 1,7 ASMR in 2016;

• latest incidence year: 6,6 ASIR in 2018, 1,7 ASMR in 2016.

Lessons Learned

• It is important to have a comprehensive approach, including all levels of screening: identification and invitation of the target population, screening, further diagnostic, treatment, follow-up after treatment.
• Multidisciplinary and multisector approach is also necessary, early collaboration of screening coordinator, decision makers and national experts in the field of public health and cancer epidemiology, genecology, cytology, histopathology, molecular diagnostic.
• International collaboration, consultations, exchange of best practices.

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