Cervical cancer screening utilization, and associated factors, in Nepal: a systematic review and meta-analysis

Barriers and facilitators to a combined strategy of HPV vaccination and cervical cancer screening among Mexican women

HPV-FASTER is an innovative public health intervention combining HPV vaccination and HPV-based screening in adult women at the same visit. FASTER-Tlalpan adapted the combined HPV-FASTER strategy in Tlalpan, Mexico City for women aged 25-45 years. To understand the barriers and facilitators to participation in a combined strategy, we conducted semi-structured interviews with 14 FASTER-Tlalpan participants. We used the constant comparative method for the analysis, as well as the socioecological model to organize the findings. At the intrapersonal level, barriers included the belief that only younger women are at risk for HPV, embarrassment about the pelvic exam, and lack of time, while facilitators were having information regarding the benefit of the combined strategy, perception of time saved by having both procedures at once, feeling reassured about their health, self-esteem regarding their health, and perceived severity of cervical cancer. Interpersonal-level barriers were experiences of stigma and prejudice, and lack of support from partners, while facilitators were family encouragement and peer-to-peer communications. Institutional-level barriers were lack of infrastructure and inconvenient hours at the health center, perceived high time burden, and low quality of care from providers, while facilitators included high-quality care by health center personnel, including partners in the combined strategy, and phone reminders. Community-level facilitators included willingness to participate. Public policy facilitators included mass information campaigns and free procedures. Our findings point to significant barriers which need to be addressed, along with facilitators which can be leveraged to scale up the combined strategy in similar settings.

Are we ready for self-sampling for cervical cancer screening? Insights from service providers and policy makers in Nepal

Cervical cancer is the leading cancer among women in Nepal, but the country has very low screening rate, with only 8.2% of women being screened. In recent years, a self-sampling kit for testing for the human papillomavirus (HPV) has been developed to allow self-sampling and enable early detection of cervical abnormalities. This kit enables women to collect cervical samples without the need for trained healthcare providers or healthcare facilities. Nevertheless, there has been a notable absence of scientific studies to analyse the feasibility and acceptability of self-sampling for cervical cancer screening in Nepal, particularly from the perspective of various service providers. The qualitative research method used semi-structured in-depth interviews and key informant interviews with healthcare providers, online service providers, and policymakers. These interviews were conducted in person with 20 participants until data saturation was achieved. Thematic analysis was performed where the translated data was coded inductively using NVivo 12. The majority of the participants identified the self-sampling method as an alternative sampling option for detection of cervical abnormalities/cancer in Nepal. Barriers to self-sampling included a low level of knowledge and information, the cost of the self-sampling kit, unclear information regarding self-sampling process and concerns about inaccurate results among women and girls, who are the end users. Similarly, factors such as knowledge and information regarding the self-sampling technique, accessibility of available services and information, and national self-care guidelines and policies for cervical cancer screening were identified as facilitators for self-sampling. It is crucial to have evidence-based discussions, especially regarding the effectiveness of a self-care approach in cervical cancer screening and help create a supportive policy environment for implementing self-care strategies in Nepal. Furthermore, disseminating education and information nationwide through campaigns to raise awareness about self-sampling is essential among beneficiaries for the scaling up of self-sampling for cervical cancer in Nepal.

Disparities and Determinants of Testing for Early Detection of Cervical Cancer among Nepalese Women: Evidence from a Population-Based Survey

BACKGROUND

Cervical cancer presents a considerable challenge in South Asia, notably in Nepal, where screening remains limited. Past research in Nepal lacked national representation and a thorough exploration of factors influencing cervical cancer screening, such as educational and socioeconomic disparities. This study aims to measure these gaps and identify associated factors in testing for early detection of cervical cancer among Nepalese women.

METHODS

Data from the 2019 Nepal Noncommunicable Disease Risk Factors survey (World Health Organization STEPwise approach to noncommunicable risk factor surveillance), involving 2,332 women aged 30 to 69 years, were used. Respondents were asked if they had undergone cervical cancer testing through visual inspection with acetic acid, Pap smear, or human papillomavirus test ever or in the past 5 years. The slope index of inequality (SII) and relative concentration index were used to measure socioeconomic and education-based disparities in cervical cancer test uptake.

RESULTS

Only 7.1% [95% confidence interval (CI): 5.1-9.9] Nepalese women had ever undergone cervical cancer testing, whereas 5.1% (95% CI: 3.4-7.5) tested within the last 5 years. The ever uptake of cervical cancer testing was 5.1 percentage points higher (SII: 5.1, 95% CI: -0.1 to 10.2) among women from the richest compared with the poorest households. Education-based disparities were particularly pronounced, with a 13.9 percentage point difference between highly educated urban residents and their uneducated counterparts (SII: 13.9, 95% CI: 5.8-21.9).

CONCLUSIONS

Less than one in ten women in Nepal had a cervical cancer testing, primarily favoring higher educated and wealthier individuals.

IMPACT

Targeted early detection and cervical cancer screening interventions are necessary to address these disparities and improve access and uptake.

Examining the availability and readiness of health facilities to provide cervical cancer screening services in Nepal: a cross-sectional study using data from the Nepal Health Facility Survey

OBJECTIVE

We assessed the availability and readiness of health facilities to provide cervical cancer screening services in Nepal.

DESIGN

Cross-sectional study.

SETTING

We used secondary data from a nationally representative 2021 Nepal Health Facility Survey, specifically focusing on the facilities offering cervical cancer screening services.

OUTCOME MEASURES

We defined the readiness of health facilities to provide cervical cancer screening services using the standard WHO service availability and readiness assessment manual.

RESULTS

The overall readiness score was 59.1% (95% CI 55.4% to 62.8%), with more equipment and diagnostic tests available than staff and guidelines. Public hospitals (67.4%, 95% CI 63.0% to 71.7%) had the highest readiness levels. Compared with urban areas, health facilities in rural areas had lower readiness. The Sudurpashchim, Bagmati and Gandaki provinces had higher readiness levels (69.1%, 95% CI 57.7% to 80.5%; 60.1%, 95% CI 53.4% to 66.8%; and 62.5%, 95% CI 56.5% to 68.5%, respectively). Around 17% of facilities had trained providers and specific guidelines to follow while providing cervical cancer screening services. The basic healthcare centres (BHCCs) had lower readiness than private hospitals. Facility types, province and staff management meetings had heterogeneous associations with three conditional quantile scores.

CONCLUSION

The availability of cervical cancer screening services is limited in Nepal, necessitating urgent action to expand coverage. Our findings suggest that efforts should focus on improving the readiness of existing facilities by providing training to healthcare workers and increasing access to guidelines. BHCCs and healthcare facilities in rural areas and Karnali province should be given priority to enhance their readiness.

Cancer Risk in Nepal: An Analysis from Population-Based Cancer Registry of Urban, Suburban, and Rural Regions

BACKGROUND

Cancer is one of the leading causes of death globally. The low and middle-income countries (LMICs) cover a major share of the global cancer burden; however, most of the LMICs including Nepal still lack national cancer control and prevention strategies. Since 1st January 2018, the Nepal Health Research Council (NHRC) started the population-based cancer registry (PBCR) in urban, suburban, and rural regions to support evidence-based cancer control intervention in each geographical region.

METHODS

Data regarding incidence and mortality was collected by the PBCR in Nepal. Indirect and direct methods were used to collect data from health facilities and communities, respectively. Registered cases of incidence and mortality from 1st January 2019 to 31st December 2019 were used. Each case was verified for correctness and duplication followed by residence confirmation via phone call. Guidelines and principles of the International Association of Cancer Registry were followed for the overall registration process including data quality control. Ethical approval was taken from the Ethical Review Board of the NHRC.

RESULT

Age-adjusted incidence (AAR) and mortality rates in Nepal were found 65.6 and 29 per 100,000 people, respectively. Every 1 in 14 men and 1 in 13 women were at risk of getting, and 1 in 28 men and 1 in 33 women were dying of cancer before age 75 in Nepal. The highest risk was found for lung cancer (1 in 80) followed by stomach and mouth among men, and in women, breast cancer (1 in 76) was the commonest among all followed by lung and cervix.

CONCLUSION

Cancer has been growing as one of the major public health burdens in Nepal. Screening with cost-effective technology, awareness, and vaccination against HPV should be a government priority including revision of treatment protocols for cancers that have higher mortality to prevent further preventable life loss from malignancies.

What rate of Iranian women perform Pap smear test? Results from a meta-analysis

In this study, an attempt was made to estimate the aggregated proportion of Pap smear test uptake among women in Iran from 2012 to 2022 using meta-analysis. The data collection process involved reviewing records registered in databases between January 1, 2012, and September 11, 2022. The final data was analyzed using random effects models, and potential heterogeneity was assessed using the I2 index. To examine publication bias, Egger's test and Funnel Plot were employed. Sensitivity analysis, specifically single study exclusion Meta-analysis, was conducted to assess the influence of each individual study on the aggregated percentage of Pap smear test uptake. A total of 28,754 women were included across the 33 articles analyzed. The pooled percentage of Pap smear test uptake for both one-time and regular screenings was found to be 46.52% (95% CI: 40.91 to 52.14) and 17.80% (95% CI: 12.42 to 23.18), respectively. No significant evidence of publication bias was detected, although the influence of smaller studies was confirmed. Sensitivity analysis indicated that the overall rate of Pap smear test uptake was not highly sensitive to the results of individual studies. The findings emphasize the low rate of regular Pap smear testing among Iranian women and suggest that tailored interventions considering cultural and geographical factors specific to different provinces in Iran could help increase the utilization of this screening service.

The differential needs and expectations from general practitioners in oncology between high-income countries and low- and-middle-income countries: results from a survey of Canadian and Nepali oncologists

Background

To address the shortage of oncologists in the wake of the rapidly increasing global cancer burden, general practitioners of oncology (GPOs) have been added to cancer care teams worldwide. GPOs are family physicians with additional training in oncology and their roles differ by both country and region. In this study, we aimed to learn about the roles and expectations of GPOs from the perspective of oncologists in Canada and Nepal.

Methods

A survey was designed and administered to Canadian and Nepali Oncologists between February and November 2022 using Research Electronic Data Capture, a secure web-based software platform hosted at Queen's University in Kingston, Ontario, Canada. Participants were recruited through personal networks/social media in Nepal and the survey was distributed through an email list provided by the Canadian Association of Medical Oncologists.

Results

The survey received 48 responses from Canadian and 7 responses from Nepali oncologists. Canadian respondents indicated that in terms of educational content delivery, clinics with oncologists followed by didactic lectures by oncologists were thought to be the most effective, followed by a small group learning and online education. Nepali oncologists also indicated didactic lectures by oncologists and small group learning would be the most effective teaching techniques, followed by online education and clinics with oncologists. Critical knowledge domains and skills most relevant for GPO training identified by Canadian respondents were managing pain and other common symptoms of cancers, as well as treatment of common side effects, followed by goals of care discussion, post-treatment surveillance for recurrence, and the management of long-term complications from treatment. Respondents from Nepal, however, suggested an approach to diagnosis to patient with increased risk of cancer, and cancer staging were the most critical knowledge domains and skills. The majority of oncologists in both countries thought a training program of 6-12 months was optimal.

Conclusion

We found many similarities in oncologist's opinions of GPOs between the two countries, however, there were also some notable differences such as the need to provide cancer screening services in Nepal. This highlights the need to tailor GPO training programs based on local context.

Implementation of cervical cancer prevention and screening across five tertiary hospitals in Nepal and its policy implications: A mixed-methods study

In Nepal, cervical cancer is the most common cancer among women despite the existing policies. This study intends to assess the implementation of cervical cancer prevention and screening through service utilization by women, knowledge and attitude among health professionals, and the perceptions of stakeholders in Nepal. This mixed-methods study was conducted in 2022 across five tertiary hospitals in Kathmandu, Nepal. The quantitative study comprised the health professionals and women attending gynecology outpatient clinics from the selected hospitals. The qualitative study comprised stakeholders including service providers and experts on cervical cancer from selected hospitals, civil societies, and the Ministry of Health and Population. The utilization of screening through pap smear among 657 women across five hospitals was 22.2% and HPV vaccination was 1.5%. The utilization of cervical cancer screening was associated with older age [adjusted odds ratio (AOR) = 1.09, CI: 1.07, 8.19], married (AOR = 3.024, CI: 1.12, 8.19), higher education (AOR = 3.024, CI:1.12, 8.42), oral contraceptives use (AOR = 2.49, CI: 1.36, 4.39), and ever heard of cervical cancer screening (AOR = 13.28, CI: 6.85, 25.73). Among 254 health professionals, the knowledge score was positively associated with them ever having a training [Standardized Beta (β) = 0.20, CI: 0.44, 2.43)] and having outreach activities in their hospital (β = 0.19 CI: 0.89, 9.53) regarding cervical cancer screening. The female as compared to male health professionals (β = 0.16, CI: 0.41, 8.16, P = 0.03) and having a cervical cancer screening guideline as compared to none (β = 0.19 CI: 0.89, 9.53, P = 0.026) were more likely to have a better attitude for screening. The qualitative findings among 23 stakeholders reflected implementation challenges in policy, supply, service delivery, providers, and community. This study showed low utilization of prevention and services by women and implementation gaps on cervical cancer prevention and screening services across five tertiary hospitals in Kathmandu, Nepal. The findings could help designing more focused interventions.

Cancer screening research in Bangladesh: Insights from a scoping review

This scoping review summarises the findings of research conducted on cancer screening in Bangladesh, including the prevalence, awareness, barriers, and evaluation of screening programmes, by performing a comprehensive search of electronic databases and gray literature. 25 studies that met inclusion criteria were included in the final analysis. Most of the studies were about screening for cervical cancer, were quantitative, were cross-sectional, and were conducted in hospital settings. The main challenges to screening uptake were shyness, fear, a lack of knowledge, and an inadequate understanding of the concept of screening. Visual inspection with acetic acid (VIA) was found to be a simple and cost-efficient way to detect early-stage cervical cancer. However, breast self-examination (BSE) was reported to be insufficient. Education was found to have a positive impact on cancer screening knowledge and practice, but more needs to be done to improve screening rates, such as the utilisation of media, particularly in rural areas. The results of this scoping review highlight Bangladesh's low cancer screening prevalence and uptake and suggest that targeted awareness campaigns and enhanced access to screening services are required to increase cancer screening uptake and reduce the cancer burden in Bangladesh.

Human Papillomavirus among Women Undergoing Papanicolaou Smear Test in the Department of Gynaecologic Oncology of a Tertiary Care Centre

Introduction

In invasive cervical specimens or precursors, high-risk human papillomavirus Deoxyribonucleic acid may be detected to identify females at risk of developing cervical cancer. This study aimed to find out the prevalence of human papillomavirus among women undergoing Papanicolaou smear tests in a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted among women undergoing the Papanicolaou smear test in the Department of Gynaecologic Oncology, Nepal Armed Police Force Hospital, between 1 June 2022 and 15 November 2022. Ethical approval was obtained from the Ethical Review Board. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among the 199 women, 6 (3.02%) (0.64-5.40, 95% Confidence Interval) had human papillomavirus infection. The mean age of the infected females was 31.17±5.57 years. Human papillomavirus DNA for 16 and 18 were detected in 4 (66.67%) and 2 (33.33%) females, respectively.

Conclusions

The prevalence of human papillomavirus in females was found to be lower than other studies done in similar settings.

Keywords

cytology; histology; human papillomavirus; Nepal; prevalence.

Cervical Papanicolaou Smear Test Screening among Patients Visiting the Outpatient Department of Gynaecology of a Tertiary Care Centre

Introduction

Carcinoma cervix is the second most common cause of death in women worldwide and the most common cause in developing countries. Cervical cancer is considered a preventable gynaecological problem as it has a long premalignant stage which can be detected by exfoliative cytology like papanicolaou smear test. The papanicolaou smear test is a simple, safe, non-invasive, and low-cost effective method for screening cervical cancer in developing countries like Nepal. The aim of the study was to find out the prevalence of cervical papanicolaou smear test screening among patients visiting the Outpatient Department of Gynaecology of a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted among patients visiting the Department of Gynaecology of a tertiary care centre after obtaining ethical approval from the Institutional Review Committee. Data from 14 April 2021 to 22 October 2022 were collected between 11 May 2023 to 26 May 2023 from the hospital records. Papanicolaou smear tests among the age group of 21 years up to 70 years were included in the study. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 11,173 patients, papanicolaou smear test was done in 572 (5.12%) (4.71-5.53, 95% Confidence Interval). Negative for intraepithelial lesion was the most common cytological pattern seen in 518 (90.55%) patients. The low-grade squamous intraepithelial lesion was the most common among abnormal epithelial cells seen in 29 (5.07%).

Conclusions

The prevalence of cervical papanicolaou smear test among patients visiting the Outpatient Department of Gynaecology was found to be similar to other studies done in similar settings.

Keywords

cervical cancer; cytology; papanicolaou smear.

Strategies to eliminate cervical cancer in China

Cervical cancer is a widely distributed disease that is preventable and controllable through early intervention. The World Health Organization has identified three key measures, coverage populations and coverage targets to eliminate cervical cancer. The WHO and several countries have conducted model predictions to determine the optimal strategy and timing of cervical cancer elimination. However, specific implementation strategies need to be developed in the context of local conditions. China has a relatively high disease burden of cervical cancer but a low human papillomavirus vaccination rate and cervical cancer screening population coverage. The purpose of this paper is to review interventions and prediction studies for the elimination of cervical cancer and to analyze the problems, challenges and strategies for the elimination of cervical cancer in China.

Cervical cancer in Nepal: Current screening strategies and challenges

Nepal has a high burden of cervical cancer primarily due to a limited screening program. Most present with advanced cervical disease. Despite no national cervical cancer control program, Nepal's Ministry of Health and Population has taken many initiatives with various international collaborations in screening, vaccination, and treating pre-invasive and invasive cancer. However, the existing prevention and treatment modalities are dismally inadequate to meet the targets of WHO's cervical cancer eliminative initiative by 2030. We provide an overview of the Ministry of Health and Population, Nepal's efforts to tackle the growing cervical cancer burden in the country. We discuss the challenges and potential solutions that could be practical and augment screening uptakes, such as single-dose vaccination and HPV DNA tests. The screen-and-treat approach on the same day could potentially address treatment delays and follow-up loss after testing positive. Our narrative summary highlights existing and innovative strategies, unmet needs, and collaborations required to achieve elimination across implementation contexts.

Immunomodulatory Role of Thioredoxin Interacting Protein in Cancer's Impediments: Current Understanding and Therapeutic Implications

Cancer, which killed ten million people in 2020, is expected to become the world's leading health problem and financial burden. Despite the development of effective therapeutic approaches, cancer-related deaths have increased by 25.4% in the last ten years. Current therapies promote apoptosis and oxidative stress DNA damage and inhibit inflammatory mediators and angiogenesis from providing temporary relief. Thioredoxin-binding protein (TXNIP) causes oxidative stress by inhibiting the function of the thioredoxin system. It is an important regulator of many redox-related signal transduction pathways in cells. In cancer cells, it functions as a tumor suppressor protein that inhibits cell proliferation. In addition, TXNIP levels in hemocytes increased after immune stimulation, suggesting that TXNIP plays an important role in immunity. Several studies have provided experimental evidence for the immune modulatory role of TXNIP in cancer impediments. TXNIP also has the potential to act against immune cells in cancer by mediating the JAK-STAT, MAPK, and PI3K/Akt pathways. To date, therapies targeting TXNIP in cancer are still under investigation. This review highlights the role of TXNIP in preventing cancer, as well as recent reports describing its functions in various immune cells, signaling pathways, and promoting action against cancer.