Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694824798227.pdf (Georgia)
Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme 2010 UNFPA Standard Progress Report 2011 GEO2R21A Support to Breast and Cervical Cancer Prevention GEO1R21A/Support to Breast and Cervical Cancer prevention 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme UNFPA Country Office in Georgia UN House, ; Fax: (995 32) 2502 71/72 Table of Content Introduction I.

Purpose II.

Resources III.

Results IV.
Financial Implementation V. Future Work Plan 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme Country: Georgia Reporting Period: 10January – 31 December, 2011 Programme Component – Reproductive Health Project IDs (use ATLAS code): GEO2R21A Project Title and ID (for co-financed projects): GEO2R21A /Support to Breast and Cervical Cancer Prevention Co-financing Donor(s): Health, Social and Cultural Affairs Department under the Municipality of Tbilisi, UNFPA Programme Component Manager: MoLHSA Implementing partners: National Screening Center, UNFPA I.
INTRODUCTION The partnership between the Health and Social Affairs Department (HSAD) under the Municipality of Tbilisi and UNFPA Georgia for Reproductive Tract (RT) cancers prevention and early detection has been launched in 2006 in Tbilisi; Based on the analyses of the data and accumulated experience, at the beginning of 2008, the project has been redesigned to focus on breast and cervical cancer screening for the targeted population in Tbilisi and the National Screening Centre (NSC) has been selected to implement this project.
This project is an important intervention to make the quality RH services more accessible for the population and runs under patronage of the First Lady of Georgia.
This innovative project is one of the first of its kind among the countries of Eastern Europe and Central Asia that aims to increase the detection of reproductive system cancers at early stages, in order to reduce the early mortality of women caused by these diseases; the project aims to achieve this through ensuring equitable access for the women of the target ages to the breast and cervical cancers screening services and at the same time to maintain high standards of the programme management, service delivery, monitoring & evaluation and accountability.
The remarkable achievements of the project, contributing to the reduction of women’s morbidity and mortality, made the federal government decide to replicate the project at the national level in 2009 – in 2010 the breast cancer screening programme has been launched in four regions of Georgia; starting from June 2011 the cancer screening programme in full scope (breast, cervical, colorectal cancer screening and prostate cancer risk management) is available for all population of Georgia through the national programme under the National Centre for Diseases Control and Public Health NCDC&PH (MoLHSA) which is also implemented by NCS.
1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme II.
PURPOSE UNDAF Outcome(s): Vulnerable groups enjoy improved access to quality health, education, legal aid, justice and other essential social services 2008-2013 UNFPA SP Outcome 2.2: Access and utilization of quality maternal health services increased in order to reduce maternal mortality and morbidity, including the prevention of unsafe abortion and management of its complications Expected CP Outcome(s): Vulnerable groups enjoy improved access to quality health, education and essential social services.
Expected CP Output: 1.2: Improved access to comprehensive sexual and reproductive health services and gender sensitive information, with special emphasis on the most vulnerable groups Implementing partner(s): UNFPA, National Screening Centre III.
RESOURCES Total budget for the project implementation in 2011 was USD 828,397.70 Source of funds: UNFPA HSAD/other donors Core resources – USD 170,000 Noncore resources (HSAD GEA03) – USD 658,397.70 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme IV.
RESULTS Project management The project management team consisted of the NSC Director, Project National Consultant, hired by UNFPA, the local consultant in Medical Epidemiology and the IT specialist; the Monitoring Assistant, as a member of the Joint Inspection Group, ensured monthly monitoring of the project implementation, following-up the women who have been screened within the frames of the project and conducting the client satisfaction survey.
UNFPA Country Office in Georgia provided overall managerial and technical support to the project.
UNFPA supported regular meetings of the project Steering Committee consisting of the First Lady of Georgia, project donors, management team and implementing partners to review the current status of project implementation, discuss the progress and challenges and agree on the future steps; In addition, the project implementation status has been discussed several times at the RH National Council Meetings at the Ministry of Labour, Health and Social Affairs.
Advocacy for expansion of the cervical cancer screening programme in the regions of Georgia Since the beginning of the project UNFPA/Georgia has been advocating for expansion of screening programme in the regions of Georgia.

In 2010 a special video has been produced with UNFPA support and aired on CNN stressing the importance of increased accessibility of cervical cancer screening cervices outside the capital.
During the Cervical Cancer Prevention Week, widely celebrated in Georgia in January 2011, UNFPA organized a high profile advocacy event to present the national Guidelines on Cervical Cancer Screening and Diagnostics, developed through UNFPA support and approved by the MoLHSA.

The meeting was attended by the First Lady of Georgia, Deputy Chairpersons of the Parliament, Minister of Health, Director of NCDC, leading professionals in the field and representatives of international and donor organizations.
UNFPA once again emphasized the importance of expansion of the cervical cancer screening programme in the regions of Georgia to make this life-saving service more accessible for women of target age throughout the country.

It is noteworthy of mentioning, that the government has decided to expand the screening programme nationwide from June 2011.
National capacity building for Breast and Cervical Cancer Screening Programme planning and implementation National capacity building to strengthen strategic planning, clinical management, implementation and quality assurance of the breast and cervical cancer screening programme has been one of the priorities for UNFPA; in this regard several significant activities were undertaken during the reporting period: 1.
Responding to the need identified by national partners on developing strategic recommendations on planning and implementation of the national screening programme in Georgia, UNFPA engaged leading European technical institutions and experts to develop national capacities in this direction.
1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme In partnership with the European Cervical Cancer Association (ECCA), as a leading partner in this initiative a Strategic Planning Meeting for the Implementation of Cancer Screening in Georgia was organised on October 10 and 11 at NCDC, which was attended by the management and technical staff of NCDC, NSC and MoLHSA.
Professor Marek Spaczyński, founder and the Director of Polish Breast and Cervical Screening programme was invited as a guest speaker to share the experience of Poland, as a country, which in many aspects resembles the situation in Georgia.

The meeting provided the forum for assessing the current status of the health system, reviewing and refining the cancer screening and prevention control objectives.
The key aspects of the Report and Recommendations for Cancer Screening in Georgia have been agreed and the first draft of the Report has been developed, which will be further discussed with NCDC/MoLHSA and finalized accordingly.

2.

Two gynaecologists- colposcopists from the National Screening Centre participated in two weeks training in UK organized by the European Federation of Colposcopy and Cervical Pathology.
The training contributed to improved theoretical knowledge and practical skills in colposcopy.

UNFPA supported and funded travel expenses of trainees.

3.
3.

UNPFA followed up the last year activity on quality assurance measures of Pap test cytology diagnosis supported in partnership with the European Cervical Cancer Association and the Union for International Cancer Control (UICC); in particular, an independent external evaluation of cervical cytology was conducted in 2010 in quality-controlled two laboratories the screening population-based programmes in Reggio Emilia and Viareggio, Italy.
This independent evaluation was undertaken to review the work of the Tbilisi laboratories cytopathology serving Screening Programme and to identify the specific skills that needed to be improved.

serving Tbilisi Based evaluation this instructional programmes were designed for two cytopathologists heading the labs in Tbilisi and training sessions were organised for them in Reggio Emilia laboratory.
This programme was designed to address the specific problems identified in the evaluation and to provide the local cytopathologists with a better knowledge of the operation of a Western European quality-controlled laboratory.
on The training in Italy was followed by a Gynaecology Cytopathology Workshop in Tbilisi on 8-14 September, 2011 conducted by three experts from Italy (supported by UICC): Prof Cesare Gentilli, Chief Consultant of Pathology; Prof Luigi Di Bonito, Professor of Anatomic Pathology and Cytopathology and Ms Clara Bosco, Director of Education for Diagnostic Services and Technical Coordinator for Pathology Services; 15 cytopatologists from the laboratories of Tbilisi and regional centres of Georgia involved in the Georgian Cervical Screening Programme were trained at this workshop.
This workshop succeeded in achieving the following results: 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme a. Disseminate the knowledge from the Italian training to a wider audience of cytopathologists who would participate in the expansion of the cervical screening programme in Georgia; b.
Establish the reputation of the two Tbilisi cytopathologists as the cytopathology leads in the country so they would be better positioned to lead the ongoing training that will be required as the programme expands; c. Refine and validate the format of the workshop and the training materials so they would better serve as the model for further workshops to be held in the country.

It is planned to repeat the independent review of cytology to verify and measure the progress that had been achieved.

4.
4.

The project partnered with the National professional association Georgian Society of Gynaecological Oncology (GSGO) and contributed to the Batumi International Cervical Pathology Conference held on June 24-26 in Batumi Georgia organized by this association.
In particular, through UNFPA support 15 gynaecologists from Tbilisi and regions of Georgia involved in the cervical cancer screening programme have improved their knowledge and skills through attending the conference and the EFC Colposcopy Course conducted by EFC experts.

5.
5.

To improve quality of clinical services of breast cancer screening program and to develop quality assurance instrument the partnership has been established with Dutch National Experts and Training Centre for Breast Cancer Screening LRCB, Netherlands.
The objective of this partnership is to assess the accuracy of mammographic screening and diagnoses in Georgia compared to established standards in use in Western Europe and establish quality assurance mechanisms of the national Breast Cancer Screening Program.
Under this collaboration three hundred and fifty mammograms taken during the six-month period from 1 November 2010 to 30 April 2011 were randomly and proportionally selected (stratified by abnormality) from the Georgian screening program archives held at the Georgian National Screening Center (GNSC), the Tatishvili Medical Center (TMC) and Tbilisi Cancer Center (TCC).
Mammograms were stripped of patient identifiers and sent together with the relevant clinical information (sample number, age and clinical history, but blinded to the original results) to the Dutch National Experts and Training Centre for Breast Cancer Screening (LRCB), where the mammograms were double red.

The consensus result will then be correlated with the original results from Georgia.
The initial phase of this study will be completed by the end of January 2012 and results will be reviewed by Georgian colleagues.

Anticipated outcomes of this study are the following:  provide study will This an independent assessment of the accuracy of mammography as conducted in Georgia.
These data will be used to identify areas where improvements are required and they will form a current baseline from which to measure progress;  It is recognised that the number of negative is insufficient to provide a statistically mammograms 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme significant estimate for the false negative rate of Georgian mammography.
However, this study will indicate whether a larger study to establish this parameter should be undertaken;  Depending on the outcomes of this study, the results could be incorporated into an article and submitted for publication should all participants agree to do this.

6.

In 2011 an additional European technical institution has been involved in the project on the initiative of the National Screening Centre – the European School of Oncology (ESO).
ESO has outlined 3-5 years plan of activities in Georgia in coordination with UNFPA/Georgia to complement already planned and ongoing capacity development interventions.

for ESO experts conducted the first workshop in Georgia on 13-14 December 2011 - two days theoretical and practical training for radiologists and radiographers on breast cancer screening was held at the Tbilisi State Medical University facilities.
This training for 35 local professionals from Tbilisi and regions of Georgia was co-supported by European School of Oncology (ESO) and UNFPA/Georgia.

It was conducted by ESO experts Dr. Rosselli and Dr. Ambrogetti.
After theoretical sessions on different topics of special interest for screening radiologists, large amount of time was devoted to showing clinical cases of specific interest, in order to show the main criteria for differentiating benign from malignant breast lesions and to improve the criteria for recall.

The on-the-job 20 training radiographers was conducted at the M. Kachinski branch of the National Screening Centre.
According to observations of ESO experts further radiologists and of training radiographers in is sterotaxic biopsy.

In addition, the experts outlined necessity of involving the medical physicist in the mammography screening program on permanent basis, who will safety international according standards.
radiation needed follow to The National Screening Center and ESO agreed to continue the cooperation between ESO and the Georgian Screening Programme with the support of the Georgian Ministry of Health, Municipality of Tbilisi, UNFPA, Italian Embassy in Georgia, with the aim of contributing to quality assurance of national breast cancer screening programme.
For this purpose the parties agreed on following:  To establish a multidisciplinary National Reference Centre (NRC) at the National Screening Center in Tbilisi consisting of professionals of each specialty - epidemiologist, radiologist, radiographer, medical physicist or engineer and pathologist;  To develop a training educational programme, with the advice of ESO, for the NRC specialists who will be committed to spread the professional skills to the other units operating in the national breast cancer screening programme of Georgia.
ESO plans for 2012 include: 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme - training of the Medical Physicist or engineer for 2-4 weeks in Europe (probably Nijmegen NL); - Training of a pathologist for 2-4 weeks in an European Institution; - Training of the radiologists in Tbilisi for initiating the stereotaxic examinations and the use of core-biopsies under ultrasound guide, by sending a visiting professor in Tbilisi for 1 week; - Review of data collection modalities for epidemiological evaluation of the national programme, through sending a visiting professor in Tbilisi for 1 week; - Organization of a pathology workshop and a second national radiology workshop in September/October 2012.
7.

The project supported increased involvement of the Primary Health Care providers in the screening programme.

For this purposes the traditional seminars for PHC providers were conducted In December 2011 in Gori.
The objectives of workshop were the following:   To Provide detailed information to doctors about the importance of primary care involvement in breast and cervical cancer screening program To involve primary care physicians in educating general population about breast and cervical cancer programs.

Both the basic clinical and the managerial aspects of breast and cervical cancer screening programmes were presented during the seminars.
A special manual on breast and cervical cancer screening for PHC providers “Main aspects of breast and cervical cancer prevention and screening; Guidelines for primary care doctors” developed through UNFPA support, were distributed among participants of the workshops; In total 50 primary care providers benefited from the workshops.

8.
8.

UNFPA further supported strengthening of screening programme implementing partners’ capacities to manage the programme – in this conjunction two workshops on Screening Programme Management Quality Assurance for the managers and lead professionals from all implementing partners involved in the project in Tbilisi and regions were supported (05.06.11 and 17.11.2011); 9.
Understanding the importance of developing a modern and well organized cancer registry in the country for monitoring the morbidity and mortality caused by cancer diseases, UNFPA in partnership with ECCA supported NCDC in this effort through organizing a study visit of two leading NCDC professionals to Comprehensive Cancer Centre in the Netherlands on December 7-9, 2011.
Georgian professionals had an opportunity to get familiar with the Data collection system by the Cancer Registry (CR); the data quality monitoring and evaluation and classification system for CR.

As a result a set of recommendations was developed to be considered in developing the Georgian Cancer Registry model.

These recommendations were presented and discussed at the strategic meeting organized by NCDC on 16 December 2011 with participation of all local and international stakeholders.
1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme Population behavior change communication campaign Through UNFPA support National Screening Centre has been rebranded through involvement of the creative designer: new logo, new templates of IEC materials were prepared; the design and structure of the NSC website (www.gnsc.ge) was changed according to the new “style” to make it more clinet-friendly.
Rebranded NSC and the Screening Programme in whole are more visible and recognizable among the general population, which will indeed contribute to increased utilization of services.
The following activities were accomplished within the reporting period in this regard:  A new PSA was created on cancer screening program and telecasted free of charge regularly on Public TV free of charge;  UNFPA supported TV PSA telecasting on the most popular commercial TV channels covering whole territory of Georgia (for three months period – September-December 2011);  Special banners with the information about the screening programme were placed on public buses, metro stations and in the metro train carriages from September 1, 2011 for 3 months period;  Flash banners with information about screening programme were posted on popular public and medical websites;  Twenty thousand copies of brochures on cancer early detection and about benefits of breast and cervical cancer screening programme were printed and distributed among the women who were screened and among Tbilisi population.
In addition, twenty thousand copies of breast self- examination twenty thousand special advertisement and flyers were distributed; printed and 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme Breast, Cervical, Prostate and Colon cancer screening and early diagnostic services provided within the reporting period The purpose of the screening programme is to maximise early detection of Breast, Cervical, Prostate and Colon cancer among the target population and to decrease morbidity and mortality caused by these diseases.
During January-December 2011:   total of 13,912 women aged 40-70, residing in Tbilisi and its surroundings were screened for breast cancer, total of 14,372 women aged 25-60, residing in Tbilisi and its surroundings were screened for cervical cancer,  3,784 men aged 45-70 were screened for prostate cancer, and  1,368 clients – both women and men aged 50-70 were screened for colon cancer [Table 1].
More than 82 % of the cases screened in each direction were conducted at the National Screening Centre, the rest were done by the sub-contracted medical institutions at their diagnostic facilities.

Table 1.
Number of Breast, Cervical, Prostate and Colon cancer screening cases, 2011 Screening Program Component Breast Cancer (mammography) National Screening Center (NSC) Tatishvili Medical Center (TMC) Tbilisi Cancer Center (TCC) Gudushauri Medical Center (GMC) Tbilisi Balneology Resort Cervical Cancer (PAP Test) National Screening Center (NSC) Tatishvili Medical Center (TMC) Tbilisi Cancer Center (TCC) Tbilisi Balneology Resort Prostate Cancer (PSA) National Screening Center (NSC) Tatishvili Medical Center (TMC) Tbilisi Cancer Center (TCC) Express-Diagnostics Tbilisi Balneology Resort Colorectal Cancer (FOBT) National Screening Center (NSC) Tatishvili Medical Center (TMC) Tbilisi Cancer Center (TCC) Tbilisi Balneology Resort Number 13,912 11,487 1,295 1,025 51 54 14,372 11,877 1,197 1,239 59 3,784 3,136 400 125 82 41 1,368 1,219 64 37 8 Percent 100% 82.6% 9.3% 7.4% 0.4% 0.4% 100% 82.6% 8.3% 8.6% 0.4% 100% 82.9% 10.6% 3.3% 2.2% 1.1% 100% 89.1% 4.7% 2.7% 0.6% Recall rate for further deeper investigations that were performed during the reporting period is distributed as follows: 28% and 3.3% of women screened for breast cancer, had performed the ultrasound and cytology investigations respectively [Table 2]; 15% and 1.75% of women screened for cervical cancer had performed colposcopy investigations and biopsies respectively [Table 3]; and 4% of subjects screened for colon cancer had performed colonoscopy.
1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme Table 2.
Breast cancer screening: total number and percentage of performed investigations, 2011 Mammography Ultrasound Cytology National Screening Center (NSC) Tatishvili Medical Center (TMC) Tbilisi Cancer Center (TCC) Gudushauri Medical Center (GMC) Tbilisi Balneology Resort Total 11,487 1,295 1,025 51 54 13,912 3,671 (32%) 153 (12%) 116 (11%) 0 6 (11%) 3,946 (28%) 453 (3.9%) 11 (1.1%) 2 (0.2%) 0 0 466 (3.3%) Table 3.
Cervical cancer screening: total number and percentage of performed investigations, 2011 PAP Smear Colposcopy Biopsy National Screening Center (NSC) Tatishvili Medical Center (TMC) Tbilisi Cancer Center (TCC) Tbilisi Balneology Resort Total 11,877 1,197 1,239 59 14,372 2,024 (17%) 50 (4%) 86 (7%) 0 2,160 (15%) 252 (2.1%) 0 0 0 252 (1.75%) Table 4.
Colon cancer screening: total number and percentage of performed investigations, 2011 FOBT test Colonoscopy National Screening Center (NSC) Tatishvili Medical Center (TMC) Tbilisi Cancer Center (TCC) Tbilisi Balneology Resort Total 1,219 64 37 8 1,368 49 (4%) 0 5 (13.5%) 0 54 (4%) The second round for the Breast Cancer screening has already started in 2010.
This year 2,153 women out of the totally screened 13,912 ones were admitted for breast cancer screening Round-2, which is ~25% of the source female population screened during the year of 2009 and 51% of female population screened within 2009 that were reached by NSC and invited by phone.

In May 2011 the second round for the Cervical Cancer screening has started.
Since then 718 women were admitted for cervical screening Round-2, which comprises ~17% of the source female population that were screened through May to December 2008 and ~34% of female population screened within same period that were reached by NSC and invited by phone.
Out of 466 women with breast cytological investigation results, 88 (19%) were detected to have a malignant breast cancer, 28 (6%) were suspicious for malignancy, 47 (10%) atypical /undifferentiated, 253 (54%) benign cases and 50 (10%) were considered as non adequate specimen for the test [Table 5].

1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme Table 5.
Cytological results of the Breast Cancer Screening, 2011 Cytology Result Non-adequate Benign Atypical/Undifferentiated Suspicious for Malignancy Malignant Total N 50 253 47 28 88 466 % 10.7% 54.3% 10.1% 6.0% 18.9% 100,00% 630 women from Breast Screening program in Tbilisi suspected for cancer were referred by the assessment team including radiologist, pat/cytologist and breast surgeon to the specialized medical facilities for further examinations and treatment [Table 6].

Table 6.
Table 6.

Referral from the National Screening Program for Specialized Breast cancer care, 2011 Facility Number of patients referred % out of total (N=13,912) National Screening Center (NSC) Tatishvili Medical Center (TMC) Tbilisi Cancer Center (TCC) Total 463 31 136 630 4% 2.4% 13.3% 4.5% The follow-up information for every patient regarding the outcomes of their treatment is being collected and will be available by end of the March 2012.
According to preliminary results during first 6 months of 2011 78% of breast cancer cases were detected at the stages I-II within the frames of the screening program [Figure 1].

Figure 1.
Breast Cancer Stages (Preliminary, Jan-June, 2011) 80% 60% 40% 20% 0% 78% 67% 33% 22% Stage I-II Stage III-IV 2007 2011 Out of the 14,372 PAP tests conducted in 2011, 90.5% of tests were evaluated to be normal ones; the rest 1,369 tests (9.5%) were evaluated as abnormal, with the results distributed as follows: 808 (59%) were Atypical Cells of Undetermined Significance (ASCUS), 116 (8.47%) were Atypical Squamous Cell – cannot exclude HSIL (ASC-H), 272 (19.9%) were Low-grade Squamous Intraepithelial Lesion (LSIL), 159 (11.6%) were High-grade Squamous Intraepithelial Lesion (HSIL), 7 (0.51%) were Atypical Glandular cells of 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme Uncertain Significance or Atypical Glandular Cells (AGUS/AGC) and 7 (0.51%) results were classified as Carcinoma [Table 7].
Women with abnormal PAP-test result were given a recommendation to repeat PAP testing in 6-12 months.

Table 7.
Table 7.

Cytological Results of PAP smears, 2011 Atypical PAP Test Number Distribution (%) of abnormal PAP Results (N=1,369) (%) abnormal PAP results among totally screened (N=14,372) ASCUS ASC-H LSIL HSIL AGUS/AGC Carcinoma Total 808 116 272 159 7 7 1369 59.02% 8.47% 19.87% 11.61% 0.51% 0.51% 100.00% 5.62% 0.81% 1.89% 1.11% 0.05% 0.05% 9.53% The National Screening Program performs colposcopy investigations for two indications: abnormal PAP test result and recommendation by gynaecologist.
In 2011, 1197 females with abnormal PAP test had colposcopy investigation done and among those, 33.2% were found to have normal histology, 20.6% showed un-satisfactory colposcopy, 35.5% CIN1, 8.9% were CIN2,3 and 1.5% had Invasive Cancer based on the colposcopy investigation.

Detailed analysis of the colposcopy investigation results by the atypical PAP test is shown in Table 8.1.

Table 8.1.
Colposcopy investigation Results among women with abnormal PAP test, 2011 Histology/Colposcopy Diagnosis Norm Not Satisfactory Colposcopy CIN1 CIN2,3 Invasive Cancer Number (%) Number (%) Number (%) Number (%) Number (%) ASCUS (n =725) 310 42.8% 146 20.1% 254 35.0% 15 ASC-H (n = 97) LSIL (n = 239) AGUS/AGS (n=5) HSIL (n = 130) Carcinoma (n=1) Total ( n = 1197) 398 33.2% 246 20.6% 429 35.8% 106 8.9% 18 0.0% 5.2% 0.0% 0.0% 9.2% 100.0 % 1.5% Colposcopy investigation results of women with normal PAP test showed that, 34% were normal by colposcopy as well, 18% had a polyp, 12.4% had un-satisfactory colposcopy, 33.8% had CIN1, 1.3% were CIN2,3 and 0.1% had Invasive Cancer based on their colposcopy findings [Table 8.2].
1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme Table 8.2.
Colposcopy investigation Results among women with Normal PAP test, 2011 Histology/ Colposcopy Diagnosis Normal Pap test (n=992) Norm Polyp Not Satisfactory Colposcopy CIN1 CIN2,3 Invasive Cancer Number (%) Number (%) Number (%) Number (%) Number (%) Number (%) 338 34.1% 182 18.3% 123 12.4% 335 33.8% 13 1.3% 1 0.1% Patients with CIN 2, 3 or suspicion for invasive cancer are given a recommendation to refer to the specialized facilities for an adequate treatment.
In 2011, 41 women with a suspicion on cervical cancer were given such recommendation.

Within National Screening Canter 96 excision and 5 ablation treatment have been conducted.

The histological-pathologic biopsy results revealed 33 cases of CIN1, 34 cases of CIN2, 21 cases of CIN3, 6 cases of CIN3-CIS, 1 case of Invasive Cancer and 1 case of vaginal neoplasia – VAIN1.
Out of 3,784 PSA conducted males, 292 (7.7%) tested positive and all of them were given a recommendation to refer to the specialized clinic.

Out of 1,368 FOBT conducted subjects 54 (4%) tested positive, all of them were conducted colonoscopy and referred to the specialized clinic.

Ambulatory surgery 168 patients underwent surgical operations and manipulations for precancerous conditions during the reporting period at the national screening center [Table 9] Table 9.
Ambulatory care (surgery), 2011 Manipulation with local anaesthesia cyst aspiration Sectoral resection with local anaesthesia Bilateral Sect oral resection with local anaesthesia Resection of cancerous skin lesion with local anaesthesia Ablation LEEP Total 23 107 21 38 1 73 263 For details of breast and cervical cancer screening epidemiology collected within the program period see Annex 1.
Knowledge gained from research, monitoring and evaluation activities: At the beginning of the Screening Program indicators were defined and set by the Municipally of Tbilisi and UNFPA.

The indicator for the all cancer screening components is defined as the percentage of target population screened for the corresponding cancer per year.
The number of population to be screened 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme annually depends on the annual budget of the project.
According to national statistics data, in Tbilisi there are 253,147 females aged 40-70 who represent the source population for breast cancer screening; as breast cancer screening is conducted once in 2 years, the annual source population will be 126,575 (253,147/2); 2011 budget allowed covering only ~20% of this population; thus the target population for breast cancer screening in 2011 will be 25,315.
Based on this information, Table 10 demonstrates the National Screening Program accomplishments in Tbilisi in 2011 with regard to the indicators.

It is clear that the National Program should put very intensive efforts to increase the screening program participation rate.

Table 10.
Table 10.

GNSP accomplishments in Tbilisi, 2011 Cancer Screening Component Breast Cancer Cervical cancer Prostate cancer Colorectal Cancer Target Population 25,315 22,266 29,212 53,861 Number Screened Percent Screened 13,912 14,372 3,776 1,198 (Indicator) 55% 65% 13% 2% As part of the monitoring and evaluation activities and internal quality control of the program performance, the National Screening Center routinely performs the Patient/client Satisfaction Survey.
In 2011 a Client Satisfaction Survey was conducted using the phone interviews with randomly selected beneficiaries.

In total 400 beneficiaries were interviewed, approximately 100 from each participating medical facility.

The survey is fully anonymous and no personal information is collected.
The questionnaire includes statements characterizing patient satisfaction or dissatisfaction with the services provided; there is a question evaluating the source of information from which the patient learnt about the screening programme.

The possible answers are scored from 1 to 5, were 1 is the strong agreement with a statement, 3 is neutral and 5 is the strong disagreement.
Collected data were analysed using the Epi Info (version 3.5.1) programme (Annex 2) - the survey questionnaire and the results of the patient satisfaction survey).

Overall, more than 90% of the women are happy with the services they get, the attitude of personnel, they are likely to recommend the screening program to their relatives and friends and, interestingly, compared to the last year results, the waiting time at the facilities to get screening services has reduced dramatically in 2011.
Furthermore, nobody has declared that they had difficulties with making an appointment for screening and nobody was referred to specific pre-defined treatment facility or a doctor.

The half of patients (50%) declared that they learned about the screening program through the television, 33% from friends and relatives and 17% from other sources such as press, radio and outdoor advertisements on public transport.
98% of screened population declared they would return to the program as it was recommended to them and also they would recommend their friends and relatives to visit the screening facility.
Main constraining and facilitating factors Main constraining and facilitating factors were at the core of the discussions at the project management meetings organized on 22 June and 25 November, 2011, attended by the First Lady of Georgia, Municipality of Tbilisi, NSC and UNFPA; It was agreed to explore opportunities for expansion of project in Tbilisi through identifying and involving new sub-contractors in order to increase geographical accessibility of services for the population in Tbilisi, which in turn will contribute to increased utilization of the Municipality funds allocated for this project; reimburse ambulatory treatment of the pre-cancerous lesions (within the cervical cancer screening component) at the NSC and Tbilisi Cancer Centre, which will 1 1 1 contribute to increased accessibility to services; in addition, it was agreed to support integration of the cervical cancer screening at the Primary Health Care level.
Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme Main constraints identified: Based on the analysis of 2011 January-October statistical and epidemiological data the following challenges were identified: - Overall participation rate in Screening Program is low to moderate and unevenly distributed among screening facilities participating in the screening programme; - Poor practice of participant invitation to the second rounds of Breast and Cervical cancer screening that could be due to invalid contact phone numbers, unavailability of fixed participant invitation protocol, human resources devoted to this particular task and other external factors.
For instance, in 2011 the screening program could actually reach only half of the participants screened for breast cancer in 2009 by phone, 50% of which did actually return to screening.
Similar problem exists with cervical cancer Screening Round-2 as well; Main facilitating factors in programme Implementation that contributed to the success of the programme are the following: - The software for the screening programme been developed and installed and is in the process of testing at the National Screening Centre.

The software is designed to fully respond to administrative, clinical and partially financial information managements needs.
According to observations of doctors and management of the Screening Centre, the software will be further advanced and upgraded in 2012 to fully respond to the financial management needs.
In this regard the suggested scope of work for 2012 is being developed by the Screening Centre IT specialist; - Government commitment to replicate the breast, cervical, colorectal and prostate cancer screening in all regions of Georgia; - Partnership between and the UN and the Government: This is the only project where Government allocates funds for cancer screening in partnership with UNFPA; - Partnership building among the local and the leading institutions from EU countries for national capacity development; - Network building: the project created and strengthened the networks among local and international professionals, especially in the Black Sea region, as well as among national professionals from the capital and regions of Georgia; - Result-based management and accountability: the project serves as the good example for accountability, efficiency and transparency; - UNFPA contribution: Financial support complemented by technical and managerial experience; project management followed UNFPA policies and procedures that positively affected efficiency of the project implementation.
The project benefited through the alliances and linkages with other projects supported by UNFPA under the UNFPA Country Programme.

Partnerships The project has a very productive collaboration with the Reproductive Health National Council of Georgia which is chaired by the First Lady of Georgia.
The Council provides an important venue for ensuring coordination among the donors interested in this field; 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme The partnership with the European Cervical Cancer Association (ECCA) and with Union for International Cancer Control (UICC) has been further strengthened in the frames of this project: - In May 2011 two cito-pathologists from National Screening Center were trained in Italy with the support of the European Cervical Cancer Association, Union for International Cancer Control and UNFPA; - A training workshop in Georgia for local cito- pathologists was conducted by cytologists from Italy particularly: Prof Cesare Gentilli U.O.
Anatomia Patologica Ospedale Unico della Versilia Camaiore, Italy and Dr. Di Bonti U.O.

Anatomia Patologica Ospedale Unico della Versilia Camaiore.
In 2011 several new partnerships have been established: - With European School of Oncology (ESO) - Two days training of radiologists and radiographers wasbe conducted by ESO international experts in Georgia and plans for the coming 4-5 years are being shaped out; - With Dutch National Experts and Training Centre for Breast Cancer Screening LRCB - The objective of this partnership is to assess the accuracy of mammographic screening and diagnoses in Georgia compared to established standards in use in Western Europe and establish quality assurance mechanisms of Breast Cancer Screening Programme; under - With the European Federation of Colposcopy and Cervical Pathology this - partnership two gynaecologists - colposcopists were trained in UK the goal of this training was to improve theoretical knowledge and practical skills in colposcopy; Comprehensive Cancer Centre in the Netherlands – to share technical expertise with NCDC on cancer organizing registry; professionals national - With UNFPA Georgia and National Screening Centre Staff participated in Global Meeting on Cervical Cancer Prevention organized by the UNFPA Technical Division in AntaIia Turkey, in May 2011.
Partnership and collaboration with the subcontractors of the National Screening Centre as well as with the Regional medical facilities which run Cancer Screening programme have been further strengthened and deepened through various capacity building activities; V. FINANCIAL IMPLEMENTATION The Project Implementation and expenditure followed the approved project budget.
Delivery rate is 100% (for details of financial implementation please see Annex 3) 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme VI.

FUTURE WORK PLAN i.

To support national capacity development for screening programmes management and provision of quality services; ii.

Support further improvements in the design and management of Tbilisi Screening Programme, including involvement of the Primary Health Care level in cervical cancer screening; iii.
Support the Black Sea Coalition on Breast and Cervical Cancer Prevention and the initiatives within the frames of this Coalition, such as building partnerships with similar organizations and programmes in the EU and the neighbouring countries to share experience and learn best lessons and build capacity of national professionals in the field; iv.

Support raising awareness of the population on the benefits of the screening programme.
National Screening Program Epidemiology, Tbilisi, 2011 [Annex 1] Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme Breast Cancer ScreeningJanuaryFebruaryMarchAprilMayJuneJulyAugustSept.Octob.Nov.Dec.TotalBreast Cancer Screening9057111240105912369991264879125011611098413912National Screening Center 8086171132992112387311067491132107011487Tatishvili Medical Center 97941086711312615813011891109841295Tbilisi Cancer Center 1025Gudushauri Medical Center51Balneology Center541.2 Performed InvestigationsType of InvestigationNPercent(%)Physical Investigation13912100%Mammography13912100%Ultrasound394628.36%Cytology4663.35%Type of InvestigationIdentified Abnormality* Distribution (%)(%) Portion among Total(N=17141) mamografia299421.52%21.52%ultrabgera109927.85%7.90%citologia28460.94%2.04%Cytology ResultN% Nonadequate429.6% Benign24355.5%Atypical/Undifferentiated378.4% Suspicious for Malignancy286.4%Malignant8820.1%Total438100%Note: * Identified Abnormality Referrs to BIRADS 3, 4 and 5.1.3 Abnormalities Identified by each Diagnostic Method and their Distribution1.4 Cytology Results Distribution1.1 Number of women screened by the Program 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme Cervical Cancer ScreeningJanuaryFebruaryMarchAprilMayJuneJulyAugustSept.Octob.Nov.Dec.TotalCervical Cancer Screening88210381244917119513861394840126811551098414372National Screening Center 78594411368501082126012367101150106411877Tatishvili Medical Center 97941086711312615813011891109841197Tbilisi Cancer center1239Balneology59Screening methodN Percent (%)PAP test14372100%Colposcopy216015.03%Biopsy2521.75% 1.3 Distribution of the Atypical Pap test ResultsAtypical PAP TestNumberDistibution (%) of abnorm(%) abnormal PAP results ASCUS80859.02%5.62%########## ASC-H1168.47%0.81%########## LSIL27219.87%1.89%##########HSIL15911.61%1.11%##########AGUS/AGC70.51%0.05%##########Carcinoma70.51%0.05%#####Total1369100.00%9.53%##########1.5 Results of atypical Pap test after colposcopy
 investigations during 2010Cytological and Colposcopy DiagnosisTotal NASCUS (n =725)72531042.8%14620.1%25435.0%152.1%00.0%ASC-H (n = 97)971616.5%3839.2%2929.9%99.3%55.2%LSIL (n = 239)2396928.9%3715.5%12853.6%52.1%00.0%AGUS/AGS (n=5)5120.0%360.0%120.0%00.0%00.0%HSIL (n = 130)13021.5%2216.9%1713.1%7759.2%129.2%Carcinoma (n=1)100.0%00.0%00.0%00.0%1100.0%Total ( n = 1197)119739833.2%24620.6%42935.8%1068.9%181.5%1.6 Distribution of Morphology Cytological and Colposcopy DiagnosisTotal NNormal Pap test (n=992)99233834.1%18218.3%12312.4%33533.8%131.3%10.1%1.2 Performed Investigations1.1 Number of women screened by the ProgramInvasive CancerNumber (%)NormNumber (%)Not Satisfactory ColposcopyNumber (%)CIN1Number (%)CIN2,3Number (%)Invasive CancerNumber (%)NormNumber (%)Not Satisfactory ColposcopyNumber (%)CIN1Number (%)CIN2,3Number (%)PolypNimber (%) 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme [Annex 2] Patient Satisfaction Survey Results Maria Kachinska Branch of National Screening Center (Varketili) N=100 Statement Strongly Agree Agree Partially Agree Disagree Strongly Disagree I am satisfied with the received medical service 48 (48%) 51 (51%) 2 (2%) 0 0 It takes a while to receive a service 0 3 (3%) 4 (4%) 32 (32%) 61 (61%) Investigation was performed on time according to schedule Doctors are friendly and cordial Administrative personal working at the Screening Center are very superficial It took a long while to make an appointment with a doctor I am not happy with the received medical service I would recommend the Screening Center to my friends and relatives Medical personnel advised me to refer to particular treatment facility or to particular doctor 72% 0 1 (1%) 0 90% 1% 49 (49%) 45 (45%) 6 (6%) 27% 2% 1% 3% 0 0 0 0 6% 89% 3 (3%) 2 (2%) 23 (23%) 71 (71%) 1% 9% 0 2% 0 3% 20% 1% 7% 77% 0 89% Did you pay any fee service provided within the programme?
If yes please specify in which investigations No Yes Mammography Ultrasound Paptest Colposcopy Cytological investigation 100% 100% 100% 100% 100% 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme Didube Branch of National Screening Center N=100 Statement Strongly Agree Agree Partially Agree Disagree Strongly Disagree I am satisfied with the received medical service It takes a while to receive a service Investigation was performed on time according to schedule Doctors are friendly and cordial Administrative personal working at the Screening Center are very superficial It took a long while to make an appointment with a doctor I am not happy with the received medical service I would recommend the Screening Center to my friends and relatives Medical personnel advised me to refer to particular treatment facility or to particular doctor Did you pay any fee service provided within the programme?
If yes please specify in which investigations Yes Mammography Ultrasound Paptest Colposcopy Cytological investigation No 100% 100% 100% 100% 100% 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme Tbilisi Oncology Center N=100 Statement Strongly Agree Agree I am satisfied with the received medical service It takes a while to receive a service Investigation was performed on time according to schedule Doctors are friendly and cordial Administrative personal working at the Screening Center are very superficial It took a long while to make an appointment with a doctor I am not happy with the received medical service I would recommend the Screening Center to my friends and relatives Medical personnel advised me to refer to particular treatment facility or to particular doctor 75% 0 9% 85% 0 1% 1% 23% 0 21% 5% 84% 11% 3% 3% 2% 75% 2% Partially Agree 1% 0 0 0 0 0 0 0 0 Disagree Strongly Disagree 2% 88% 7% 1% 22% 47% 18% 1% 95% 1% 7% 0 3% 75% 49% 79% 1% 3% Did you pay any fee service provided within the programme?
If yes please specify in which investigations Mammography Ultrasound Paptest Colposcopy Cytological investigation No 99% 100% 100% 100% 100% Yes 1% 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme Tatishvili Medical Center N=100 Statement Strongly Agree Agree Partially Agree Disagree Strongly Disagree I am satisfied with the received medical service It takes a while to receive a service Investigation was performed on time according to schedule Doctors are friendly and cordial Administrative personal working at the Screening Center are very superficial It took a long while to make an appointment with a doctor I am not happy with the received medical service I would recommend the Screening Center to my friends and relatives Medical personnel advised me to refer to particular treatment facility or to particular doctor Did you pay any fee service provided within the programme?
If yes please specify in which investigations Mammography Ultrasound Pap test Colposcopy Cytological investigation No 100% 99% 100% 99% 100% Yes 1% 1% Total N=400 1 1 1 Standard Progress Report GEO1R21A – Breast and Cervical Cancer Screening Programme How did you learn about the Screening Programme?
Frequency Percent Poster on the buses Friends Press Radio Other Television Total 1 131 4 2 63 196 397 0.3% 33.0% 1.0% 0.5% 15.9% 49.4% 100.0% Will you return to the planned follow up visit as it was recommended to you Frequency Percent Yes No Total 389 9 398 97.7% 2.3% 100.0% Reasons for not coming for the follow up planned screening Frequency Percent Not satisfied with biopsy performance Holds private insurance Hysterectomy performed Continues treatment in oncology clinic Superficial attitude and the facility has an old equipment Extirpation of Uterus and cervix Because of business and no time to visit No target age any more It takes a lot of time to get service at the facility 1 1 1 1 1 1 1 1 1 Total 9 0.11% 0.11% 0.11% 0.11% 0.11% 0.11% 0.11% 0.11% 0.11% 100.0%