Slovenia has come a long way to become one of the most successful countries in the WHO European Region in the fight against cervical cancer. From having had one of the worst statistics in Europe on cervical cancer incidence, Slovenia has managed to turn the tide thanks to political will, cooperation and a robust screening programme.

A shared vision for change

Slovenia established its national cancer registry in the 1960s, which enabled Slovenian health authorities to track cancer incidence. A notable increase in cervical cancer rates in the 1990s sounded the alarm among experts, and led to the establishment of ZORA, Slovenia’s national cervical cancer screening programme.

“We used to have statistics among the worst of Europe – our cervical cancer incidence was really high,” explains Dr Urska Ivanuš, Head of ZORA. “With ZORA, managed by the Institute of Oncology Ljubljana, we built a population-based, centralized and comprehensive programme which soon delivered very concrete, tangible results: cervical cancer incidence has almost halved since we established ZORA.”

Dr Ivanuš describes one of the keys to such a remarkable accomplishment: “One of the important factors for success is a shared vision of the stakeholders, which should be led by the example of the core team. Believing in evidence, believing in the cause, working hard and with enthusiasm, listening and understanding all the stakeholders, monitoring and adjusting – all of this is crucial for the successful implementation of change.”

Regular rather than opportunistic screenings

Through ZORA, the practice of opportunistic screening – offering ad hoc screening tests to women visiting health centres for other reasons – was abandoned. Opportunistic screening has proven to have very limited impact on cervical cancer incidence. Instead, ZORA started screening women once every 3 years.

“There were some concerns we might miss out on cancers, but it turned out to be quite the contrary,” explains Dr Ivanuš. As the changes to the screening frequency were implemented, the rate of women with positive results requiring a call-back dropped from 15% to 5%.

“In short: we managed to screen more women, monitor results more efficiently, report back better to screening providers and also back to women themselves, and achieve better overall results,” says Dr Ivanuš. “Our ZORA team had a dream. Now that dream is a concrete plan: a plan to eliminate cervical cancer!”

Never wait for the first signs

The ZORA programme has been well accepted among Slovenian women, and more than 70% now attend screenings regularly.

“Women should think about screenings as part of a healthy lifestyle. Just as they do their daily exercise or try to eat healthy, they should make sure they are screened regularly. This is an important message we should convey to all women. Don’t wait for the first signs, as they will come late,” stresses Dr Ivanuš.

“Cervical cancer is one of the rare cancers where we can actually detect what is called ‘pre-cancer’. It can be a very small change in the cervix, limited to the surface, and if we catch it and treat it, we can prevent cancer from developing,” says Dr Ivanuš. “Cervical cancer is also the only cancer where we have 2 important, safe and effective public health interventions available: screening and vaccination.”

The 90–70–90 targets

“We can see global momentum, and we have the necessary tools for success. But to eliminate cervical cancer, we must achieve 3 crucial targets,” explains WHO Representative in Slovenia Dr Aiga Rurane:

• 90% of girls fully vaccinated with the human papillomavirus (HPV) vaccine by 15 years of age;
• 70% of women screened using a high-performance test by age 35 and again by age 45; and
• 90% of women identified with cervical cancer treated.

“For maximum impact, these 90–70–90 targets must be implemented simultaneously,” adds Dr Rurane.

With remarkable results for 2 of the targets – 70% of women screened and 90% of women identified with cervical cancer treated – Slovenia could very well become one of the first European countries to reach all 3 targets.

“We have not yet reached the benchmark of vaccinating 90% of girls. Slovenia has been vaccinating girls in the 6th grade of primary school against HPV free of charge since 2009. But the routine vaccination programme is attended by 60% of these girls, which is not enough to achieve the desired population-wide effects of the vaccination,” explains Dr Ivanuš.

“We need to increase coverage, implement primary HPV screening with more accurate tests that enable longer screening intervals, and strengthen the monitoring system,” she adds.

“Our success so far has been possible thanks to the continued efforts and dedicated work for many years of many health professionals in Slovenia, multiple partnerships, and the continued commitment of the Government,” says Dr Rurane. “Slovenia can be proud of what has been achieved, and it sets an example for countries across the Region and globally.”