Albania upgrades its cervical cancer screening programme with WHO’s support
On 17 November 2020, WHO is launching the Global Strategy to Accelerate the Elimination of Cervical Cancer. To mark this event, we look at Albania’s success story of cervical cancer screening.
Cervical cancer is the second most common type of cancer among women of reproductive age in Albania, affecting 134 new women each year. Yet cervical cancer is preventable through human papillomavirus (HPV) vaccination and screening. With WHO’s support, the country took action by setting up a national screening programme.
HPV screening – a success story
Until as recently as 2018, cervical cancer screening in Albania was limited to opportunistic Pap smear tests. Opportunistic screening involves offering ad hoc screening tests to women visiting health centres for other reasons. This approach has proven to have very limited impact on the disease, not only in Albania but all over the world.
In addition, many rural health centres in Albania did not have qualified personnel or equipment for gynaecological sampling. This meant that women had to travel to an urban health facility to have a vaginal swab, and then take their own sample to one of the few cytology laboratories, located mostly in Albania’s capital Tirana, for processing. Of great concern was the fact that the process did not include quality assurance throughout the screening pathway.
In light of these challenges, the Ministry of Health decided to rethink their strategy for cervical cancer screening. In 2017, WHO provided expert advice and detailed recommendations, notably to introduce HPV testing and to set up a screening quality assurance system.
Three years later, on 30 January 2019, Albania officially moved to HPV testing. The Institute of Public Health’s Department of Public Health Monitoring and Noncommunicable Diseases took responsibility for coordinating the cervical cancer screening programme at the national level. Dr Alban Ylli, Head of the Department, recognized WHO’s support as “not only useful – it was essential.”
WHO’s 2017 recommendations informed many decisions, such as which age groups of women should be screened. The recommendations were reflected in Albania’s cervical cancer screening technical document and policy briefings. Following the understanding that the majority of cervical cancers in Albania occur slightly later in women’s lives, it was decided to provide screening firstly to women aged 44 and 49 with an HPV test, and to younger age groups in a later phase.
Pilot screening programme
In 2017, a pilot screening programme involving 1000 women conducted in the Fier region in southern Albania was launched. It proved to be an invaluable step.
“We learned so much thanks to the pilot – how women behave, how the system reacts, how the centres of primary health care were prepared, the role of regional hospitals, etc.,” explained Dr Ylli.
“It’s key to start with a pilot in a limited community or region so that you learn – you gain experience and you learn how to do less harm. Because a screening programme can do harm; if the system is not prepared, it is easy to throw these healthy women into the hands of inexperienced or unprepared physicians,” he continued.
“Organization issues are also key: you learn which way works better for inviting women, and how to administer the supplies or work together with the hospitals and health centres. Most regional hospitals in Albania don’t have the capacity for colposcopy, so you have to identify where the positive cases will go. All these details are only discovered through a pilot.”
One of the important insights provided by the Fier pilot was that women in Albania generally prefer the option of self-administering the HPV test. The screening process has been designed around this desire for empowerment.
Every year, 15 000 women aged 44 or 49 receive one of the HPV laboratory kits distributed by the Institute of Public Health to every primary health-care centre via the regional directorates of public health. The women are identified from the local general practitioner lists, and the primary health-care centres are responsible for contacting them. This is done by community nurses who phone women or visit them at home in rural areas.
The HPV laboratory kits contain illustrated and written instructions on how to self-sample. Women are given the option of self-sampling at home or visiting a primary health centre to self-sample there or request that the sample be taken by health staff.
To reduce costs and improve the quality of the screening programme, the HPV test is interpreted in a central laboratory, and primary health-care personnel are trained to ensure the quality of the tests.
Because many gynaecologists were unaware of this programme, collaborative groups involving gynaecologists, public-health leaders and primary health-care workers were set up to strengthen efforts to increase HPV screening.
Albania also plans to introduce another age group (women aged 40 years) into the screening programme to increase its coverage, but this has not yet been possible due to a shortage of laboratory kits.
Albania’s progress in the development of HPV testing since 2017 demonstrates the value of using WHO’s expertise and knowledge base to inform the design of a modernized screening programme tailored to the needs of a country. Albania’s experience also shows the wisdom of conducting a pilot or restricted regional programme before rolling out cervical screening nationwide, and of providing women with the opportunity for self-sampling.
