Improving Access to Cervical Cancer Screening and Treatment

Ingrid Hein

August 25, 2017

In sub-Saharan Africa, the integration of cervical cancer screening services with existing family planning clinics led to a 72% treatment rate for women with precancerous lesions, according to results from a new study.

The fate of a woman with cervical cancer — known as "cancer of the mouth of the womb" in sub-Saharan Africa — can be much worse than living with HIV, said Heather White, DrPH, senior technical advisor of noncommunicable diseases at Population Services International, a nonprofit organization.

The disease is treatable but is usually detected too late, and access to treatment is scarce, Dr White told Medscape Medical News.

The challenge is that you may have only one cancer center for the entire country. Dr Heather White

"The challenge is that you may have only one cancer center for the entire country," she explained. And even if women do have access to cancer treatment, getting an appointment and getting to the center become "serious issues."

Cervical cancer is the leading cancer in women in sub-Saharan countries, particularly those with high burdens of HIV. According to the World Health Organization (WHO), it is the fourth most common cancer in women worldwide, with more than 85% of cases in low-resource regions.

In 23 of 48 sub-Saharan countries, the incidence of cervical cancer is 34.8 per 100,000 women. In Botswana, for example, the mortality rate is 24.6 per 100,000 women.

Family planning programs are natural entry points for prevention programs because the target group for cervical cancer screening is the same as the target group for family planning services — women 30 to 49 years of age — said Raveena Chowdhury, deputy director of cervical cancer prevention at Marie Stopes International in London, United Kingdom, during a presentation on July 25 at the International AIDS Society (IAS) 2017 Conference in Paris.

This integration was implemented under the direction of Marie Stopes International — in partnership with Population Services International and the International Planned Parenthood Federation — to increase uptake of the Cervical Cancer Screening and Preventive Therapy Initiative, which is funded by the Bill and Melinda Gates Foundation.

Screening and Treatment Sites

"We first conducted a joint desk review of the problem," Dr White reported. "We sat down with Ministry officials in each country to understand their priorities, and mapped out our respective clinics and decided where to offer services, based on the volume of patients seen, to optimize both screening and treatment."

The research team identified 483 screening sites located in family planning clinics operated by Marie Stopes International in Kenya, Nigeria, Tanzania, and Uganda and 244 cryotherapy treatment sites.

Local health providers were trained to screen patients and provide cryotherapy by local experts and by master trainers from the ministries of health in each country.

To improve awareness of the disease and the benefits of early detection, the group developed a series of information pamphlets and talking points for patients.

"We answered basic questions," Dr White explained. What is cervical cancer? What are the benefits of being screened? What should a woman expect if she is screened and has to be treated with cryotherapy, or if she needs additional care?

Between June 2013 and July 2017, the clinics conducted 1.9 million cervical cancer screenings and treated 29,000 women with precancerous lesions.

There was also an unexpected impact on other services. "We were really surprised to see the numbers jump for IUDs [intrauterine devices] and implants when cervical cancer services were integrated," Dr White told Medscape Medical News.

"We feel confident we can offer these services side by side and not sacrifice quality; they integrate well," she added.

Successful Integration of Services

To understand the initial trend in service uptake, the researchers conducted 547 exit interviews at program clinics in Uganda over an 18-month period, from 9 months before the launch of the cervical cancer services to 9 months after implementation.

"Cervical cancer screening services were new to these clinics, so we didn't have a historic comparison," Dr White explained.

Overall, 77% of clients reported that they had accessed other clinic services, including long-acting reversible contraceptives and other family planning options.

The average uptake of common contraceptive methods in each facility was significantly higher in the 3 months after implementation of the program than in the 3 months before implementation for implants (41 vs 57 women; P < .0001) and for IUDs (24 vs 42 woman; P < .0001). However, there was no notable increase in the use of injectables.

A Treatable Disease

This year, two new indicators — human papillomavirus (HPV) vaccination and cervical cancer screening for HIV-positive women — were added to the criteria used to monitor HIV and AIDS, according to the annual UNAIDS-led Global AIDS Monitoring 2017 report. And The Global Fund now allows countries to include cervical cancer services in requests for funding.

"For me, as a public health professional, it stands to reason that every woman 30 and older should be screened at least once in her lifetime for a disease we can treat," said Dr White.

Family planning integration is an "overwhelmingly positive strategy," but it requires robust supervision and logistics systems, Chowdhury said in her presentation.

Dr White said she agrees that the integration of cervical cancer services "with family planning just makes common sense." However, she acknowledged, there are operational challenges, such as fragmented funding structures, the need for increased coordination among clinics, and the regular training and supervision of clinical service providers.

International AIDS Society (IAS) 2017 Conference, Paris, France. Presented July 25, 2017. Presentation TUSA04.

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