Centre for Chronic Prevention and Control
Cervical Cancer

Background and History of Cervical Screening in Canada

Cervical cancer is one of the most preventable cancers; the Papanicolaou (Pap) smear test has been used to screen for pre-cancerous lesions in asymptomatic women for the past 50 years. In Canada, as early as 1973, the Conference of Deputy Ministers of Health explored the need for comprehensive screening programs for cancer of the cervix. In 1976, the Walton Task Force recommended that health authorities support the development of cervical cancer screening programs and that all women be encouraged to participate (Walton, 1976). In 1980 a survey assessing the impact of the Task Force concluded that the recommendations had not been widely implemented at the provincial level (Kassirer, 1980). In response to this and concerns about the significance of new data, changing sociosexual patterns and wide variation in the implementation of the 1976 recommendations, the Task Force was reconvened in 1980 (Walton, 1982). Recommendations made in 1982 related to the frequency of screening, laboratory quality control and follow-up mechanisms. Measures to improve the quality and sensitivity of screening programs, recruitment of women never screened and the development of government-sponsored registries were seen as essential components of an effective system and as potentially more effective than attempts to increase the frequency of screening.

In 1989, a National Workshop on Screening for Cancer of the Cervix reviewed the 1982 recommendations on screening for cancer of the cervix and recognized that programs in Canada were still not fully effective: not all women at risk were being screened; some physicians had not acquired the necessary skill to take satisfactory smears; some laboratories were too small to provide adequate experience for staff and adequate quality control; and some women with detected cytologic abnormalities were receiving inadequate follow-up and management (Miller, 1991). Conversely, some women were being screened too frequently, resulting in inappropriate use of resources. Recommendations reiterated the need for an organized approach and addressed the following issues: the frequency of screening; the management of abnormalities; information systems; training and quality control requirements for laboratories and programs. The recommendations were accepted by the Conference of Deputy Ministers of Health in November, 1990, who requested that a report of a regular review of developments be made to them on a periodic basis.

The Society of Obstetricians and Gynecologists of Canada, the Gynecologic Oncologists of Canada and the Society of Canadian Colposcopists supported the development of formal screening programs. The recommendation with respect to a screening interval of 3 years concerned these groups in the absence of adequate information systems and high-quality laboratory services; also of concern was the recommendation for repeat smears without colposcopy for low-grade squamous intraepithelial neoplasia. These groups suggested that until patient information systems and high-quality laboratory services are in place, annual screening of sexually active women should continue to be the standard of practice (Stuart, 1991).

As a follow-up to these activities supported by Health Canada and to review the situation within the provinces with respect to the development of organized screening programs, another workshop, Interchange ‘95, was held in 1995 (Interchange ‘95, 1995). The purpose of this Workshop was not to make recommendations but to identify whether the previous recommendations were still relevant, and, if so, to identify the barriers to implementing these recommendations and the best approaches to overcoming these barriers. The Workshop focused on three specific but interrelated components of a comprehensive cervical cancer screening program namely, information systems, quality improvement and recruitment. Provincial and territorial representatives involved in cervical cancer screening on a clinical or programmatic level attended the workshop along with policy makers from the federal and provincial governments, and other national organizations.

The majority of the recommendations of the 1989 Workshop were seen to be still relevant; however, concerns were raised that the recommendations on quality assurance programs only related to cytology. It was felt that the recommendations needed to be updated particularly in relation to enhanced community involvement in policy and program development; broader quality improvement processes to incorporate guidelines for smear taking and clinical care, as well as for cytology. Specifically, it was suggested that there should be a mechanism to ensure the quality of smear-taking, smear-preparation, interpretation of the smear and follow-up of both normal and abnormal smears, as well as indicators that the program as a whole was functioning to ensure that all at-risk women were recruited and retained within the system. It was noted that, in the past, little attention had been paid to the integration of quality assurance or quality improvement activities within each of the relevant disciplines. Where practice guidelines or quality assurance processes had been developed, they had occurred in isolation.

Participants at Interchange ‘95 requested a continued presence of the federal government in encouraging and facilitating information exchange between the provinces and providing some direction and leadership in the area of standards and quality of care. To this end, all provinces and territories were invited to participate in the Cervical Cancer Prevention Network (CCPN), an informal association of federal and provincial representatives with the relevant clinical professional bodies. Represented are the Society of Obstetricians and Gynecologists of Canada, the College of Family Physicians of Canada, the Canadian Society of Cytology, the Gynecologic Oncologists of Canada, the Society of Canadian Colposcopists and the Canadian Nurses Association.

Objectives

The purpose of the CCPN is to continue to reduce the morbidity and mortality from cervical cancer and its precursors in Canada by facilitating the implementation or enhancement of organized screening programs.

Responsibilities

Three Working Groups of the CCPN have focused their attention on the development of the following three components of an organized screening program: effective recruitment strategies, information systems and an integrated set of practice guidelines as the basis of a quality management program within the provincially-based screening programs.