Cervical cancer screening in Tamilnadu, India: a feasibility study of training the village health nurse

Task shifting to nonphysician health workers for improving access to care and treatment for cancer in low- and middle-income countries- a systematic review

BACKGROUND

Cancer is a complex global health issue overburdening health systems especially in low- and middle-income countries (LMICs). This burden is becoming more severe and complex as the global shortage of cancer care workforce persists. Since task shifting offers an alternative to address workforce shortages, a systematic review with the following research question was carried out: What is the scope of roles and tasks shifted to nonphysician health workers in improving access to cancer control services? The aim of this review is to critically identify, appraise and present evidence on how task shifting could be integrated and scaled to expand access to quality cancer control services in LMICs.

OBJECTIVE

The aim of this review is to critically identify, appraise and present evidence on how task shifting could be integrated and scaled to expand access to quality cancer control services in LMICs.

METHODS

Four databases were searched - CINAHL, EMBASE, MEDLINE and SCOPUS from inception to October 15, 2022, and included all studies that reported task shifting of cancer control services to nonphysician health workers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines was followed to report the review process. Risk of bias was assessed using the National Heart, Lung, and Blood Institute quality assessment scale. The studies were summarized using narrative synthesis. A meta-analysis could not be carried out because the review only assessed the scope of roles that were shifted to nonphysician health workers and because of the heterogeneity in the characteristics of the studies included in the review.

RESULTS

The search identified 170 articles out of which 16 were included in the review. Three studies were randomized controlled trials, four were cluster randomized trials, while 9 were cross-sectional. Tasks were shifted to primary healthcare workers, nurses, and community health workers. Tasks shifted included screening, patient education, and diagnostic procedures. Evidence from the studies showed that the quality and effectiveness of tasks performed were comparable, and in some cases, better than usual care.

CONCLUSIONS

Findings showed that tasks in certain areas of cancer control services such as screening, education, and diagnosis can be shifted to nonphysician health workers and that it could be effective in improving access to certain cancer control services. Therefore, this review has shown that task shifting could be an effective strategy in addressing current workforce shortages in cancer care and that there is a need to examine the care required along the cancer continuum to better understand which interventions can most effectively be shifted to more advanced health professionals such as pharmacists to improve access to cancer control services in LMICs.

Novel educational training of para medical professionals in cervical cancer screening

Background

Cervical cancer is a public health problem in India due to weak national screening policy compounded by lack of resources including scarcity of trained personnel to carry out community-based screening program. Para medical professionals (PMPs) are closely related to women in local communities. Hence, training PMPs by incorporating novel technology and reduced time duration to achieve adequate competence in screening is an area underutilized and needs to be explored.

Materials and methods

A pilot cross sectional analytical study was conducted at a tertiary referral cancer center using a shorter version of educational intervention of 2 weeks duration (EI2W) involving PMPs. Pre- and post-training assessment of knowledge, attitude, and practice (KAP) was done using questionnaires consisting of 5 domains viz. awareness of cervical cancer, awareness of cervical pre-cancer, practical screening methodology (practice oriented), data management and aspects of human papilloma virus (HPV). Wilcoxon signed-rank test was used for comparison and the degree of change was measured using analysis of covariance (ANCOVA). A p value of <0.05 was considered significant.

Results

118 PMPs were included. There was a significant improvement in scores of all domains (except cervical pre-cancer domain), following introduction of EI2W. Knowledge scores, post EI2W was better in Auxiliary Nurse Midwives (ANMs) than other participants. Awareness regarding cervical cancer was higher with more years of experience. The KAP analysis showed excellent interrater reliability in the practice 0.726 (0.649-0.792) followed by knowledge domain 0.711 (0.626-0.783).

Conclusion

EI2W was effective in significantly improving the competence of PMPs, thus reducing human resource constraints in cervical cancer prevention and elimination.

[Early detection and prevention of cervical cancer: knowledge, attitudes and practices of FHS professionals]

The study aimed to investigate the knowledge, attitudes and practices of professionals of the Family Health Strategy (FHS) on the control of uterine cervical cancer (CCU) recommended by the Ministry of Health (MS). This is a cross-sectional study, which used a self-administered questionnaire with the doctors and nurses of the FHS of Juiz de Fora, MG, in 2019. For analysis, the chi-square and Fisher's exact test were used, 5% level of significance. Among the 170 surveyed, which corresponded to 93% of FHS professionals in the city, the prevalence of adequate knowledge was 39.4% and had association with younger age and female gender. The prevalence of an adequate attitude was 59.5% and of appropriate practices 77.6%, both associated with a longer time since graduation. The presence of the Ministry of Health guidelines in the units was associated with the outcomes, knowledge and adequate practice, confirming the importance of support material for consultation by professionals. Only 28.2% of professionals reported having received training in the last 3 years and 50.3% carried out educational actions for users. The need for permanent education actions with professionals is highlighted, aiming at a more effective action to confront and eradicate CCU.

Cervical cancer screening status and implementation challenges: Report from selected states of India

BACKGROUND

Cervical cancer contributes to 6%-29% of the cancers in India. Although the Government of India in 2010 integrated cancer screening within the National Programme for the prevention of Non-communicable Diseases, only 22% of women aged 15-45 years had undergone examination of the cervix by 2016. This prompts the question regarding the organisation of the program's implementation and service delivery and regarding challenges that may explain poor screening uptake.

METHODS

Semi-structured interviews were held with program managers and implementers in seven districts of three selected States of India. The data analysis looked at program content, the organisation of screening delivery, and the challenges to the implementation of the program, considering six theoretically derived dimensions of public health capacity: leadership and governance, organisational structure, financial resources, workforce, partnerships, and knowledge development.

RESULTS

Participants perceive the existing capacities across the six domains as insufficient to implement the CCS program nationwide. A context specific implementation, a better coordination between the program and district health facilities, timely remuneration, better maintenance of data and a strong monitoring system are possible solutions to remove health system related barriers.

CONCLUSION

The study provides evidence on the practical challenges and provides recommendations for strengthening the capacities of the health system.

Cervical Cancer Prevention Efforts in India

Purpose

Cervical cancer is one of the leading cancers among women in India. Its prevention and control require a concerted effort to improve awareness among women regarding primary and secondary prevention strategies as well as access to care for treatment and palliation. A focused strategy is important to reach the World Health Organization’s targets for cervical cancer elimination, due to be completed by 2030.

Methods

Currently available literature was reviewed regarding cervical cancer prevention strategies in India including various national programmes and other initiatives on the part of government, non-governmental organizations and professional organizations. Their applicability to the present situation was assessed.

Results

National programmes need to build on success stories of various states and neighbouring countries as well as to audit the performance. Strengthening of cancer registries and improvement of linkages between different healthcare levels with incorporation of task-shifting, adding digital technology and supporting programmes that promote women’s welfare and health will also provide synergy to cancer control programmes. In the current pandemic era, HPV self-sampling can be an ideal method for screening. The development of an affordable, point-of-care HPV test is urgently needed to facilitate its introduction in low- and middle-income countries. HPV vaccination efforts need to be speeded up.

Conclusion

Scaling up of cervical cancer prevention with inclusion of widespread HPV vaccination and primary HPV test should be the new standard of care.

Assessment of Barriers and Facilitators to the Delivery of Care for Noncommunicable Diseases by Nonphysician Health Workers in Low- and Middle-Income Countries: A Systematic Review and Qualitative Analysis

IMPORTANCE

Cardiovascular disease, cancer, and other noncommunicable diseases (NCDs) are the leading causes of mortality in low- and middle-income countries. Previous studies show that nonphysician health workers (NPHWs), including nurses and volunteers, can provide effective diagnosis and treatment of NCDs. However, the factors that facilitate and impair these programs are incompletely understood.

OBJECTIVE

To identify health system barriers to and facilitators of NPHW-led care for NCDs in low- and middle-income countries.

DATA SOURCES

All systematic reviews in PubMed published by May 1, 2018.

STUDY SELECTION

The search terms used for this analysis included "task shifting" and "non-physician clinician." Only reviews of NPHW care that occurred entirely or mostly in low- and middle-income countries and focused entirely or mostly on NCDs were included. All studies cited within each systematic review that cited health system barriers to and facilitators of NPHW care were reviewed.

DATA EXTRACTION AND SYNTHESIS

Assessment of study eligibility was performed by 1 reviewer and rechecked by another. The 2 reviewers extracted all data. Reviews were performed from November 2017 to July 2018. All analyses were descriptive.

MAIN OUTCOMES AND MEASURES

All barriers and facilitators mentioned in all studies were tallied and sorted according to the World Health Organization's 6 building blocks for health systems.

RESULTS

This systematic review and qualitative analysis identified 15 review articles, which cited 156 studies, of which 71 referenced barriers to and facilitators of care. The results suggest 6 key lessons: (1) select qualified NPHWs embedded within the community they serve; (2) provide detailed, ongoing training and supervision; (3) authorize NPHWs to prescribe medication and render autonomous care; (4) equip NPHWs with reliable systems to track patient data; (5) furnish NPHWs consistently with medications and supplies; and (6) compensate NPHWs adequately commensurate with their roles.

CONCLUSIONS AND RELEVANCE

Although the health system barriers to NPHW screening, treatment, and control of NCDs and their risk factors are numerous and complex, a diverse set of care models has demonstrated strategies to address nearly all of these challenges. These facilitating approaches-which relate chiefly to strong, consistent NPHW training, guidance, and logistical support-generate a blueprint for the creation and scale-up of such programs adaptable across multiple chronic diseases, including in high-income countries.

Community Health Workers Improve Linkage to Hypertension Care in Western Kenya

BACKGROUND

Elevated blood pressure (BP) is the leading global risk factor for mortality. Delay in seeking hypertension care is associated with increased mortality.

OBJECTIVES

This study investigated whether community health workers, equipped with behavioral communication strategies and smartphone technology, can increase linkage of individuals with elevated BP to a hypertension care program in western Kenya and significantly reduce BP.

METHODS

The study was a cluster randomized trial with 3 arms: 1) usual care (standard training); 2) "paper-based" (tailored behavioral communication, using paper-based tools); and 3) "smartphone" (tailored behavioral communication, using smartphone technology). The co-primary outcomes were: 1) linkage to care; and 2) change in systolic BP (SBP). A covariate-adjusted mixed-effects model was used, adjusting for differential time to follow-up. Bootstrap and multiple imputation were used to handle missing data.

RESULTS

A total of 1,460 individuals (58% women) were enrolled (491 usual care, 500 paper-based, 469 smartphone). Average baseline SBP was 159.4 mm Hg. Follow-up measures of linkage were available for 1,128 (77%) and BP for 1,106 (76%). Linkage to care was 49% overall, with significantly greater linkage in the usual care and smartphone arms of the trial. Average overall follow-up SBP was 149.9 mm Hg. Participants in the smartphone arm experienced a modestly greater reduction in SBP versus usual care (-13.1 mm Hg vs. -9.7 mm Hg), but this difference was not statistically significant. Mediation analysis revealed that linkage to care contributed to SBP change.

CONCLUSIONS

A strategy combining tailored behavioral communication and mobile health (mHealth) for community health workers led to improved linkage to care, but not statistically significant improvement in SBP reduction. Further innovations to improve hypertension control are needed. (Optimizing Linkage and Retention to Hypertension Care in Rural Kenya [LARK]; NCT01844596).

Cervical cancer screening in rural India: Status & current concepts

Cervical carcinoma is one of the most common and dreaded diseases of women, and in India, it accounts for 16 per cent of total cervical cancer cases occurring globally. The situation is more alarming in the rural areas where the majority of women are illiterate and ignorant about the hazards of cervical cancer. Different screening strategies such as rural cancer registries and camp approach for cancer detection have been found useful in minimizing the problem of cervical cancer in the villages. Various screening techniques such as visual inspection with acetic acid, visual inspection with Lugol's iodine, visual inspection with magnification devices-magnavisualizer, Pap smear and HPV-DNA testing have been suggested and tried under low-resource settings of our country, and cervical cytology screening has been found effective in reducing incidence of the disease. In the present review, feasibility of different screening methods has been assessed to find out the most suitable mode applicable at the rural level. Single lifetime screening particularly of high-risk women along with analysis of cost-effective tumour markers such as Argyrophilic nucleolar organizer regions (AgNOR) counts to discriminate high-risk dysplasia cases appears to be an appropriate approach in fighting against cervical cancer.

A Step Toward Timely Referral and Early Diagnosis of Cancer: Implementation and Impact on Knowledge of a Primary Care-Based Training Program in Botswana

Introduction

Health system delays in diagnosis of cancer contribute to the glaring disparities in cancer mortality between high-income countries and low- and middle-income countries. In Botswana, approximately 70% of cancers are diagnosed at late stage and median time from first health facility visit for cancer-related symptoms to specialty cancer care was 160 days (IQR 59-653). We describe the implementation and early outcomes of training targeting primary care providers, which is a part of a multi-component implementation study in Kweneng-East district aiming to enhance timely diagnosis of cancers.

Methods

Health-care providers from all public facilities within the district were invited to participate in an 8-h intensive short-course program developed by a multidisciplinary team and adapted to the Botswana health system context. Participants' performance was assessed using a 25-multiple choice question tool, with pre- and post-assessments paired by anonymous identifier. Statistical analysis with Wilcoxon signed-rank test to compare performance at the two time points across eight sub-domains (pathophysiology, epidemiology, social context, symptoms, evaluation, treatment, documentation, follow-up). Linear regression and negative binomial modeling were used to determine change in performance. Participants' satisfaction with the program was measured on a separate survey using a 5-point Likert scale.

Results

176 participants attended the training over 5 days in April 2016. Pooled linear regression controlling for test version showed an overall performance increase of 16.8% after participation (95% CI 15.2-18.4). Statistically significant improvement was observed for seven out of eight subdomains on test A and all eight subdomains on test B. Overall, 71 (40.3%) trainees achieved a score greater than 70% on the pretest, and 161 (91.5%) did so on the posttest. Participants reported a high degree of satisfaction with the training program's content and its relevance to their daily work.

Conclusion

We describe a successfully implemented primary health care provider-focused training component of an innovative intervention aiming to reduce health systems delays in cancer diagnosis in sub-Saharan Africa. The training achieved district-wide participation, and improvement in the knowledge of primary health-care providers in this setting.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier NCT02752061.

Economic burden of cancer in India: Evidence from cross-sectional nationally representative household survey, 2014

With the ongoing demographic and epidemiological transition, cancer is emerging as a major public health concern in India. This paper uses nationally representative household survey to examine the overall prevalence and economic burden of cancer in India. The age-standardized prevalence of cancer is estimated to be 97 per 100,000 persons with greater prevalence in urban areas. The evidence suggests that cancer prevalence is highest among the elderly and also among females in the reproductive age groups. Cancer displays a significant socioeconomic gradient even after adjusting for age-sex specifics and clustering in a multilevel regression framework. We find that out of pocket expenditure on cancer treatment is among the highest for any ailment. The average out of pocket spending on inpatient care in private facilities is about three-times that of public facilities. Furthermore, treatment for about 40 percent of cancer hospitalization cases is financed mainly through borrowings, sale of assets and contributions from friends and relatives. Also, over 60 percent of the households who seek care from the private sector incur out of pocket expenditure in excess of 20 percent of their annual per capita household expenditure. Given the catastrophic implications, this study calls for a disease-based approach towards financing such high-cost ailment. It is suggested that universal cancer care insurance should be envisaged and combined with existing accident and life insurance policies for the poorer sections in India. In concluding, we call for policies to improve cancer survivorship through effective prevention and early detection. In particular, greater public health investments in infrastructure, human resources and quality of care deserve priority attention.

Task shifting for non-communicable disease management in low and middle income countries--a systematic review

BACKGROUND

One potential solution to limited healthcare access in low and middle income countries (LMIC) is task-shifting- the training of non-physician healthcare workers (NPHWs) to perform tasks traditionally undertaken by physicians. The aim of this paper is to conduct a systematic review of studies involving task-shifting for the management of non-communicable disease (NCD) in LMIC.

METHODS

A search strategy with the following terms "task-shifting", "non-physician healthcare workers", "community healthcare worker", "hypertension", "diabetes", "cardiovascular disease", "mental health", "depression", "chronic obstructive pulmonary disease", "respiratory disease", "cancer" was conducted using Medline via Pubmed and the Cochrane library. Two reviewers independently reviewed the databases and extracted the data.

FINDINGS

Our search generated 7176 articles of which 22 were included in the review. Seven studies were randomised controlled trials and 15 were observational studies. Tasks performed by NPHWs included screening for NCDs and providing primary health care. The majority of studies showed improved health outcomes when compared with usual healthcare, including reductions in blood pressure, increased uptake of medications and lower depression scores. Factors such as training of NPHWs, provision of algorithms and protocols for screening, treatment and drug titration were the main enablers of the task-shifting intervention. The main barriers identified were restrictions on prescribing medications and availability of medicines. Only two studies described cost-effective analyses, both of which demonstrated that task-shifting was cost-effective.

CONCLUSIONS

Task-shifting from physicians to NPHWs, if accompanied by health system re-structuring is a potentially effective and affordable strategy for improving access to healthcare for NCDs. Since the majority of study designs reviewed were of inadequate quality, future research methods should include robust evaluations of such strategies.

Challenges to effective cancer control in China, India, and Russia

Cancer is one of the major non-communicable diseases posing a threat to world health. Unfortunately, improvements in socioeconomic conditions are usually associated with increased cancer incidence. In this Commission, we focus on China, India, and Russia, which share rapidly rising cancer incidence and have cancer mortality rates that are nearly twice as high as in the UK or the USA, vast geographies, growing economies, ageing populations, increasingly westernised lifestyles, relatively disenfranchised subpopulations, serious contamination of the environment, and uncontrolled cancer-causing communicable infections. We describe the overall state of health and cancer control in each country and additional specific issues for consideration: for China, access to care, contamination of the environment, and cancer fatalism and traditional medicine; for India, affordability of care, provision of adequate health personnel, and sociocultural barriers to cancer control; and for Russia, monitoring of the burden of cancer, societal attitudes towards cancer prevention, effects of inequitable treatment and access to medicine, and a need for improved international engagement.

Oxidative stress and antioxidant status in cervical cancer patients

Cervical cancer (CaCx) is a global public health problem as it is the second most common cancer leading to the death of women worldwide. Many references revealed that the low levels of antioxidants induce the generation of free radicals leading to DNA damage and further mutations. In the present study attempt have been made to evaluate the levels of serum Lipid peroxide, Nitric Oxide (NO(.)) Erythrocytic-Superoxide Dismutase (RBC-SOD), Vitamin-C, serum Copper (Cu) and serum Zinc (Zn). 120 patients were divided in 4 groups according to the increasing CaCx stages i.e. stage I, II, III & IV respectively. All the patients were around the age group of 25-65 years. 30 healthy women between the same age group were treated as controls. Highly significant increased values of MDA, NO(.) and Cu were observed (p<0.001) whereas the activity of RBC-SOD, levels of Vitamin-C and Zn were significantly decreased in CaCx patients as compared with healthy controls (p<0.001). Cu/Zn ratio was found to be altered in CaCx patients. From our findings it can be concluded that the oxidative stress is induced among CaCx patients, which inturn increases the risk of CaCx.

Knowledge, attitudes and practices on cervical cancer screening among the medical workers of Mulago Hospital, Uganda

BACKGROUND

Cervical cancer is the commonest cancer of women in Uganda. Over 80% of women diagnosed in Mulago national referral and teaching hospital, the biggest hospital in Uganda, have advanced disease. Pap smear screening, on opportunistic rather than systematic basis, is offered free in the gynaecological outpatients clinic and the postnatal/family planning clinics. Medical students in the third and final clerkships are expected to learn the techniques of screening. Objectives of this study were to describe knowledge on cervical cancer, attitudes and practices towards cervical cancer screening among the medical workers of Mulago hospital.

METHODS

In a descriptive cross-sectional study, a weighted sample of 310 medical workers including nurses, doctors and final year medical students were interviewed using a self-administered questionnaire. We measured knowledge about cervical cancer: (risk factors, eligibility for screening and screening techniques), attitudes towards cervical cancer screening and practices regarding screening.

RESULTS

Response rate was 92% (285). Of these, 93% considered cancer of the cervix a public health problem and knowledge about Pap smear was 83% among respondents. Less than 40% knew risk factors for cervical cancer, eligibility for and screening interval. Of the female respondents, 65% didn't feel susceptible to cervical cancer and 81% had never been screened. Of the male respondents, only 26% had partners who had ever been screened. Only 14% of the final year medical students felt skilled enough to use a vaginal speculum and 87% had never performed a pap smear.

CONCLUSION

Despite knowledge of the gravity of cervical cancer and prevention by screening using a Pap smear, attitudes and practices towards screening were negative. The medical workers who should be responsible for opportunistic screening of women they care for are not keen on getting screened themselves. There is need to explain/understand the cause of these attitudes and practices and identify possible interventions to change them. Medical students leave medical school without adequate skills to be able to effectively screen women for cervical cancer wherever they go to practice. Medical students and nurses training curricula needs review to incorporate practical skills on cervical cancer screening.

Coming to terms with Vietnam: the Viet/American Cervical Cancer Prevention Project

The Viet/American Cervical Cancer Prevention Project embraces a dual mission. We seek to develop sustainable, cost-effective cervical cancer prevention services for women in Vietnam. Because the problem of cervical cancer in Vietnam is in part a legacy of the Second Indochinese War, we also seek to examine obstacles to reconciliation by presenting what most acknowledge to be a remedy in advance of what some will perceive to be an accusation. Certain research and commercial interests have produced obstacles to our dual mission in Vietnam. The Alliance for Cervical Cancer Prevention, supported by the Bill and Melinda Gates Foundation, has failed to endorse Pap screening for developing countries and is conducting clinical trials which may further disaffect medically underserved groups. Visual screening techniques combined with immediate ablative treatment methods are incompatible with the requirements of "first do no harm." Because the Pap smear will probably be a component of any future human papillomavirus (HPV)-based or visual- based screening programs, it serves the interests of those promoting noncytologic screening methods to also support the development of Pap screening services. Research on HPV screening in developing countries raises concerns of commercial exploitation. Because Pap screening is feasible wherever cervical screening is appropriate, it is inappropriate to delay the development of Pap screening services pending research into HPV vaccines or alternative screening technologies. Quality management is the point at which public health and diagnostic pathology intersect and will remain an indispensable element of cervical screening programs irrespective of the screening test(s) eventually used. Pap screening in developing countries is an ethical imperative without a substantial political constituency and will benefit from the engagement of organized cytology.

Nursing roles in cancer prevention position statements

Preventing cancer saves the labor of mending social, economic, cultural, and emotional upheaval engendered by a diagnosis of cancer. The four position statements discussed in this article provide a wealth of perspective regarding the professional organizations' views on cancer prevention and the important roles of nurses.

Midwives' descriptions of their familiarity with cancer: a qualitative study of midwives working with population-based cervical cancer screening in urban Sweden

Nurse-midwives are responsible for taking Papanicolaou (Pap) smears in Swedish population-based cervical cancer screening programs. A research project examining the screening program from the perspective of different stakeholders includes an interview study of 21 midwives working in Stockholm. This article explores the way the midwives describe cancer-related knowledge and aspects of screening, contrasting this with relevant findings from a substudy of 66 healthy women participating in screening. A semistructured interview guide with open-ended questions was used to investigate ideas about benefits and risks in the screening program, risk factors for cervical cancer, the reliability of the test itself, sources of information/knowledge relevant for cervical cancer screening, and the manner in which the midwife described her role in the screening program. The transcripts of the audiotaped interviews were analyzed thematically using a team approach. The interviewed midwives showed a great deal of consensus in their descriptions of lacking familiarity with cervical cancer and its prevention and treatment. The midwives said they lack recent education and knowledge, often avoiding use of the word "cancer" with women attending screening. It seems that the midwives experienced little professional guidance in discussing cancer-related issues with women attending the screening program. In this study, they appeared to rely on personal knowledge, values, and experience instead.

Improved access to women's health services for Alaska natives through community health aide training

This project demonstrates the effect of increasing the skills of Community Health Aides (CHAs) on the use of specific preventive health services by women in remote Alaska villages. Eight CHAs were trained in specimen collection for Pap and sexually transmitted disease testing, and in clinical breast examination. Skill competency was monitored. Computerized medical records of all women between the ages of 18 and 75 in the four villages with trained CHAs and in four comparison villages (n = 1093) were checked for Pap status prior to CHA training and again 12 months later. All eight CHAs achieved competency and provided services in their village clinics with telephone support from an experienced clinician. The post-training year Pap test rate of women who were overdue for a Pap test was 0.44 in the villages with trained CHAs; the rate among the women in the comparison villages was 0.32 (p = .079).

The Robert Tiffany Lectureship. Vital signs at the millennium: becoming more than we are

Presenting this lecture named for my colleague, the late Robert Tiffany, is an honor. He was part of the first International Conference on Cancer Nursing 20 years ago, which was my first international meeting. It was part of what expanded our Texas--only cancer prevention and detection program for nurses into an international effort. Lessons acquired through this work in the past include learning to respect and honor cultural differences, adapting control programs to the resources at hand, accepting a role as a leader and being an agent for change, and passing on what has been learned to others. The challenges of today include the worldwide death and disability toll of lung cancer, the threat of breast cancer and the promise of regular screening to lower its morbidity and mortality, and the hope that a willingness to adapt screening for cervical cancer in developing countries will lower its mortality rate. Twenty years in the future we can expect nurses to remain educators, exemplars, and agents of change; cancer prevention and early detection to rise in the hierarchy of care; continued collaborative care between physicians and nurses; enhanced patient care through information access; and a larger role for cancer genetics in nursing practice.

Impact of cancer screening on women's health

Worldwide, 31% of cancers in women are in the breast or uterine cervix. Prevention of cervical cancer is effective with the use of the cervical Pap smear test if applied in an organized and continuous fashion, including treatment of precancerous lesions. At best such programs have led to a 60% decrease in cervical cancer incidence and mortality in the Nordic countries. Early detection of breast cancer in a population based screening may lead to a 30% reduction of mortality from this disease in the screened population. Measures to guarantee high coverage and attendance, adequate field facilities, organized program for quality control and adequate facilities for diagnosis and treatment are prerequisites of successful programs. In absolute terms the contribution of screening to the total mortality reduction among middle-aged populations is small, much smaller than the potential gains from cancer prevention.