Effective, Low-Tech Screening of Cervical Cancer
11/16/2009
Ricky Lu on increasing access to early detection of cervical cancer
It is 8:30 am on a sunny September morning in Mozambique. I am with 12 Mozambican midwives, nurses and physicians who are attending the second day of a breast and cervical cancer screening workshop. Our task is to educate women who are waiting for their family planning consultation, on cancer screening. We've discussed a technique to engage these women, and are now trying it out. We ask the women, "How many of you personally know of anyone who died of cervical cancer?" That day, similar to what we experienced when we ask the same question in the Philippines, Indonesia, Guyana and Peru, someone steps forward to tell their story.
As cervical cancer remains the second most common cancer and leading cause of cancer deaths among women living in low to middle income countries, this is not surprising. This is in stark contrast to women in high-income countries where the rates of cervical cancer incidence and mortality have declined dramatically and pushed this once dreaded disease out of the top ten list, largely due to effective screening programs1,2 and access to treatment. Currently, approximately 80 percent of all cervical cancer cases worldwide occur in developing countries where they have less than 5 percent of the resources for screening.
If discovered in the later stages, when the tumor cells have spread out of the cervix and into the confines of the pelvis and elsewhere, cervical cancer is deadly. According to the American Cancer Society, the five year survival is only about 20-30 percent for advanced cancer. This fact is well illustrated by an anecdotal report from a colleague in the Philippines where there is no universal access to screening services. At their institution, two out of three cervical cancer cases are in the advanced stages, and one out of every three of these women die within one year of diagnosis. As the growth and development of this cancer occurs over a 15-20 year period, there is ample time to catch the disease before it progresses.
Early screening and treatment are effective at reducing rates of cervical cancer, and vaccines against human papillomavirus (HPV), the virus that causes cervical cancer, are now also available. Though there have been remarkable developments in novel approaches for prevention, screening and treatment, there are great inequalities in access to these technologies. More than 95 percent of women have never had a Pap test, and many countries simply do not have the resources to procure vaccines or to support the human resources and laboratory infrastructure required to provide new screening tests.
This inequality in access to screening can be greatly reduced by the use of simple, low technology, and cost effective solutions. The "single visit approach" (SVA), championed by Jhpiego, is a recognized alternative to the cytology-based model of cervical cancer prevention services and involves visual inspection of the cervix with application of acetic acid (VIA), followed by immediate treatment with cryotherapy for eligible lesions at the same visit. The Federation of International Gynecology and Obstetrics and the American College of Obstetrics and Gynecology have separately endorsed the use of VIA and cryotherapy for cervical cancer prevention services and recent studies have demonstrated its cost-effectiveness.
Jhpiego has been at the vanguard of global cervical cancer prevention efforts since 1997, when it conducted early clinical trials in Zimbabwe. The study helped establish the test qualities of VIA and developed the SVA. In 1999, with funding from the Bill & Melinda Gates Foundation, Jhpiego and five other international organizations formed the Alliance for Cervical Cancer Prevention (ACCP). Jhpiego implemented projects assessing the safety, acceptability and feasibility of the SVA to cervical cancer prevention, using VIA and cryotherapy; and has also developed training materials and helped to define implementation guidelines for countries wishing to launch their own prevention efforts.
Key lessons learned from this body of work include:
• Visual Inspection using acetic acid (VIA), has a sensitivity equivalent to or better than that of a Pap smear, although its specificity is lower. VIA is safe and effective in detecting pre-cancerous lesions and provides immediate results so the woman can be linked to treatment or referral, using a single visit approach.3
• Women are eager to access screening, and will come for testing and treatment even in very poor and/or conservative societies, as long as they trust the health care providers, and are provided with simple but clear messages about the benefits of screening;
• Midlevel providers can provide high quality SVA services, and are highly motivated to do so.4 As an example, in Ghana, eight nurses screened more than 20,000 women in 5 years.
New screening technologies will someday become affordable and available to women worldwide. Until then, we continue to advocate for equal access to screening for all women, using a comprehensive approach to prevention that includes primary prevention (vaccination), and cytology-based screening where feasible, and includes the SVA in low-resource settings, where a vast majority of women who have been neglected can finally have access to screening.
References
1 Gustafsson L, Ponten J, Zack M, Adami HO (1997) International Incidence Rates of Invasive Cervical Cancer after Introduction of Cytological Screening. Cancer Causes Control 8: 755-763.
2 Nygard JF, Skare GB, Thoresen SO (2002) The Cervical Cancer Screening Programme in Norway, 1992-2000: Changes in Pap Smear Coverage and Incidence of Cervical Cancer. J Med Screen 9: 86-91.
3 Royal Thai College of Obstetricians and Gynecologists/JHPIEGO Corporation Cervical Cancer Prevention Group. Safety, Acceptability and Feasibility of a Single-Visit Approach to Cervical Cancer Prevention in Rural Thailand: A Demonstration Project. Lancet 2003;361(9360):814-20.
4 Sanghvi H, Limpaphayom K, Plotkin M et al (2008) Cervical Cancer Screening Using Visual Inspection with Acetic Acid: Operational Experiences from Ghana and Thailand. Reproductive Health Matters 2008;16(32):67-77.
Dr. Ricky Lu is the technical director for the FP/RH and cervical cancer prevention unit at Jhpiego. Sharon Kibwana is a program officer for the East and Southern Africa region at Jhpiego.
Thank you for posting this cogent, comprehensive summary!
— Meg Wirth, Maternova on 2009-11-30
This is a great example of how cost-effective diagnosis can be quickly implemented and yield positive results. Great work!
— Neha Agarwal on 2009-12-14
For those of us in africa and the huge resources in Africa, these new technologies should be affordable. But corruption in all ramification aided by the concept of democracy will never allow the new technologies become affordable. Advocacy remains the weapon for now and many crusaders must join their voices in stamping out cervical cancer in africa and other developing countries.
— samuel on 2009-12-15
This is a very nice concept. It should be widely publicized and deployed, especially in Africa. I will join to do that in Nigeria.
— Jude Chimdi Ohanele on 2009-12-20