Z. Krebsforsch. 74, 120--122 (1971) �9 by Springer-Verlag 1971

Evaluation of Cancer Screening in Wiirttemberg (Federa l l~epublic of Germany)

E x p e r i e n c e s w i t h an I n t e g r a t e d Sys tem*

G. NEU~ANN

Received July 6, 1970, accepted October 6, 1970

Zusammen/assung. Fiir 750/0 der 775000 Frauen zwischen 35 und 60 Jahren ist in Nord- wfirttemberg und Siidwiirttemberg~Hohenzollern eine gynakologische Krebsvorsorgeunter- suchung vertraglich gesichert und de facto mit der flblichen kassen~rztliehen Versorgung gleichgestellt. Im ersten Vertragsjahr, 1968, wurden 24818, 1969 63862 Frauen untersucht. Bei 7,8 bzw. 5,6~ wurde der Abstrich nach Papanicolaou Grad IV oder V beurteilt, mit einer signifikant hhheren Rate bei Untersuchung dutch praktische J~rzte im Vergleich zu Gyn~kolo- gen. Obwohl nur 9,20/0 der zur Untersuchung heranstehenden Frauen sieh beteiligten, wurden 32% yon 643 1969/70 bekanntgewordenen Kollumkarzinomf~llen durch Vorsorgeuntersuchung entdeckt. Das Auffinden sines Falles yon Papanicolaou Grad IV oder V erforderte 1968 rd. 3200 DM, 1969 rd. 3800 D~.

Summary. Four about 750/0 of the 775000 women between the ages of 35 and 60 in Nord- wiirttemberg and Siidwiirttemberg-Itohenzollern one free cancer screening per year is provided by a formal contract. In 1968 24,818 examinations were performed, in 1969 63,862. The rate for smears in Papanieolaou's grade IV and V was 7.8 per 1000 in 1968 and 5.6 per 1000 1969. The yield of eases was significantly higher among the women attending a practioner than those of being examined by a gynaeeologist. Of 643 eases of cancer of the cervix 320/0 were detected by screening though only 9.2o/o of all women were examined. The detection of one ease on Papanieolaou's grade IV and V requested in 1968 about 880 $, in 1969 about 1040 $.

I n spite of the long t r ad i t i on of the German H e a l t h Insurance Sys tem access to modern p reven t ive medicine has only now become possible on a v o l u n t a r y basis. The admin i s t r a t ive d is t r ic t of Nordwi i r t t emberg , wi th abou t 3.3 mil l ion inhabi- t an ts , was the first d is t r ic t in the Federa l Republ ic to negot ia te a formal con t rac t be tween H e a l t h Insurance organsia t ions including organisat ions for provid ing social a id for the poor on the one hand and Doctor ' s organisa t ions on the other. The same a r r angemen t was p rov ided for the ad jacen t d is t r ic t of S i idwi i r t temberg- Hohenzol lern. This caters for abou t 75 % of the 775,000 women between the ages of 35 and 60, age-l imits being b y no means rigid. F o r every woman there is guaran- t eed one free examina t ion per yea r including pa lpa t ion of the breast , pelvic examina t ion , and t ak ing of a cervical smear. These examina t ions are pe r fo rmed by gynaecologis ts and general prac t ioners , and a p a t i e n t m a y a t t e n d a doctor of her own choice. The l i t e ra tu re abou t the new examina t ion was worded careful ly and care was espeeiMly t a k e n to ensure con t inu i ty be tween clinical and l a bo ra to ry invest igat ions . Since October 1968 a school for cytological technieans is opera t ing a t the Univers i ty of Ulm.

* Vortrag gehalten auf dam I0. Internationalen KrebskongreB in Houston 1970.

Evaluation of Cancer Screening in Wiirttemberg 121

In 1968, the first year of the programme, 24,818 examinations were performed. This number is not quite so unsatisfactory if one realises that up to the end of 1967 virtually no screening had been done at all. The number of smears taken in 1968 for clinical reasons was 19,123 (Nordwiirttemberg only); those taken for preventive reasons numbered 20,030, in 1969 the figures were 28,496 and 40,378 respectively. The number of smears in Papanieolaou's grade IV and V amounted to 193, giving a rate of 7,8 per 1000. An additional 625 smears were graded in Papanieolaous' grade I I I . By a follow-up it is known that histological confirmation of cancer was obtained in 11% of grade I I I eases, 57 % of grade IV eases and 86% of grade V eases. In 1968 every 142nd woman who had a cancer screening test showed cytological evidence of cancer of the cervix. The number of eases of Papanieolaou's grades IV and V gives a fair estimate of the positive findings, but no informations about false negative results are available.

In 1969 the number of examinations increased to 63, 862, that is 157 % more than 1968, but this means still only 9.2 % of all woman entitled to cancer screening.

The number of smears taken by general practitioners increased from 13.1% in 1968 to 26.4 % in 1969, that is by more than 102 %. The yield of eases with Papani- eolaou's grade IV und V was 10 per 1000 for practitioners in I968 and 8.7 per 1000 in 1969. For gynaeeologists it was 7.1 and 5.3 respectively. The difference between these two groups is significant at the 0.001 level. The coverage shows big regional differences : Already in the city and county of Ulm 31% of all women participate in cancer screening, whereas in other rural districts only a few smears have been taken.

Another at tempt to achieve a high coverage was made through the guild insurances. They sent a letter inviting all their female members between 35 and 40 years of age to have free cancer screening. 492 of them were interviewed in a special survey and in 41 o/; a smear was taken. With a few exceptions the menlbers were in complete agreement with the action of their insurance organisation.

The yield of eases of Papanieolaou's grade IV and V in 1969 was slightly below the yield in 1968. This might be expected, for at the beginning of a voluntary mass campaign many people seek a medical examination because of symptoms which should have already motivated them to attend a doctor.

The 193 respectively 359 eases of carcinoma of the cervix detected by screening may be compared with other figures. In 1968 154 women in the same area died from cancer of the cervix, that is 5.9 per 100,000.

The attack-rate is not known, as no cancer registry exists. But, from the preli- minary results of a special epidemiologieal investigation, the number of new eases of carcinoma of the cervix may be estimated. Within one year 643 eases were registered, 32 % of them being detected by preventive examination. This nmnber is consistent with the number of Papanieolaon's grade IV and V eases found in the screening tests. Emphasis should be put on the fact that by examination of a relative small number of women such a high number of eases resulted.

The screening is paid for in the same manner as normal medical services, being 3.00 $ for the physical examination and 3.20 $ for evaluation of the smears. For 1968 the costs amounted to about 155,000 $, in 1969 to about 400,000 $. The

122 G. Neumann: Evaluation of Cancer Screening in Wiirttemberg

detection of one case of Papanieolaou 's grade IV and V required in 1968 about 880 $, in 1969 1,040 $. This should be compared with the amount of about 10 million $ payed by the General I tea l th Insurance of S tu t tgar t (with about 252,000 members) for clinical medical services.

The increase in the number of examinations performed is proving the value of a completely integrated system.

Additional remarks: The number of deaths of cancer of the cervix in 1969 was 168 (= 6.4 per 100,000). From January 1st, 1970 to June 30th, 1970 50,992 examinations were performed, that is 89 per cent more than during the same time in 1969.

Med.-Dir. Priv.-Doz. Dr. G. Neumann D-7000 Stuttgart 1, Sehickhardtstra~e 35