THE NATIONAL PLAN TO PREVENT AND COMBAT CANCER IN ROMANIA, IN THE GLOBAL CONTEXT

Roxana-Elena Bohîl?ea

Department of Obstetrics and Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest, Romania

Abstract: Cervical and breast cancer remain the most frequent neoplasias that endanger the lives of Romanian women every year. The actual system regarding cancer screening must change. Opportunistic screening is not an option. Romanian female population needs a real plan, real changes, medical education, an effective vaccination program, cervical and breast cancer prevention and early detection, as well as specialized medical centers for curative and palliative treatment. The solution is the founding of Regional Screening Centers with financial autonomy, dedicated staff, and well-individualized locations, with equipment intended exclusively for the conduct of screening programs, based on standardized procedures of medical practice guidelines and mechanisms that ensure quality following European guidelines. Equal chances for everyone.

Keywords: cervical cancer, breast cancer, regional screening centers, vaccination, chances for women

Cancer remains one of the leading causes of death in the European Union (EU) and worldwide. The first European plan to fight cancer "Europe against Cancer Plan", dating from the late 1980s, led to the adoption of European legislation on tobacco and occupational health. Since then, EU Member States have taken several actions and committed, accordingly to the United Nations Sustainable Development Goals, to reduce premature mortality from chronic diseases, including cancer, by a third by 2030; the commitment also aimed the World Health Organization (WHO) non-transmittable disease targets, which included a 25% reduction in cancer mortality.

On December 2, 2003, the "Council Recommendation on cancer screening" (1) was published in the Official Journal of the European Union. The European Council disposed the development and implementation in member countries of screening programs for cervical, breast, and colorectal cancer as an integral part of the obligations of the Community Treaty regarding the accomplishment of national policies intending to improve public health, preventing illness, and detecting factors that endanger human health.

The screening principles as a method for chronic non-transmittable disease prevention were published by the WHO in 1968 and by the European Council in 1994, establishing the high-quality standards and good practice guidelines that should govern the screening application.

Screening allows cancer detection in the pre-invasive stage or the early stages of invasiveness so that the lesions can be effectively treated, increasing the chance of curability. The most important indicator of screening effectiveness is the mortality rate specific to the pathology decrease. Screening participation must be freely consented based on the clear and complete presentation of the necessary information to participate in the screening of asymptomatic people. Public health services can only achieve the cost-effectiveness of a screening program if it is systematically implemented, covers the entire target population, and respects the latest good medical practice guidelines. Systematic implementation requires the organization of a call/recall system for screening patients, with quality assurance during the entire process, from appropriate diagnosis to correct treatment and post-therapeutic monitoring services, based on evidence-based medical practice guidelines. Centralized data systems must include the list of all categories of the screening program target group, the screening test results, the follow-up, and the final diagnosis. All data collection, storage, transmission, and analysis procedures within the medical registers involved must be in full compliance with the personal data protection legislation, according to the directives issued by the European Parliament and the Council of Europe. Screening quality refers to both the process analysis and the obtained results, which must be quickly reported to the population and the screening providers; the screening process analysis is facilitated by associating its database with cancer registries and mortality databases. To ensure adequate organization and quality control, the Member States must allocate adequate human and financial resources, while assuring equal, fair access to screening, taking into account the special needs of particular socio-economic groups included in the target population.

Following the first report published in 2008 at the request of the European Council (2), which showed that, despite the progress made, EU Member States did not meet their objective set for the minimum number of examinations, during 2009-2013, the European Commission carried out the "European Partnership for Action against Cancer" (EPAAC), financed as a joint action within the EU Health Program, to stimulate and support the development of National Cancer Control Plans in the Member States. The EPAAC joint action was continued with the CANcer CONtrol (CANCON) joint action, which was completed in February 2017 with the publication of a European Guide to Cancer Plans and a set of health policies that, all together, continue to support the organization of population-based screening programs for the three tumor locations, which must, however, be implemented under the European Guidelines for Quality Assurance in screening programs, guidelines that define the organizational and implementation core, so that these programs provide a maximum of benefits and a minimum of risks.

The analysis of the screening recommendation implementation of the European Council from 2003 in the second report elaborated and published in 2017 (3) highlighted the fact that the breast cancer screening program is ongoing in 25 of the 28 EU member states, 95% of women aged 50-69 are tested, and cervical cancer screening is ongoing in 22 of the Member States, covering around 72% of the target age group 30-59, with huge discrepancies between the Member States regarding the status of screening implementation and expansion.

The European Commission has funded and supported the development of evidence-based European Guidelines for Quality Assurance in screening programs for cervical, breast, and colorectal cancer. These guidelines are constantly revised and updated, incorporating all existing scientific evidence (4-7). The European Commission has also established the European Initiative for Breast Cancer and the European Initiative for Colorectal Cancer, expert groups with the role to provide recommendations and guidelines and ensure the quality of screening, diagnosis, and treatment services for breast and colorectal cancer.

Romania had a complete lack of organized cancer screening programs at a national level until 2012, when, following a pilot program at the regional level carried out in the North West region, the national program for early active detection of cervical cancer was initiated using Papanicolau test in a screening regime financed from the Health Ministry budget. Since 2016, Romania has had a draft National Cancer Control Plan (NCCP). The testing strategies through screening programs recommended by the Specialized Commission in Oncology of the Health Ministry were developed during 2009-2016 in the form of a specific chapter on secondary prevention in the NCCP, being developed within the EPAAC joint action and were completed and publicly communicated in 2016 within the CANCON Joint Action.

According to the centralized data by the Cancer Screening in the European Union Report on the implementation of the Council Recommendation on cancer screening, 2017 (3) regarding the implementation stage of the European Council recommendation (2003/878/EC), Romania is among the few EU Member States that have not yet organized population screening programs for breast and colorectal cancers. The organization of a breast cancer screening program was also conducted in the North-West region, within a project financed by the Norway - EEA financial mechanism, but the results of this program were not used and developed within an expansion program. From the target population of Romania, evaluated in the period 2012-2013 at approximately 1.3 million, the invitation rate and the examination rate in the pilot center were 0.2%, respectively 2460 tests corresponding to a participation rate of 82% of the invited population, no reporting of screening results, in terms of diagnosis, treatment, and case progress.

The latest European Union report dates from July 2020 and focuses on four main areas of the cancer problem in Europe: determinants, screening, and early diagnosis, access to cancer treatment, care and research, rare forms of cancer, and childhood cancer (8). In numbers, poor coverage and wide variability in cancer screening implementation among European countries translate into a mammography screening coverage rate ranging from 17% to 84%, a cervical cancer screening coverage rate varying between 4 and 71%, and a population screening coverage rate for colorectal cancer of 1-53%. Romania declares the same figures, the screening participation rates for breast and cervical cancer being contradictory, and the examination rates so low, that it is obvious that until this moment in Romania we do not have functional population screening programs for any of the three neoplastic pathologies prioritized by the European Council. Regarding cervical cancer screening, given that in 2018 this pathology contributed approximately 9% of all cancer cases, the screening program included a population of all ages, with a target number of 1,127,544 women, of which 65% were invited, actually included in the screening and examined 103,886 women, respectively 9.2%, the participation rate being 14.2%.

Starting with the 2003 recommendations, scientific and technological progress have added new methods with increased performance in breast, cervical, and colorectal cancer screening; digital mammography, digital breast tomography, or nuclear magnetic resonance as a complementary method addressed to women with dense breast tissue, HPV testing, fecal immunological test or endoscopy are progressively implemented within the European Union program. The results obtained in the field of neoplastic risk prediction disclose a new strategy in development: screening based on risk stratification. Regarding early diagnosis, WHO recommends three essential key levels in achieving optimal diagnostic systems in the early stages of the neoplastic disease: awareness and addressability, clinical assessment, diagnosis and staging, and finally access to high-quality treatment.

The new Europe's Beating Cancer Plan focuses on all the key strategies of the disease: prevention, early diagnosis, treatment, care, and increasing the quality of life of patients. Based on the support of the Member States, the leaders of the European Parliament, including the Members of the "MAPs Against Cancer" group that worked alongside the European Commission to improve cancer prevention and healthcare in Europe, are integrating the existing national plans to fight cancer in each European state. The development of the EU Cancer Plan will take place close to the Mission on Cancer, a new initiative of the Horizon Europe Framework Program for Research and Innovation, which maximizes the impact of European support for research and innovation and demonstrates the relevance of their results for society.

The World Health Organization (WHO) launched on 17 November 2020 the Global strategy to accelerate the elimination of cervical cancer “Cervical Cancer Elimination Day of Action”, having as the purpose to vaccinate 90% of the target population against HPV, to ensure cervical cancer screening in 70% of eligible women at least twice in their lifetimes and to assure treatment for 90% of women who present a cervical lesion or a positive screening test, including cases needing palliative care, by 2030. WHO recommends as primary screening test HPV DNA detection, starting at the age of 30, with a frequency of 5 to 10 years; the age group 30-49 is regarded as having priority for screening in the general population (9).

The national health strategy 2014-2020, assumed by Government Decision no. 1028/2014, mentioned among the major public health issues that in women, breast and cervical cancer are the malignancies with the greatest impact on premature mortality (before 65 years), with over 70,000, respectively 50,000 potential years of life, lost to premature deaths each year. The document emphasized the fact that "Romania performs sub-optimally in the field of prevention, including for the early detection of cervical cancer, mortality caused by this disease rising or at least being stable" and that "the recently established national cervical cancer screening program requires several years of implementation, sustained funding, increased performance to specific standards before the first significant signs of stable impact on mortality emerge." It was also emphasized that the high rates of morbidity and mortality make cervical cancer primary prevention by vaccination against the Human Papilloma Virus (HPV) a highly relevant and necessary intervention in Romania since HPV 16 and 18 strains are responsible for about 70% of cervical cancers.

Primary and secondary prevention efforts for preventable cancers are addressed in the national health strategy through two specific objectives regarding cervical cancer, respectively:

• Consolidation/development of the management capacity and/or implementation of the vaccination program according to the current national calendar and ensuring the necessary resources for an improved national vaccination calendar (by including the expansion of anti-HPV vaccination).

• Reducing the cancer burden in the population by detecting the early stages of the disease and reducing the specific mortality in the medium-long term through organized screening interventions.

Regarding the results of the national health programs, it is predicted that the initiation of the national program for the early detection of cervical cancer was a necessity derived from the extremely unfavorable epidemiological profile of this malignant pathology among women in Romania - 3 or 4-fold higher incidence and mortality than European averages.

In the Activity Report of the Health Ministry for the year 2018 (the latest available), it is stated that this year 116,253 HPV vaccinations were carried out in population groups at risk (girls 11-14 years old). Thus, if we consider that an annual cohort of girls has a population of about 100,000 people and that each girl should have two/three vaccination doses, we can estimate that in 2018 HPV vaccination coverage was below 10%. The same report of the Health Ministry states that the cervical screening subprogram worked in 2018 with 75 networks, carrying out tests according to table 1. The incidence of the 2 types of pathologies, breast cancer and cervical cancer in 2018 is shown in Table 2.

Table 1. Cervical cancer screening subprogram results. Source: Health Ministry, Activity Report 2018

Table 2. Incidence of cancers studied in Romania and in Europe, 2018. Source: Globocan 2018

The standardized mortality for the two pathologies in Romania compared to the European Union is presented in figures 1 and 2. Based on the analysis, we concluded that the progress achieved by Romania since the beginning of the implementation of the national health strategy 2014 - 2020 in terms of health status on the two pathologies is of small impact, the annual incidence remaining above the European rate (WHO Europe) for both diseases, greatly exceeding cervical cancer (+54%), Europe bringing together all the member states, including the states of Eastern Europe, where the health status is traditionally more precarious.

Figure 1. Standardized breast cancer mortality, RO vs. EU 28, 2011 – 2016. Data source: Eurostat

The incidence analysis in Globocan is based on estimates, given that in Romania it is reported only through the Cluj and Timi?oara regional registers. For this reason, for the mortality analysis, we chose the EU - Eurostat database. Especially in the case of mortality, an increase in breast cancer mortality is observed in Romania, while the EU presents a decreasing trend. The standardized mortality rate from cervical cancer is 4 times higher in Romania compared to the EU average, with cervical cancer being an avoidable cause of death.

Figure 2. Standardized mortality from cervical cancer, RO vs. EU 28, 2011 – 2016. Data source: Eurostat

In 2020, we analyzed and published the characteristics of mortality due to cervical cancer in Romania, including trends and differences in mortality over the last two decades between Romania and Europe, between the regions of the country and urban-rural environments, analyzing the implications of these data from the point of view of public health policies (10). The analysis started in 2001, with 2016 being the last year available for Europe, and 2019 for Romania. In 2001, Europe registered 10,570 deaths from cervical cancer, of which 17% came from Romania, which placed our country in 3rd place among European countries, after Poland and Germany, alongside which it contributed 51% to European mortality through cervical cancer at that time (11). In 2002, Romania occupied the first place with the highest mortality in Europe due to cervical cancer, and the difference to the European average was enormous, respectively 276%, respectively 18.8 versus 4.8 deaths per 100,000 women in Romania compared to Europe. Until 2016, there is a 58% reduction in mortality in the EU and 56% in Romania, however, still has the highest rate, 3.7-fold higher than the European average. Among the 32,558 avoidable deaths due to cervical cancer recorded in Romania between 2001-2019, 61% occurred in women under the age of 65, and 14% of them were in young women under the age of 44 (10). In 2019, there are statistically significant changes compared to 2001, with the South becoming the most affected region, followed by the South-East and North-East regions, the Bucharest-Ilfov region remaining the weakest contributor, although mortality here recorded an 8% increase, probably due to the increase in the number of inhabitants (10). Nationwide, the downward trend in standardized cervical cancer mortality is evident, but throughout the analyzed interval, higher rates of this parameter are maintained in rural areas; between 2001-2019 the mortality reduction reaches 25%, and the rates in the urban and rural areas falling by 22 and 32%, respectively, but the rural population continues to remain disadvantaged (10). Of course, Romania’s situation is not unique, despite its huge gap in cervical cancer mortality compared to the EU. Evidence suggests that cervical cancer mortality rates are higher in Central and Eastern Europe and access to organized screening programs is detrimental compared to the rest of the continent.

The fact that breast cancer continues to represent the main cause of cancer morbidity and mortality in women worldwide despite the progress made by the EU in the implementation of screening programs, with wide variations between countries and socio-economic categories. In 2020, we carried out and published a statistical analysis that aimed to quantify the health deficit due to breast cancer in Romanian women, compared to the average of the European female population, 10 years after accession (12). In the last decade (2005–2015), the number of breast cancer cases increased by 35% worldwide, and about one-fifth of this increase was due to increased incidence rates (13). The incidence of breast cancer (age-standardized rate) has decreased only in countries with a high social development index, with all other countries showing an increase in the indicator (13). In terms of mortality, the number of deaths worldwide increased by 21%, but the age-standardized death rate decreased globally by 6%, with the decrease in mortality observed especially in countries with medium and high social development index (14). In 2007, mortality from breast cancer in Romania was 9% lower compared to the EU, but in 2016 all the advantage that Romania had at the beginning of the interval was lost, with both populations reaching the same mortality rate. Overall, we found a 6% increase in Romania and a 5% decrease in the EU. The increasing trend of breast cancer mortality in Romania was also highlighted in the previous decade and is assumed to continue in the future, which will increase the health gap compared to the EU (12). In 2007, women in Romania had one of the lowest life expectancies at birth among all EU member countries (76.8 years), with a gap of 5.4 years compared to the EU average. Our study reveals a slight upward trend in this parameter for both Romania and the EU, with a significant reduction in the gap; thus, at the end of the analyzed interval, life expectancy at birth increased by 3% in Romania and 2% respectively in the EU, and the difference reached 4.8 years. The contribution of breast cancer to reduced life expectancy at birth was 0.45 years in 2007 and slowly increased to 0.48 years in 2016 (12). Access to organized breast cancer screening programs is significantly limited in Eastern Europe compared to the rest of the continent, although organized mammographic screening is proven to reduce breast cancer mortality. Moreover, Eastern European countries not only have limited capacities to organize population screening but usually also lack high-quality data to quantify the incidence of this pathology (12).

The National Romanian Law 293/2022 for Cancer Prevention and Combat will be implemented between the years 2023-2030 (15). Breast cancer, is the most frequent type of cancer among Romanian females, being the first cancer mortality cause in the female population in our country. In 2020, there were 12 085 new cases of breast cancer and 3 918 breast cancer deaths. The main target is to decrease the mortality by 5%, by implementing a national population screening program for women aged 45-74 years, during UCOP (Human Capital Operational Program), assuring the necessary equipment as well as the personnel to carry out the investigations, genetic testing introduction (settlement of genetic testing for BRCA1, BRCA2, CHECK2, PALB, ATM, settlement of the panel testing of genes involved in breast cancer, by next-generation sequencing, settlement of panel testing for all newly diagnosed breast cancer patients, updating these panels whenever necessary), monitoring patients with breast cancer and fertility conservation (establishment of a radiotherapy center in each county, assuring the necessary investigations, respecting the indications for concomitant treatment – radio-chemotherapy, fertility evaluation at the beginning of the treatment) and founding 20 accredited centers for the diagnosis and treatment of breast cancer.

Although cervical cancer is no longer one of the most frequent cancers in Europe, Romania is the 4th most frequent after breast, colorectal, and lung cancer; in 2020, the incidence in the cancer population was 7.5%, with a mortality of 3.3% from national total number of deaths by cancer. Unfortunately, the National Cervical Cancer Screening Program does not cover 20% of the target population. The first objective of the law is to decrease mortality by 5%, by making the National Cervical Cancer Screening Program more efficient, by introducing genetic testing, founding 8-10 accredited centers for minimally invasive approaches, and hopefully eliminating cervical cancer. Genetic testing is addressed to patients with active HPV infection to assure targeted immunotherapy. Somatic genetic testing for TTN, PIK3CA, MUC4, and KMT2C genes, regardless of HPV status, is designed to establish targeted therapy. The necessity of the settlement of the panel of genes involved in the detection of cervical cancer through next-generation sequencing, and also the settlement of panel testing for all newly diagnosed patients with cervical cancer, is sustained in the newly adopted law 293/2022. The National Plan for Cancer Prevention and Combat contains the national strategy to eliminate cervical cancer, taking into account the objectives set by the WHO, but also the local reality of Romania, and one of the goals is achieving a vaccination against HPV rate among the eligible population of 30% until 2025 and 40% in 2030 (15).

The operational framework of the National Cancer Prevention and Combat Plan should take into account, before genetic testing expanding, the following deficiencies in the functionality of the screening programs, which are the basis of the cancer mortality situation in Romania, depicted in the figures previously:

• The main problem of screening programs in our country is the absence of a computerized system and databases capable of storing patients’ records, evolution monitoring, 5-year survival, and contact with the patient for screening or monitoring consultations. Therefore, there should be set up a mandatory rule for the patient to come to regular consultations set up and announced in advance, but above all, the digital system must be created, and funds and staff must be allocated to it as it is essential as underlined by European guidelines containing the quality standards in population screening. As we have shown before, Romania is not only deficient in screening coverage, but also in reporting data at the national and international levels (16).

• The poor access to medical services for women in rural areas, due to cultural, educational, geographical, economic, and information barriers, creates a major social inequity, all the more important as the proportion of the rural population is increased in Romania. The results of previous personal studies have shown the continuous presence of barriers to accessing preventive and curative services for the rural population, even though the legislation guarantees equal access to health services for all citizens. The analysis of cancer mortality by geographical region supports the disparities in socio-economic development between the various regions of the country, but it should reflect in the provision of health services as it is unacceptable for a developed European country (16).

• The lack of genuine national statistical indicators in the conditions of integration of the DRG reporting system and the contractual relationship with the Health Insurance House. The statistical indicators of the disease have the role of creating an overview necessary to understand the disease evolution trends both at the population level (incidence, prevalence, survival) and individual level and to also quantify the effectiveness of the diagnosis and therapeutic approaches. It is not possible to carry out an analysis of the costs involved in genital and mammary malignant pathology for individuals, for families, or for the health system as is the analysis of survival rate in Romania and there are no data on the evaluation of the quality of life. The quantitative data on the state of health, and the use of health services related to cancer, that is available for Romania are fragmentary, it is necessary to combine multiple sources and can only provide a partial picture of the impact of this pathology in the population and on the use of healthcare services (16).

• Cases are reported under a common diagnostic code, lacking etiological individualities; secondary diagnosis is not fully reported. The correct and efficient way in which the observation sheets are filled should be established through protocols adapted to each health unit/ facility, the full diagnosis of disease should necessarily include the diagnosis of the main condition with its clinical form, evolutionary stage, etiological diagnosis, and full secondary diagnoses. In the case of cancers, the diagnosis must contain the stage of the disease according to the latest FIGO/TNM classification, the histological form according to the WHO classification, the degree of histopathological differentiation, the location of the metastases if they exist, the clinical form or the diagnosis of presentation, complemented by the diagnosis of associated diseases (16).

• The Health Ministry has achieved a particularly important step in medical practice by developing, publishing, and updating clinical guidelines. They are the best practice recommendations for good medical care based on published scientific evidence. The guidelines must be adjusted to protocols specific to each health unit/ facility. For all patients to equally benefit from a standardized way of diagnosing and therapeutic, the Health Ministry, through specialized commissions, must create a mechanism for controlling the implementation of these guidelines. Currently, there are huge discrepancies between medical practices in rural-urban areas, between the health units of the same city, and even between the doctors belonging to the same health unit/ facility. The number of guidelines and protocols must increase, and the medical practice must be standardized and homogeneous so that the continuity of screening programs with coherent programs for diagnosis and treatment of precursor lesions or early stages of genital and mammary cancers can be ensured. Mortality from genital and mammary cancer will not decrease in Romania until primary, secondary, and tertiary prevention will work is organically integrated and unfragmented, in a standardized and highly effective manner (16).

• The lack of the National Cancer Registry, whose centralized functioning has been stopped since 2008, needs to be repaired urgently.  Reports of cancer cases worldwide are based on national cancer registries. The national rare disease registry – recently created, is incomplete, with Lynch syndrome being absent in statistics, although it represents 5% of colorectal cancers and the specialty of medical genetics, although present among medical specialties, has a reduced and inconsistent representation in health facilities, which also must be improved (16).

Screening failure in Romania can be explained by two major conceptual errors: the integration of the screening program in the health system of diagnosis and treatment, and the granting of the pivotal integrative role to the family doctor within this program. The medical service providers within the national cervical cancer screening program are represented by the hospitals, offices specialized in obstetrics and gynecology, and medical analysis laboratories in the field of cytology. This is proof of the organization of a screening network for early active detection of cervical cancer, consisting of the following health structures: information and counseling centers for women, advising them on preventive measures for cervical cancer and mobilizing the population eligible for Papanicolaou testing, centers for the collection of cervical cellular material, laboratories for medical analysis in the field of cervical cytology, centers for diagnosis and treatment of precursor or incipient lesions detected under the subprograms. Considering that the health facilities with beds are not exclusively under the coordination of the Health Ministry, their budgetary situation is at the limit, making it very difficult to provide medical care for emergencies of chronic cases, and do not have the necessarily computerized systems needed for extensive databases linked to the population health records, national cancer, and rare disease registers, do not have staff dedicated to conducting appointments, it is obvious that the allocation of funds dedicated to screening is lost in a mass of global shortcomings in which the acute needs will always be other than the support of effective and sustainable screening, as the coverage rates of the eligible population prove it, in the figures for previous years. The central operational element of the health facilities with beds, is addressability, and that of the screening system is the calling, recalling, scheduling, keeping records, and covering the healthy population; the attempt to make these two different systems work simultaneously in the same locations, with the same deficient staff, has led to the malfunctioning so far of testing within the program. The specialized health facilities that are currently implementing the program do not carry out a population screening according to the European Union regulations, but an opportunistic one, testing the patients who come to the health units for other diseases or with symptoms within the gynecological sphere (16).

The family doctor represents another dysfunctional element within the only existing screening program in Romania. The primary healthcare facilities are not equipped with gynecological tables, the family doctors are not accredited and do not want to collect material for the Babe?-Papanicolaou test, and the offices are not connected to a digital network capable of storing the records of the patients. Also, their lack of involvement in taking part in patients scheduling for the anti-Covid vaccination has proved their inefficiency in prophylaxis. The family doctor does not have the qualification to steer positive patients to screening for targeted explorations, and the results of invasive explorations reach them sporadically through the medical letter brought by the patient. In addition, the family doctor’s journey for referral-gynecologist harvesting-gynecologist for result interpretation by the family doctor for a referral to the medical unit of diagnosis and treatment implies a daunting time consumption for any employed woman who has to allocate 5 days of her leave for cervical cancer screening, without including breast cancer screening, for which she will have to address and pay a gynecologist and mammography. The involvement of the family doctor must gain a new status; he can detect by anamnesis the presence of abnormal uterine bleeding, can highlight the presence of risk factors, and can inform the patient about the increased risk they have of developing certain neoplasias, thus participating in the medical education their patients, explaining to them the usefulness of primary and secondary prevention measures, can inform about the age at which screening programs are recommended, thus contributing to their success. Informing patients about the risks, modalities of prophylaxis, and abnormal symptoms that they should report immediately is the key role of the family doctor in the early diagnosis of genital and breast cancer (16).

I propose a radical change of the national approach to screening, through the complete financial-operational separation of medical services intended for screening from medical services for therapeutic purposes. Conducting screening in emergency hospitals, chronic or outpatient hospitals can maintain a minimum screening rate in short term, including elderly patients with chronic conditions or disabilities who address medical services in an emergency or the context of chronic illness, but the impossibility of monitoring the screening results of these patients represents a major disadvantage for the sustainability of the program and is strongly not recommended by specialists. Therefore, I believe that the optimal solution should be to set up  Regional Screening Centers with financial autonomy, dedicated financial resources from European funds, and funds from national programs of the Health Ministry and the Health Insurance House, with dedicated staff, well-individualized locations, with equipment intended exclusively for the conduct of screening programs, based on standardized procedures of medical practice guidelines and mechanisms that ensure quality following European guidelines. Setting up these autonomous centers will pave the way and provide the material basis for the functioning of other screening programs, with colorectal cancer already being a requirement of the European Union, with other lung and prostate cancer programs currently under evaluation. The grouping under the same institutional roof of several specialties will make possible the multidisciplinary approach to the case, constantly recommended by the EU and impossible to achieve in the current system in which theoretically all information is centralized at the primary medicine level. In addition, primary prevention through HPV vaccination could gain promotion and confidence, an appropriately administered location, and genuine records of vaccinated people, able to statistically support the reporting of adverse reactions and efficacy (16). 

The Regional Screening Centers project is supported by the Romanian Society of Preventive Medicine and the concept will be addressed in detail, argued, and exhaustively, compared to functional organizational models worldwide, in future issues of the Romanian Journal of Preventive Medicine.

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