SOGC–GOC–SCC Joint Policy Statement. No. 255, March 2011. Cervical cancer prevention in low-resource settings

Disparities in cervical cancer screening participation in Iran: a cross-sectional analysis of the 2016 nationwide STEPS survey

BACKGROUND

One of the most important concerns in every healthcare system is the elimination of disparities in health service utilization and achievement of health equity. This study aimed to investigate the disparities in cervical cancer screening participation in Iran.

METHODS

A cross-sectional study was conducted using data from the National Non-Communicable Risk Factors Survey in 2016 (STEPs 2016). Data on cervical cancer screening in addition to demographic and socio-economic factors from 15,975 women aged 18 and above were analyzed. The distribution of surveyed women with regard to cervical cancer screening practice was described. Chi square and logistic regression were used to assess the association of demographic and socio-economic factors with cervical cancer screening participation.

RESULTS

Overall, 52.1% of women aged 30-59 years, had undergone cervical cancer screening at least once in their lifetime. Participation rate in cervical cancer screening programs varied between provinces; ranging from 7.6% in Sistan and Baluchestan to 61.2% in Isfahan. Single marital status, illiteracy, being employed, and having no insurance coverage were associated with lower participation. Age and area of residence were insignificant predictors for participating in cervical cancer screening program. Analysis of the cervical cancer uptake rates across the socio-economic levels revealed that the service is less utilised by high income groups.

CONCLUSIONS

Participation in cervical cancer screening program in Iran is not optimal and could be improved. With regard to the distribution of cervical cancer screening practice, social and geographical disparities indicate the need for further research and more comprehensive strategies in order to reduce them.

Cervical cancer screening through human papillomavirus testing in community health campaigns versus health facilities in rural western Kenya

OBJECTIVE

To determine the effectiveness of community health campaigns (CHCs) as a strategy for human papillomavirus (HPV)-based cervical cancer screening in rural western Kenya.

METHODS

Between January and November 2016, a cluster-randomized trial was carried out in 12 communities in western Kenya to investigate high-risk HPV testing offered via self-collection to women aged 25-65 years in CHCs versus government health facilities. Outcome measures were the total number of women accessing cervical cancer screening and the proportion of HPV-positive women accessing treatment.

RESULTS

In total, 4944 women underwent HPV-based cervical cancer screening in CHCs (n=2898) or health facilities (n=2046). Screening uptake as a proportion of total eligible women in the population was greater in communities assigned to CHCs (60.0% vs 37.0%, P<0.001). Rates of treatment acquisition were low in both arms (CHCs 39.2%; health facilities 31.5%; P=0.408).

DISCUSSION

Cervical cancer screening using HPV testing of self-collected samples reached a larger proportion of women when offered through periodic CHCs compared with health facilities. The community-based model is a promising strategy for cervical cancer prevention. Lessons learned from this trial can be used to identify ways of maximizing the impact of such strategies through greater community participation and improved linkage to treatment. ClinicalTrials.gov registration: NCT02124252.

Feasibility of thermocoagulation in a screen-and-treat approach for the treatment of cervical precancerous lesions in sub-Saharan Africa

BACKGROUND

The use of thermocoagulation for the treatment of cervical precancerous lesions has recently generated a great deal of interest. Our aim was to determine the feasibility of this outpatient procedure in the context of a cervical cancer (CC) screen-and-treat campaign in sub-Saharan Africa.

METHODS

Between July and December 2015, women living in the area of Dschang (Cameroon) aged between 30 and 49 years, were enrolled in a CC screening study. HPV self-sampling was performed as a primary screening test and women who were either "HPV 16/18/45-positive" or "positive to other HPV types and to VIA" were considered screen-positive, thus requiring further management. The primary outcome was the percentage of screen-positive patients who met the criteria to undergo thermocoagulation. The secondary outcome was the assessment of the procedure's side effects immediately after treatment and at the 1-month follow-up visit.

RESULTS

A total of 1012 women were recruited in the study period. Among 121 screen-positive women, 110 of them (90.9%) were eligible to be treated with thermocoagulation. No patients discontinued treatment because of pain or other side effects. The mean ± SD (Standard Deviation) score measured on the 10-point Visual Analogue Scale (VAS) was 3.0 ± 1.6. Women having less than 2 children were more likely to report a higher pain score than those with more than two (4.2 ± 2.0 versus 2.9 ± 1.5, respectively; p value = 0.016). A total of 109/110 (99.1%) patients came to the 1-month follow-up visit. Vaginal discharge was reported in 108/109 (99.1%) patients throughout the month following treatment. Three patients (2.8%) developed vaginal infection requiring local antibiotics. No hospitalizations were required.

CONCLUSION

The majority of screen-positive women met the criteria and could be treated by thermocoagulation. The procedure was associated to minor side effects and is overall feasible in the context of a CC screen-and-treat campaign in sub-Saharan Africa.

TRIAL REGISTRATION

The trial was retrospectively registered on November 11, 2015 with the identifier: ISRCTN99459678 .

Developing the Evidence Base to Inform Best Practice: A Scoping Study of Breast and Cervical Cancer Reviews in Low- and Middle-Income Countries

BACKGROUND

Breast and cervical cancers have emerged as major global health challenges and disproportionately lead to excess morbidity and mortality in low- and middle-income countries (LMICs) when compared to high-income countries. The objective of this paper was to highlight key findings, recommendations, and gaps in research and practice identified through a scoping study of recent reviews in breast and cervical cancer in LMICs.

METHODS

We conducted a scoping study based on the six-stage framework of Arskey and O'Malley. We searched PubMed, Cochrane Reviews, and CINAHL with the following inclusion criteria: 1) published between 2005-February 2015, 2) focused on breast or cervical cancer 3) focused on LMIC, 4) review article, and 5) published in English.

RESULTS

Through our systematic search, 63 out of the 94 identified cervical cancer reviews met our selection criteria and 36 of the 54 in breast cancer. Cervical cancer reviews were more likely to focus upon prevention and screening, while breast cancer reviews were more likely to focus upon treatment and survivorship. Few of the breast cancer reviews referenced research and data from LMICs themselves; cervical cancer reviews were more likely to do so. Most reviews did not include elements of the PRISMA checklist.

CONCLUSION

Overall, a limited evidence base supports breast and cervical cancer control in LMICs. Further breast and cervical cancer prevention and control studies are necessary in LMICs.

Use of a portable diathermy machine for LEEP without colposcopy during see-and-treat management of VIA-positive cervical lesions in resource-poor settings

OBJECTIVE

To compare the effectiveness of cryotherapy and loop electrosurgical excision procedure without colposcopy (visual LEEP) in treating cervical lesions detected through visual inspection with acetic acid (VIA).

METHODS

In rural southeast Nigeria, women with VIA-positive lesions who were eligible for ablative treatment were selected to undergo immediate cryotherapy with nitrous oxide. Women with VIA-positive lesions who were not eligible for ablative treatment were selected to undergo visual LEEP at the same visit. A portable diathermy machine was used for LEEP. Participants were re-evaluated 6 months later using VIA. The main outcome measures included persistent VIA positivity at 6 months, duration of procedure, second clinic visits for complications, and patient acceptability.

RESULTS

In total, 304 women completed the study. Persistent VIA-positivity rates, duration of procedure, second clinic visits for complications, and patient acceptability were similar in the 2 groups.

CONCLUSION

Visual LEEP and cryotherapy have similar efficacy and patient acceptability in see-and-treat management of VIA-positive cervical lesions. In see-and-treat VIA-based cervical cancer prevention programs in low-resource countries, visual LEEP can be used to treat women who do not meet the criteria for ablative treatment. This would increase the treatment coverage of women with VIA-positive lesions and improve program efficiency.

Screening for Cervical Cancer in Low-Resource Settings in 2011

Context.—Cervical cancer remains the most common malignancy in women living in low- and middle-income countries, despite the decline of the disease in countries where cervical cytology screening programs have been implemented.

Objectives.—To review the current incidence of cervical cancer in low-resource countries, the availability and types of screening programs, and the treatment options.

Data Sources.—Literature review through PubMed, Internet search, and personal communication.

Conclusions.—Although data are incomplete, available figures confirm that the rate of cervical cancer deaths and the availability of cervical cancer screening programs are inversely proportional and vary, in general, by the wealth of the nation. Despite the success of cervical cytology screening, many major health care organizations have abandoned screening by cytology in favor of direct visualization methods with immediate treatment of lesions by cryotherapy provided by trained, nonmedical personnel.

Global inequalities in the care of women with cancer

Cancer is a leading cause of global mortality, and women in low- and middle- income countries are disproportionately affected due to vulnerabilities related to gender inequality, poverty and environmental factors. Cancers affecting women are given low priority in the developing world and resources for screening, diagnosing and treating cancer are limited. The Millennium Development Goals may serve as a guide to design programs that address the allocation of cancer services, equipment, medications and trained health care providers. This article aims to provide readers with strategies to advocate for gender parity in worldwide cancer control policies.

Motivations and preferences of rural Nigerian women undergoing cervical cancer screening via visual inspection with acetic acid

OBJECTIVE

To determine the motivations and preferences of women participating in visual inspection with acetic acid (VIA) mass cervical cancer screening programs in southeastern Nigeria.

METHODS

By means of interviewer-based questionnaires, data were collected from women participating in mass cervical cancer screenings with VIA in 3 randomly selected communities in each of 2 southeastern Nigerian states between March 1, 2011, and March 31, 2012.

RESULTS

A total of 2312 women were interviewed. Support from husband and community opinion leaders were the most frequently reported factors that motivated the women to participate in the screening. Most participants expected an immediate result for the screening test and immediate treatment for any abnormalities detected.

CONCLUSION

Community-based advocacy for cervical cancer screening is a very effective method of creating awareness for cervical cancer screening. Support from spouses and community leaders are important factors in a woman's decision to utilize cervical cancer screening services in southeastern Nigeria. Immediate results and treatments would make the most impact. Family and community participation should be integrated into cervical cancer prevention programs. This, together with a "see and treat" approach, may be central to overcoming the poor utilization of cervical cancer screening services in Nigeria and similar rural settings.

Human papillomavirus vaccination in low-resource countries: lack of evidence to support vaccinating sexually active women

Vaccines against the human papillomaviruses (HPV) that cause around 70% of cervical cancer cases worldwide are highly efficacious when administered before infection with the viruses, which occurs soon after initiation of sexual activity. Despite recommendations from key public health bodies that the primary target population for HPV vaccination should be young adolescent girls, numerous articles have suggested widening the target age group to include older adolescent girls and adult women. These articles cite evidence of efficacy and cost-effectiveness when making recommendations, and they rarely take into account the difficult resource-allocation issues faced by decision makers in low-income countries. Authors and sponsors of these articles are usually from high-income countries and sometimes include vaccine manufacturers. This review discusses the strengths and weaknesses of several types of evidence offered by these papers in support of vaccination of a broad age range of girls and women. It concludes that the greatest public health benefit and value for resources will come from vaccinating girls before sexual debut and exposure to HPV, particularly in low-resource areas.