Taiwan Breast cancer, Oral cancer, and Colorectal Cancer Screening Programs

The Taiwanese national cancer screening program began in 1985 by providing Pap smear tests for women. At the same time, trial-based screening programs were initiated for colorectal, breast, and oral cancer high-risk groups. In 1999, outreach services for breast cancer and oral cancer were started and gradually scaled up to the national level. This national screening service not only provided screening tests but also built up a screening information system and a cancer screening registry to monitor the quality of screening services. At the beginning, registration for cancer screening was processed by using paper forms, and the capacity and timeliness of data processing were limited. A computerized registry combined with a screening information system was introduced, in 2002, and in 2004 the system was improved to an internet-based registry with a feedback system; as a result, that the nation-level screening database developed rapidly.

Evolution of Cancer Screening in Taiwan

Since January 2004, the Health Promotion Administration (formerly Bureau of Health Promotion) started to subsidize citizens aged 50-69 years for colorectal cancer screening every two years. Screening for colorectal cancer included two phases. Phase one utilized the fecal immunochemical test for mass screening. Subjects with positive results would be referred to the phase two confirmatory diagnosis with colonoscopy. The age range was expanded to 50-74 years in June 2013. With regard to breast cancer screening, the Health Promotion Administration started to subsidize women aged 50-69 years for mammography every two years. In November 2009, the age range was expanded to 45-69 years. In 2000, women aged 40-44 years with second-degree relatives ever diagnosed with breast cancer were included. With regard to oral cancer, the mass screening service first provided annual oral inspection for citizens over 18 years of age who were smokers or had the betel nut chewing habit. Starting on January 1st, oral cancer screening was adjusted to provide a biennial screening for citizens over 30 years of age who were smokers or chewed betel nuts.

To increase cancer screening coverage, the Ministry of Health and Welfare (formerly the Department of Health) provided special funding for cancer prevention and control after raising the tobacco tax. The funding not only increased the capacity of regional health centers to provide outreach services to community populations for colorectal, oral, and breast cancer screening (from certified breast imaging hospitals), but also proposed to change the original concept in which hospital-based practices placed more emphasis on cancer treatment than on cancer prevention. This policy built up the so-called “in-reach screening services”. Accordingly, starting in 2010, the screening services could also be provided not only by regional health centers, but also by certified fecal occult-blood testing laboratories, dental clinics, and other medical hospitals, so that the number of subjects undergoing colorectal, oral, and breast cancer screening increased substantially.

Establishing the Screening Database

Screening data collection, processing, and analysis were crucial for the improvement of preventive services. Such a task requires regular surveillance of screening quality, systematic review of up-to-date clinical evidence, and continuous audit of the accuracies of the screening database. Therefore, the establishment of a screening database system was needed to evaluate the effectiveness of the cancer screening strategies, which would be the basis for further policymaking.

To reach this goal, in 2004, the Health Promotion Administration (formerly the Bureau of Health Promotion) funded a research proposal called “Taiwan breast cancer, oral cancer, and colorectal cancer screening database and informative systems: an implementation project”. With the collaboration of the government and academic researchers from the College of Public Health, National Taiwan University, a surveillance system was started for the nation-level screening database. Step-by-step, between 2004 and 2006, the internet-based platform and its feedback system were established. It proposed to introduce a user-friendly system, with hopes to reduce the difficulties of first-line users in the data registry processes and improve the overall efficiency.

Under the integration of the nation-level screening database, the surveillance system, and the internet-based platform with its feedback system, first-line users have generally become familiarized with the operating methods. To improve the efficiency of the system in face of the increased number of users and increased need to protect the privacy of individual data, another research project called “Taiwan breast cancer, oral cancer, and colorectal cancer screening database and informative system: a maintenance project”, was launched in 2007. The Health Promotion Administration collaborated with academic researchers from the College of Public Health, National Taiwan University to improve the system platform environment, upgrade the system functionalities, elevate data security standards, and develop debugging mechanisms based on the feedback system. A total of 338 computer programs had been updated to meet the feedback needs of the first-line users. Until 2009, the usage of the system reached, on average, 24,000 person-times per month. Furthermore, with the evaluation of systematic reviews of evidence-based medicine, the screening indicators, such as the positive rate, referral rate, positive predictive value, and detection rate, could be evaluated with statistical models, which was also the basis for further policymaking on cancer screening.

Through the evaluation of the effectiveness of cancer screening and the related feedback system from first-line users, the target population for oral cancer screening was revised in 2010 to cover the population over 30 years who was smoking and chewed betel nuts, instead of those over 18 years of age. Also to improve the screening efficiency, batch upload via virtual private network was established, and the usage and data volume increased substantially. In 2012, the average login number reached approximately 63,000 person-times per month. To accommodate the rapid increase and future integrating capacity, in 2012, the Health Promotion Administration launched a project called “Taiwan multiple cancer screening and follow-up database: an integrated information system”. This project intended to integrate all the screening-related databases, including the Breast Cancer, Oral Cancer, Colorectal Cancer Screening Database, Cervical Cancer Screening Database, Taiwan Cancer Registry, Taiwan Mortality Registry, Taiwan Household Registration, and Human Papillomavirus Vaccination Case Management Database. The aim of this project was to make a useful connection between different relevant screening databases following the global trend of “big data concept”, hoping to develop novel and individualized cancer screening strategies.