Elsevier

European Journal of Cancer

Volume 36, Issue 17, November 2000, Pages 2191-2197
European Journal of Cancer

Cervical cancer screening in Belgium

https://doi.org/10.1016/S0959-8049(00)00308-7Get rights and content

Abstract

A description is given of the burden of cervical cancer and the status of screening in Belgium until 1998. Screening is essentially opportunistic and generally performed at yearly intervals. A programme for organised screening — promoting one cervical smear every 3 years for women aged between 25 and 64 years — is being set up in the Flemish Region alone. Important progress has been made concerning the development of technical guidelines on the collection of an adequate Papanicolaou (Pap) smear, uniform terminology for the cytological report and the follow-up of positive tests. The implementation of the programme is confined to the provinces that are instructed to make women and physicians aware of the screening policy. The establishment of a screening register, allowing for individualised invitation of women, was hampered by strict privacy laws and by the heterogeneity of software used for data entry in cytological laboratories. The impact of the Flemish programme was further limited since the reimbursement of smear taking by a gynaecologist or a general practitioner (GP) and the cytological reading are not conditioned by the respect of guidelines. This is due to the fact that the organisation of preventive healthcare and the financing of medical activities concerns distinct authorities. The coverage of the target population is good in Flanders (82.3% according to certain estimates), but is achieved at the expense of an important amount of over-screening. The coverage is lower in the Walloon and the Capital Region. Rationalisation of the policy regarding cancer screening involving all concerned authorities of the country is necessary.

Introduction

An overview is given of the burden of cervical cancer and the organisation of screening in Belgium. In order to understand the important differences between the south and the north, it is useful to introduce briefly the federal structure of the country. This article deals mainly with the Flemish situation at the end of 1998. Less information is available on the two other regions.

Belgium has a very complex political structure. It is divided into three geographically separated regions: the Flemish Region (female population of 3.0 million), the Walloon Region (1.7 million women) and the Capital Region of Brussels (0.5 million women) (see Fig. 1). Another administrative layer, based on linguistic criteria, is superimposed on this: the Flemish, the French and the German community. The Capital of Brussels belongs to both the Flemish and French communities. The heterogeneous repartition of administrative responsibilities complicates decision-making in sectors such as social affairs and public health.

The organisation of preventive healthcare in Belgium is, since the state reform in 1980, confined to the communities, while curative care remains a national matter. A formal cervical cancer screening programme, based on the European guidelines, currently exists only in the Flemish community. It is not applied in the Brussels Region.

Periodical screening by specialised mobile teams or in fixed centres has been organised since 1965. This vertical system was abandoned in the beginning of the 1980s because of low attendance. Meanwhile, opportunistic screening, by private gynaecologists and to a lesser degree by general practitioners (GPs), has gradually increased.

In 1994, the Flemish Government decided to re-orientate the organisation of secondary prevention of cervical cancer according to the European guidelines [1]. Since then, early detection of cervical cancer is evolving from strictly opportunistic to more organised screening.

Section snippets

Incidence

In 1993, the National Cancer Register (NCR) reported 749 cases of cervical cancer of which 482 (64%) cases occurred in the Flemish Region, 206 (28%) in the Walloon Region and 61 (8%) in Brussels. The crude rate is 14.5 cases per 100 000 women-years for the whole of Belgium. The annual age-standardised rate, based on the world reference population, is 10.8/105 women. Cervical cancer ranks third after breast and colon cancer. The cumulative incidence between 0 and 74 years is 1.02%. The incidence

Aims

The general principles, formulated in the European Guidelines on Quality Assurance in Cervical Cancer Screening [1] form the basis of the Flemish programme. It targets almost 1.6 million women between 25 and 64 years old, residing in the Flemish Region. Nine and a half per cent (9.5%, 95% confidence interval: CI 8.9–11.3) of the Flemish female population in the age group 25–64 years underwent a total hysterectomy [7]. This proportion should be subtracted from the total population. Women

Situation in the south of Belgium

In 1992, a broad consensus on cervical cancer screening was accepted by the cancer detection centres of the French-speaking universities and confirmed by the concerned professional scientific societies [18]. The European guidelines and the Flemish instructions on uniform cytological interpretation and follow-up are generally agreed upon. The definition of the target age group is somewhat different. It is proposed that Pap smear screening should begin 3 years after initiation of sexual contact.

Discussion and conclusions

Opportunistic screening is still dominant in all Regions of Belgium. In Flanders, an organised screening programme according to the European recommendations is being established. Nevertheless, the evolution to a more organised approach is slow, as it depends upon the voluntary adaptation of professional behaviour of physicians, which is not always evident in a liberally organised healthcare system. A relatively high coverage rate of the target population has already been achieved, but at the

Acknowledgements

The project received financial support from the European Commission (Contract grant sponsor: European Union, Commission of the European Communities, Directorate-General for Employment, Industrial Relations and Social Affairs; Contract grant number: SOC 97 201143).

Neither the European Commission nor any person acting on its behalf is liable for any use made of this information.

References (12)

There are more references available in the full text version of this article.

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