- DOCUMENT SENT TO LATVIAN HEALTH MINISTRY - (English translation) Ministry of Health
Proposal of Latvian Association of Gynecologists and Obstetricians (LAGO),
Latvian Association of Family Doctors (LAFD), Latvian Association of Oncologists
(LAO), Latvian Association of Oncogynecologists (LAOG), Latvian Association of
Cytologists (LAC) for changes in the regulation of Cabinet of Ministers Nr.1036
with the supplement Nr.2 ‘Programme of the preventive examinations’
The proposal is created and formulated after the round-table discussion organized by
LAGO on September 18, 2006:
What is the situation with the cervical cancer screening in Latvia?
The presidents of the mentioned above associations and representatives of LAGO,
Latvian Oncology Center, Ministry of Health, Health Compulsory Insurance State
Agency, State Laboratory of Virology, WHO, EUROCHIP participated at the discussion.
As the result of discussion, there is the subsequent proposal:
Make changes in ‘Programme of the preventive examinations’ – the regulation of Cabinet
of Ministers Nr.1036, December, 2004, with the supplement Nr.2 (corrected in
November, 2005) contains the Paragraph 2.3.1. (Paragraph 2.3. Cancer screening), which
text is:

The gynecological examination (including the examination of breasts) with taking
the smear from cervix of uterus for the oncocytological assessment in women in
age from 20 to 35 years has to be done one time per year. If the result of smear is
normal, the gynecological examination and the taking of smear has to be repeated
one time per three years. The gynecological examination with taking of the smear
in women in age from 35 to 70 years has to be done yearly.
OBJECTIONS AND EXPLANATIONS:
1. Such kind formulation does not define clearly and not explain what
localization of cancer screening it is. At this case, it means the cervical cancer
screening.
2. The gynecological examination is not the cervical cancer screening test. The
gynecological examination consists of the physical examinations that are used
for assessment of status of female genitals and is not the screeningexamination test at all. The screening test is the oncocytology smear or
specimen from the cervix of uterus, the same as mammography examination
in the case of breast cancer or PSA test in the case of prostate cancer.
3. Such kind of approach and formulation regarding to the target age for
screening, how often the oncocytology smear has to be taken, is, from one
side, precisely formulated, but, at he same time, divided, that, subsequently,
create two screening situations for two different age target populations. If it is
a preferable model for this stage of screening to manage economically
existing finance, it means that these two screenings have to be managed
separately. But, taking in account the fact, that around 98 percent of women in
group of the registered cervical cancer cases are in age above 30 years and the
latent phase of disease (why this disease is screened!) is until 10 – 12 years,
we suggest the screening to start at 25 years age as it is in most countries in
Europe. Regarding to the interval to repeat the test, we suggest just one
interval that is three years as studies and experience in other countries prove
the clinical and economical effectiveness this interval in the screening
programmes. (Look at the given table)
Recommended screening policy in countries of the European Union.
(Ballegooijen et al. 2000; Anttila et al. 2004).
Target age group Screening
interval
(years)
Austria
Belgium (a)
Denmark
Finland
France
Germany
Greece (b)
Ireland (c)
Italy
Luxembourg
Netherlands
Portugal (d)
Spain (d)
Sweden
U.K. (England)
20+
25-64
23-59 (f)
30-60
25-64
20+
25-64
25-60
25-64
15+
30-60
20-64
25-65
23-60
20-64
1
3
3
5
3
1
3
5
3
1
5
3
3
3(e)
3 or 5
Smears per
Population
woman lifetime subjected to
formal
programme
(%)
70+
14
13
7
14
50+
14
8
14
75+
7
16
14
14
10-16
n.r.e.
58
90
100
<5
90
n.r.e.
n.r.e.
13
n.r.e
100
n.r.e.
n.r.e.
100
100
Proportion of
women
screened in a 3or 5-year period
(%)
n.r.e.
78
75
93
n.r.e.
80
n.r.e.
n.r.e.
50
n.r.e.
77
n.r.e.
n.r.e.
82
61
a) Policy related to the Flemish region of Belgium; b) Policy related to pilot studies; c) policy
planned for one region of the country; d) Policy for one region of the country only; e) 5-yearly at ages
50-60 years; f) corrected. n.r.e. data was not available in the references
This interval is corresponding to the guidelines for European Union
countries “Comprehensive Cervical Cancer Control”, June, 2006.
4. It is absolutely unclear what is the type of the announced screening in the
country in such kind of the formulation: opportunistic (seeking of the case at
any episode of health care, that is initiated by person herself, and expenses of
the test are covered by the state) or organized (the state is asking actively the
target population to make the test, that expenses are covered by the state, and
follows population). The existing screening in Latvia seems to be the
opportunistic that, according to the studies and experience of other countries,
is not so effective to diminish the incidence and mortality related to the
cervical cancer. More effective, from the clinical and the economical point of
view for country, is the organized screening. And, regarding to the
epidemiological situation of the cervical cancer in Latvia, only the best
solution of problem is organization and implementation of the organized
screening urgently. This position has to be the base for further strategy in
country regarding to the cervical cancer screening, and other localization
cancers’ screenings also. The separate and united Register of Cancer
Screenings has to be organized (as example could be Finland) with main task
to ask and invite the target population to perform the screening tests, to
control the screened percentage and follow-up, to create database and to
exchange data with Cancer Register.
5. The invitation has to be created as the special form with several parts. Woman
with this form, after receiving, can attend the state paid or privately practicing
doctor (difference between these two professionals is that the visit and taking
of the smear at privately practicing doctor is paid by woman herself, but, at
the state paid doctor, the visit and taking of the smear is paid by Health
Compulsory Insurance State Agency) and doctor (state or private) sends the
taken smear itself with this special form to laboratory, that performs the
reading of test and the state pays for that. The task of laboratory after the
reading of test is to send the result on one part of the special form to doctor
who has done the taking of smear and on other part of the special form to
Register of Cancer Screenings.
6. The main part in this screening-programme is laboratory that reads the smear,
and saves for certain time period (five years and more) the abnormal smears
for epidemiological, studying and quality control purpose.
7. The united and accepted in country guidelines for follow-up, treatment, the
control intervals have to be created for general practitioners and
gynecologists, and doctors (state and private) must follow them very strongly,
if the smear result reveals any precancer lesion. LAGO has the main role in
this process.
SUGGESTIONS to Ministry of Health that would be done urgently to diminish the
incidence and mortality related to the cervical cancer in Latvia:
1. Change the regulation of Cabinet of Ministers Nr.1036, December, 2004, with
the supplement Nr.2 (corrected in November, 2005) in this wording and
editorial:

Paragraph 2.3. Cancer screening, and Paragraph 14. as well:
2.3.1. The oncocytology smear of cervix of uterus as the screening test
for cervical cancer has to be done in women from 25 to 70 years age
one time per three years, if the result of test is normal.
14. This paragraph is related to finance
(I don’t translate – Ilze Viberga)
2. Organize the work-group at Ministry of Health with obligatory involving and
participation of representatives of the mentioned above professionals’
associations to work on urgent planning, organization and implementation of
the organized cervical cancer screening, Register of Cancer Screenings and
related to it tasks in Latvia.
The list of participants at the round-table discussion who accepted the document:
Dace Rezeberga – LAGO
Dace Matule – LAGO
Maira Jansone – LAGO
Jana Žodžika – LAGO
Jekaterina Vasiļjeva – LAGO (resident)
Alda Urtāne – LAGO (resident)
Ludmila Eņģele – Latvian Oncology Center
Ella Ņesterenko – Latvian Oncology Center
Valentīna Grjunberga – Latvian Oncology Center
Dace Baltiņa – Latvian Oncology Center
Sarmīte Veide – LAFD
Līga Kozlovska – LAFD
Vaira Īrisa Kalniņa – State Laboratory of Virology
Consultants:
Andrea Micheli – EUROCHIP (Italy)
Paolo Baili – EUROCHIP (Italy)
Ahti Anttila – EUROCHIP (Finland)
Aiga Rūrāne – WHO
On behalf of LAGO Dr. Ilze Viberga MD, PhD
- HEALTH MINISTRY REPLY- (English translation) MINISTRY OF HEALTH OF REPUBLIC OF LATVIA
addresses
Riga
Dates and numbers
To president of Latvian Association of Gynecologists
and Obstetricians D.Rezeberga
Regarding to the proposal for changes in
the regulation of Cabinet of Ministers Nr.1036
‘The order of organization and financing of health care’.
Ministry of Health thanks specialists of Latvian Association of Gynecologists
and Obstetricians for the given suggestions for changes in the regulation of Cabinet of
Ministers Nr.1036 ‘The order of organization and financing of health care’ in the
submitted letter.
We inform that your given suggestions will be assessed in the work-group that
task is to prepare the changes in the mentioned regulation of Cabinet of Ministers.
We are of the opinion that the developing of suggestions for implementation of
the organized cervical cancer screening in Latvia, including the organization of united
Register of Cancer Screenings, needed financing, quality provision, control etc. are in the
competence of specialists, in this case – specialists of Latvian Associations of
Gynecologists and Obstetricians, Family Doctors, Oncologists. Because of that, Ministry
of Health asks you, in collaboration with other institutions, work on the concrete
suggestions (model or versions of it) for solving of the mentioned problem and submit
them to Ministry of Health to make a decision.
State Secretary
U.Likops
Signature
Contact person