COMMUNITY PROGRAMS TO CONTROL CÂNCER OF THE CERVIX

Cancer of the Cervix is the site of the disease in which the control measures are more offective. Mass screening is the best way to reach the aims of a public health program. Cervical cancer prevention and detection must be carried out according to the patterns of each community. It is not recommended to limit the examination to pre-symptomatic women, because the general objective of detection is the discovery of cancer cases a good time before it would be done by the initiative of the patients themselves. Mass examination is able to change the general picture of cancer stages at the time of diagnosis. The kind of organization which carries out the detection of cervix cancer does not matter very much. The work can be executed in cancer or general hospitais, in special clinics, in health centers or even in physician’s offices. The simple taking of vaginal smears by unprepared personnel or even by the patient herself cannot be recommended. To co-ordinate the work of the detection units a Central or Basic Unit is necessary. Complete diagnosis and treatment should be only carried out in very well equiped and staffed institutions. These conditions are generally found in cancer hospitais, cancer clinics and in gynecological departments of Universities and high standar general hospitais. A well organized recording system is necessary to an affective follow-up. After-care must be planned, according to the needs and possibilities of each case. Home care is mandatory in advanced cases and is really effective if organized as a Service of the Hospitais. In the special field of cancer of the female genital organs, emphasis must be given to the teaching of physicians in methods of detection and dignosis. To cover the needs of a mass screening program, a great deal of cytologists and pathologists must be provided. The same can be said about cyto-tecnicians. It is not possible to have the examínation performed by gynecologists in every community. General practicioners can be teached and trained in three or for months. Public education must be conducted very carefully, showing the importance of early diagnosis and the advantages of periodical examination. In Brazil, cancer control is carried out through a large net-work of institutions and units under the supervision of the National Service of Cancer of the Ministry of Health. The great majority of these institutions and units are private. 1490 beds in cancer hospital are available. Prevention and detection of cervical cancer are conducted in 43 autonomous Clinics and in the out-patient departments of Cancer University and General Hospitais. Cytology, Schiller’s test and colposcopy are used routinely in most of the Detection Clinics. Biopsy is performed according to the information obtained through the other items. A Mass Screening Program was planned in Brazil. A Pilot Project on Mass examination in the State of Rio de Janeiro is under way. A group of 517.000 women over 30 years of age are assigned for examination. It is expected to cover about 50 per cent of this group, what was already reached in Niteroi, which is the State largest city. 20.000 records were already analyzed. A reduction of the rate of stages III and IV, from 65 to 30 per cent was already obtained. The cancer rate was 2.25 per cent. The experience in a small and undervelloped community, where a wandering medical group performed the examinations is given to show the difficulties and how they can be overcomed.

The same can not be said from large countries in devellopment, where good medicai Services and well trained sonnel only exist in large cities. In these last countries, the câncer control pro gram in most o£ the communities has to be very modest in regard to their own Services, depending on facilities offered by the main cities of the country.
Câncer of the cervix is, undoubtedly, the site of the disease, in which the control measures are more effective.
There are some favourable conditions for the control of câncer of the cervix, which must be emphasized, as follows : 1) Cancer's danger signals are easily observed by patients; 2) the accessibility of the organ facilitates its examination; activities to the examination of asymptomatic people, in order to detect câncer in its earliest stage. In such eventua-9) the follow-up of the patients lity, it is not easy to select the cases to be examined, mainly in relation to the female genital organs.
does not involve complicate measures or great expenses; 10) rehabilitations is mostly com plete.
It is more logical to extend the exa mination to all women, by considering that the general objective of detection is the discovery of câncer cases, within a given population, a good time before it would be done by the initiative of In spite of the important role played the patients themselves, pressed by by hospitais or autonomous detection alarming symptoms. centers and even by physician's offices, in the improvement of early diagnosis in a community, the only way to reach the aims of a public health program is the mass screening.

B -PREVENTION, DETECTION AND MASS SCREENING
Mass examination is able to change the general picture of câncer stages at the time of diagnosis. In the first screening covering all the population of a community, the rate of detected can-The detection centers are generally cer of the cervix cases is very high, established in cities with very dense because many women with population, well prepared by the cân cer educational campaign, and receive people for consultation referred from such an opportunity. To organize and to carry out a mass screening program, out of the knowledge of the number of women to be examined, a complete plan must be estabíished, taking into consideration the medicai and other personnel needed, the place of examination, the period of time necessary, the public education possibilities, the connection with other centers where the specimens and pa tients are to be sent after detection, the registration and the evaluation of expenses.
To co-ordinate the work of the de tection units and of the wandering me dicai groups a central or basic unit is necessary. This center unit may be a câncer or general hospital in the area, to which the following tasks must be g) Examination of patients sent, in order to have a complete diagno-As it will be emphasized in the chapter about the brazilian experience, the best solution for this problem is the organization of wandering medicai groups, headed by a highly prepared physician, spending the time needed in each community to cover the assigned population group. After having finished its task in one community, the same group goes to another one, starting all over again.
Ghese physicians are able to perform a careful medicai examination, using colposcopy, performing biopsies and establishing diagnosis, with the help of the reports about the tests made with the specimens they have previously sent to the laboratory. way the greatest majority of patients, who have to be sent to other parts of the country, are intended just for treatment and not for diagnosis.
A well organized mass screening proved to be the best method used in the control of câncer of the cervix. The knowledge of the size and composition of the population gives an epidemiological significance to the screening, esta- A well organized recording system is necessary to an effective follow-up. It is preferable tbat tbe re-examination of tbe treated patient be performed at tbe same institution, wbere sbe was previously treated, and even by tbe same doctor, wbo did conduct tbe treatment.
Tbis condition creates in some cases so cial and economic difficulties because Pbysical examination, pelvic examination, X-ray and otber tests give tbe stage of tbe disease.
Even in tbe cases referred for treat ment witb diagnosis already establisbed, complete medicai examination is recommended.
of travei, bed and board expenses. In , r r , . . sucb cases finantial support and otber Ireatment of câncer of tbe cervix is ^ , r , 1 , racilities must be provided.
still perrormed by surgery and radiotberapy. Cbemotberapy may offer some benefits in advanced cases or be used togetber witb surgery or witb tbe aim to improve tbe results.
In câncer of tbe cervix, follow-up is mandatory, not only to cbeck tbe reradiotberapy, sults, in order to obtain valuable infor mation for statistics, but also because of the possibility to detect a recurrence in time, when treatment can still be effective.
After care must be very well planned, according to the needs and possibilities of each case. Post-operative radiotherapy and other prolonged after-treatments should be carefully planned, offering to the patient out of the hos pital the necessary facilities, until her complete rehabilitation.
After-care must be continued, even when the patient has no more chances of complete recovery and deteriorates progressively.
Home care is mandatory in such ca ses and is really effective if organized as a Service of the Hospitais. The cooperation of some voluntary agencies is very useful, helping in the housekeeping and providing the necessary means to improve the social, economic and psychologic conditions of the patient. Some advanced cases cannot stay at home. Special hospitais for such cases are not recommended. It is more advisable to give them the necessary care in hospi tais accepting, also, cases presenting other kinds of chronic disease or in small nursing homes.
In the special field of câncer of the female genital organs, enphasis must be given to the teaching of physicians in methods of detection and diagnosis.
Pélvis and specular examination would be part of the routine of every physical examination. The general practicioner would also be familiar with methods of taking smears from the cervix for cytological examination and would be able to use the Shiller's test and to perform a punch biopsy. The needed training can be provided in the pre-graduate and post-graduate leveis in the Departments of Gynecology of the Universities and in câncer hospitais.
The distribution of special pamphlets of instruction to all general practitioners is very helpful. It is necessary to include the general practitioner in the câncer control program, because he is the first to see the patient and from his orientation and decision depends many times the future of the patient.
To cover the needs of a mass screening program, a great deal of cytologists and pathologists must be provided. In order to convince people to be The use o£ gynecologists would be a examined, avoiding cancerophobia, the good solution, but it is impossible, following points must be taken in conmainly in the small communities. Health sideration: center doctors are not technically prepared to perform the task without a previous training. Five or six lectures are not suficient to give them possibilities of judgement. In order to give an outline of the entities, which cooperate in the control of câncer, the following list is pre- The co-operation of Hinselmann in colposcopy, and of Franz and Limhurg in special pathology, who taught their techniques to the Institute staff, contributed very much to the progress of the activities. Therefore, the Gynecolo gical Institute became atrue Center of training for physicians who want to learn the new procedures. These figures give only a general idea of the problem, but do not establish the incidence and prevalence of cervical câncer.
Mass and periodic examinations covering the population of the different areas of the country is the best way to collect epidemiological information, because the screening is based in the previous knowledge of the size and composition of the population to be studied.
In order to establish the possibility of a mass screening program in a national levei, a Pilot project is presently conducted in the State of Rio de Ja In order to get earlier cases, public education was started emphasizing the importance of periodic examination, but avoiding to speak about câncer. All means of propaganda, as posters, pamphlets, short movie films, press and ra dio, were used. Lectures were given in more than 100 different places.  The medicai group has some special material, including a small colposcope, which was adapted, covering the needs of visibility.
Until now, 6 groups only were ganized, because it was recommended to them to start slowly in order to check the first results mainly the producti- The 6 Moving Groups alone, presently in operation, are expected to perform about 60.000 examination in one year. Adding 20.000, which should be performed in the Central and Peripherical Units, mass screening may cover about 80.000 women in one year. According to the results of the first year, the number of Moving Groups can be increased in order to reach the 250.000 expected examinations ond to start the second screening in the Communities already visited. If this same number of Moving Groups is maintained, it will take three years to complete the first screening.
In order to make the task of the Moving Groups easier, the State of Rio de Janeiro was divided into 6 areas, comprehending each of them a group of Counties.
The activities of the Moving Groups started very recently and consequently it is not yet possible to evaluate precisely the results of the Pilot Project. However, some data and special aspects of the obtained experience can be presented.
The data recorded in the Central and Permanent Units from the beginning of their detection activities were used for this presentation. Some comments about the moving groups will also be made. phlets, radio, press, movie-films and talks to different groups of women are used intensively during a few days.
When examination starts, the number of applications is generally very high.

RESULTS
According to the data obtained in the mass screening programs carried American and Canadian out m some cities the percentage of examined women is about one half of the female population over 20 years. Generally, the screening was restricted to the cytological examination of smears obtained from the vaginal pouch by nurses.
As it was already said, the mass screening in the brazilian Pilot Project includes physical and pelvic examina tion, Schiller's test, colposcopy and, eventually, biopsy. The examination is also extended to breast, skin and accessible mucosas. Pre-cancerous conditions, bening tumors and other lesions are also detected by these examinations.
In the Expectation that 50 per cent of the women's population over 30 years of age will participate of the first screening, about 250.000 exami nations have to be made.
The greatest productiveness belongs to the Wandering Groups because they dedicate themselves exclusively to this activity. They are working 8 hours, performing 32 examinations daily, but they are allowed to prolong their time cal study of the specimen, in order to determine the existence or not of an invasive carcinoma.
Out of the 20.000 computed cases, 540 had câncer, representing 2.25 per cent. His very high rate can be explained because most of the patients were referred to the Hospital (Central Unit) after a long period of time from the beginning of the disease. In some Peripherical Units this rate was lower, decreasing to one per cent.
In a second screening this rate was 0,6 per cent.
In the city of Niterói, about 50 per cent of the 42.000 women over 30 years of age were already examined, but the collect of data concerning this group is not yet complete. Clinicai and epidemiological aspects suggested by the analysis of the data collected in the Registry of the Pilot Project will provide a complete report about the results obtained.
In order to give an idea of the work performed by the moving groups in Peripherical Units were computed. Over 22.000 cytological examinations were made. The cytologic specimens from the cervix were always taken with an Ayre blade from the squamo-columnar junction and from any area of the cer vix which was abnormal. When the presence of blood or pus could not be explained by lesions of the cervix, spe cimens were collected from the endocervix and endometrium. The same behaviour was followed in old women.
According to the Papanicoulaou's classification, 39 per cent of the group III and 96 per cent of the groups IV and V had câncer.
Systematic colposcopy started later and therefore only 7.000 colposcopical examinations could be computed. The number of atypical changes reached 17.5 per cent. The colposcopic findings were very helpful, alowing a selective biopsy. In about 3 per cent of the ca ses with negative cytology, colposcopic findings did lead to the diagnosis of câncer.
Biopsy of the cervix was performed in about 12 percent of the examined cases. In the first group of cases, when colposcopy was not systematic, punch biopsy was used. Afterwards biopsy was always selective. When histology showed atipical cells or carcinoma in situ, a biopsy by conization was recommended, followed by careful histologi-he help of the Women's Organizations Against Câncer it is supposed that this inconvenient can be avoided.
It is not yet possible to calculate exactly the cost of each examination. However, in order to reduce the expenses to a minimum, the following prin cipies and measures were adopted: a) Limitation by sex (only women) and by age; Neither hospital nor health center were to be found. The first impression was that an adequate place could not be obtained to install the Unit. At last, a retired physician lent his office, located in an old and small house. The equipment was obsolete, but good enough to permit examination.
The moving group, headed by a woman doctor, obtained housing and board in private homes because there are no hotels in the city.
The educational campaign lasted three days and was very sucesseful.
In the first 2 weeks the number of consultantions was o ver 30 daily. After this period of time some difficulties appeared. The clerk in charge of the records and registry resigned and it was impossible to obtain number of applications of patients decreased. It was decided to interrupt the activities. 600 examinations were made and 9 cases of câncer were detected. This experience was very helpful, showing that even in communities without facilities it is possble to carry out a mass screening. The problem of allied personnel is fundamental. With substitute. The SUMMARY Câncer of the Cervix is the site of the disease in which the control measures are more offective. Mass screening is the best way to reach the aims of a public health program. Cervical câncer prevention and detection must be carried out according to the patterns of each community. It is not recommended to limit the examination to pre-symptomatic women, because the general objective of de tection is the discovery of câncer ca ses a good time before it would be done by the initiative of the patients themselves.
Mass examination is able to change the general picture of câncer stages at the time of diagnosis.
The kind of organization which carries out the detection of cervix câncer does not matter very much. The work can be executed in câncer or general hospitais, in special clinics, in health centers or even in physician's offices.
The simple taking of vaginal smears by unprepared personnel or even by the patient herself cannot be recom mended.
To co-ordinate the work of the de tection units a Central or Basic Unit is necessary.
Complete diagnosis and treatment should be only carried out in very well equiped and staffed institutions. These conditions are generally found in cân cer hospitais, câncer clinics and in gynecological departments of Universities and high standar general hospitais.
A well organized recording system is necessary to an affective follow-up. After-care must be planned, according to the needs and possibilities of each case. Home care is mandatory in advanced cases and is really effective if organized as a Service of the Hospitais.
In the special field of câncer of the female genital organs, emphasis must be given to the teaching of physicians in methods of detection and dignosis. To cover the needs of a mass screening program, a great deal of cytologists and pathologists must be provided. The same can be said about cyto-tecnicians. Cytology, Schiller's test and colposcopy are used routinely in most of the Detection Clinics. Biopsy is performed according to the information obtained through the other items.