Overcoming Barriers in the Implementation of Programs for Breast and Cervical Cancers in Cali, Colombia: A Pilot Model

[Synthesis of evidence and recommendations: guidelines for cervical cancer screening, detection, and treatmentSíntese de evidências e recomendações: diretrizes para rastreamento, detecção e tratamento do câncer do colo do útero]

Objectives

Synthesize the recommendations developed by the World Health Organization (WHO) for the screening and treatment of women with pre-cancerous lesions for cervical cancer prevention, with a view to improving the quality of care and health outcomes.

Methods

The guidelines prepared by WHO follow the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) method for the preparation of guidelines, as set forth in the WHO Handbook for Guideline Development. A synthesis of the recommendations of two WHO guidelines was carried out. Additionally, a systematic search was conducted in PubMed, Lilacs, Mhealth Systems Evidence, Epistemonikos and gray literature of studies developed in the Americas to identify barriers, facilitators, implementation strategies, and indicators.

Results

A total of 19 recommendations and ten good practices were formulated for screening pre-cancerous lesions of the cervix and treating cervical cancer. Implementation barriers and facilitators were identified, and indicators were created for assessing adherence and outcomes.

Conclusions

The recommendations provide guidance for the screening and treatment of women with pre-cancerous lesions for cervical cancer prevention, with a view to improving the quality of care and health outcomes. Implementation in Latin America and the Caribbean is considered.

Barriers and facilitators to cervical cancer screening among under-screened women in Cuenca, Ecuador: the perspectives of women and health professionals

Background

Cervical cancer screening is a cost-effective method responsible for reducing cervical cancer-related mortality by 70% in countries that have achieved high coverage through nationwide screening strategies. However, there are disparities in access to screening. In Ecuador, although cervical cancer is the second most common cancer in women, only 58.4% of women of reproductive age have ever been screened for cervical cancer.

Methodology

A qualitative study was performed to understand the current barriers to screening and to identify strategies that could increase uptake in Azuay province, Ecuador. Seven focus group discussions (FGDs) were conducted with under-screened women and health professionals (HPs). The FGDs were recorded and transcribed. Content analysis was done using the socio-ecological framework to categorize and analyse the data.

Results

Overall, 28 women and 27 HPs participated in the study. The two groups perceived different barriers to cervical cancer screening. The HPs considered barriers to be mainly at the policy level (lack of a structured screening plan; lack of health promotion) and the individual level (lack of risk perception; personal beliefs). The women identified barriers mainly at organizational level, such as long waiting times, lack of access to health centres, and inadequate patient–physician communication. Both groups mentioned facilitators at policy level, such as national campaigns promoting cervical cancer screening, and at community and individual level, including health literacy and women’s empowerment.

Conclusions

The women considered access to health services the main barrier to screening, while the HPs identified a lack of investment in screening programmes and cultural patterns at the community level as major obstacles. To take an integrated approach to cervical cancer prevention, the perspectives of both groups should be taken into account. Additionally, new strategies and technologies, such as self-administered human papillomavirus (HPV) testing and community participation, should be implemented to increase access to cervical cancer screening.

[Control of cervical cancer in the primary care setting in South American countries: systematic reviewControl del cáncer cervicouterino en los servicios de atención primaria de salud en los países de América del Sur: revisión sistemática]

Objetivo.

Descrever as estratégias para prevenção e controle do câncer do colo do útero (CCU) na atenção primária à saúde (APS) na América do Sul.

Métodos.

Revisão de literatura em duas etapas: revisão documental em sites governamentais de Argentina, Bolívia, Brasil, Chile, Colômbia, Equador, Paraguai, Peru, Uruguai e Venezuela; e revisão sistemática da literatura nas bases LILACS, MEDLINE, Scopus, SciELO e Science Direct.

Resultados.

Foram incluídos 21 documentos institucionais (planos, guias de prática e diretrizes nacionais) e 25 artigos. Todos os países tinham taxas elevadas de morbimortalidade por CCU. Predominou o rastreamento oportunístico na APS, embora os documentos disponíveis sinalizassem intenções e estratégias para diagnóstico precoce e acompanhamento longitudinal dos casos suspeitos e confirmados, preferencialmente na rede pública. Todos os países adotavam uma concepção abrangente de APS, embora o processo de implementação estivesse em estágios heterogêneos e predominassem a focalização e a seletividade. Destaca-se pior acesso ao rastreamento para mulheres de regiões rurais ou remotas e para povos originários. A indisponibilidade de serviços de APS próximos às residências/comunidade foi uma importante barreira para o rastreamento do CCU.

Conclusões.

A fragmentação dos sistemas de saúde e a segmentação na oferta de serviços são obstáculos para a prevenção e o controle do CCU na América do Sul. São necessários programas organizados de rastreamento do CCU e a incorporação de busca ativa para realização do Papanicolaou via APS. A interculturalidade nas práticas e a formulação de políticas numa perspectiva interseccional são fundamentais para superar as iniquidades no controle do CCU nos países sul-americanos.

Coordination Models for Cancer Care in Low- and Middle-Income Countries: A Scoping Review

Background: The coordination of cancer care among multiple providers is vital to improve care quality and ensure desirable health outcomes across the cancer continuum, yet evidence is scarce of this being optimally achieved in low- and middle-income countries (LMICs). Objective: Through this scoping review, our objective was to understand the scope of cancer care coordination interventions and services employed in LMICs, in order to synthesise the existing evidence and identify key models and their elements used to manage and/or improve cancer care coordination in these settings. Methods: A detailed search strategy was conducted, aligned with the framework of Arksey and O’Malley. Articles were examined for evidence of coordination interventions used in cancer care in LMICs. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension Guidelines for Scoping Reviews, which included a checklist and explanation. The PRISMA flow diagram was utilised to report the screening of results. Data were extracted, categorised and coded to allow for a thematic analysis of the results. Results: Fourteen studies reported on coordination interventions in cancer care in LMICs. All studies reported a positive impact of cancer coordination interventions on the primary outcome measured. Most studies reported on a patient navigation model at different points along the cancer care continuum. Conclusions: An evidence-based and culturally sensitive plan of care that aims to promote coordinated and efficient multidisciplinary care for patients with suspicion or diagnosis of cancer in LMICs is feasible and might improve the quality of care and efficiency.

Role of Self-Sampling for Cervical Cancer Screening: Diagnostic Test Properties of Three Tests for the Diagnosis of HPV in Rural Communities of Cuenca, Ecuador

Background: HPV primary screening has shown effectiveness for cancer prevention; however, gynaecological examination is considered uncomfortable. Self-sampling methods increase the acceptance of screening. The aim of this study is to compare the sensitivity and specificity of clinician sampling versus vaginal and urine self-sampling for HPV diagnosis. Methods: A diagnostic test study was conducted in a rural parish of Cuenca, Ecuador. A total of 120 women participated. Each participant self-collected urine and vaginal samples and underwent clinician sampling for HPV testing. The latter was considered as the golden standard. All three samples were processed with the same amplification and hybridization protocol for HPV detection (Hybribio) following the manufacturer’s instructions. Results: Characteristics of the participants were: median age 35 years; 40.8% married; 46.7% had a primary level of education; and median age of sexual onset, 17.6 years. The prevalence of any type of HPV with clinician sampling was 15.0%, 17.5% with urine sampling and 18.3% with vaginal self-sampling. Self-sampling sensitivity reached 94.4% (IC 74.2–99.9), and specificity 92.1% (IC 85.2–95.9). Urine sampling had a sensitivity of 88.8% (IC 67.2, 96.9), and specificity 94.1% (IC 67.2–96.9). The negative predictive value was 98.9% (IC 94.2–99.8) for vaginal self-sampling and 97.6% (IC 92.6–99.4) for urine sampling. Conclusions: This study shows that vaginal and urine self-sampling methods have similar sensitivity and specificity compared with clinician sampling for the diagnosis of HPV. The correlation between HPV genotypes among the three tests is satisfactory.

Interventions to improve early cancer diagnosis of symptomatic individuals: a scoping review

OBJECTIVES

To summarise the current evidence regarding interventions for accurate and timely cancer diagnosis among symptomatic individuals.

DESIGN

A scoping review following the Joanna Briggs Institute's methodological framework for the conduct of scoping reviews and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist.

DATA SOURCES

MEDLINE (Ovid), CINAHL (EBSCOhost) and PsycINFO (Ovid) bibliographic databases, and websites of relevant organisations. Published and unpublished literature (grey literature) of any study type in the English language were searched for from January 2017 to January 2021.

ELIGIBILITY AND CRITERIA

Study participants were individuals of any age presenting at clinics with symptoms indicative of cancer. Interventions included practice guidelines, care pathways or other initiatives focused on achieving predefined benchmarks or targets for wait times, streamlined or rapid cancer diagnostic services, multidisciplinary teams and patient navigation strategies. Outcomes included accuracy and timeliness of cancer diagnosis.

DATA EXTRACTION AND SYNTHESIS

We summarised findings graphically and descriptively.

RESULTS

From 21 298 retrieved citations, 88 unique published articles and 16 unique unpublished documents (on 18 study reports), met the eligibility for inclusion. About half of the published literature and 83% of the unpublished literature were from the UK. Most of the studies were on interventions in patients with lung cancer. Rapid referral pathways and technology for supporting and streamlining the cancer diagnosis process were the most studied interventions. Interventions were mostly complex and organisation-specific. Common themes among the studies that concluded intervention was effective were multidisciplinary collaboration and the use of a nurse navigator.

CONCLUSIONS

Multidisciplinary cooperation and involvement of a nurse navigator may be unique features to consider when designing, delivering and evaluating interventions focused on improving accurate and timely cancer diagnosis among symptomatic individuals. Future research should examine the effectiveness of the interventions identified through this review.

National Cancer Information System Within the Framework of Health Insurance in Colombia: A Real-World Data Approach to Evaluate Access to Cancer Care

PURPOSE

The National Cancer Information System (NCIS) has been operating since 2014, including information reported by health care insurers and providers on people with cancer diagnosed and treated within the Colombian health system. Its main purpose is to identify barriers to an effective access to cancer diagnosis and treatment across the country. We aimed to describe the methodology, scope and results in terms of access to health services with real-world data provided by the NCIS.

METHODS

Reporting of all cases of cancer by insurers and providers is mandatory by law. Data gathered include demographic and clinical information about new and old cases of cancer who receive health services. Over the years, the reporting process has been automated and it is currently performed in real time. Data quality is ensured through a standardized data-monitoring process. Access to health services is monitored by quality measures defined by consensus.

RESULTS

Since 2015, prevalent cases of invasive cancer have increased from 163,776 to 331,021 in 2020 (increment of 102.12%). Regarding quality measures, the proportion of people staged at diagnosis has increased over the years, especially in breast cancer. Meanwhile, early diagnosis is still concerning for breast and prostate cancer. Time to diagnosis and treatment have not consistently reached the expected goals in breast, cervical, and prostate cancer, whereas they have shown a better level of compliance for stomach and colon and rectum tumors, still not reaching the highest performance.

CONCLUSION

The real-world information approach provided by the NCIS may be complementary for cancer control planning in Colombia, emphasizing better management processes of health insurers and providers by identifying barriers for timely access to health care.

Health system strengthening: Integration of breast cancer care for improved outcomes

The adoption of the goal of universal health coverage and the growing burden of cancer in low- and middle-income countries makes it important to consider how to provide cancer care. Specific interventions can strengthen health systems while providing cancer care within a resource-stratified perspective (similar to the World Health Organization-tiered approach). Four specific topics are discussed: essential medicines/essential diagnostics lists; national cancer plans; provision of affordable essential public services (either at no cost to users or through national health insurance); and finally, how a nascent breast cancer program can build on existing programs. A case study of Zambia (a country with a core level of resources for cancer care, using the Breast Health Global Initiative typology) shows how a breast cancer program was built on a cervical cancer program, which in turn had evolved from the HIV/AIDS program. A case study of Brazil (which has enhanced resources for cancer care) describes how access to breast cancer care evolved as universal health coverage expanded. A case study of Uruguay shows how breast cancer outcomes improved as the country shifted from a largely private system to a single-payer national health insurance system in the transition to becoming a country with maximal resources for cancer care. The final case study describes an exciting initiative, the City Cancer Challenge, and how that may lead to improved cancer services.

Mobile Applications: Breaking Barriers to Early Breast and Cervical Cancer Detection in Underserved Communities

BACKGROUND

Although potentially curable with early detection and timely treatment, breast cancer (BC) and cervical cancer (CC) remain leading causes of death for Colombian women. Lack of education, complicated administrative processes, and geographic limitations hinder early cancer detection. Today, technological tools permeate the society and could assess user risk, deliver customized information, and provide care coordination. We evaluated the effectiveness of a free mobile application (mApp) to reach women, understand misconceptions, identify users at risk for BC and/or CC, and coordinate screening tests in Cali, Colombia.

METHODS

The mApp was developed and advertised in four healthcare facility waiting rooms. It used educational, evaluative, and risk factor questions followed by brief explanations to assess the population's knowledge, educate on BC and/or CC, and identify users in need of screening test(s). Women who required screening were navigated and enrolled in the national cancer program.

RESULTS

From August 2017 to August 2019, 1,043 women downloaded the mApp. BC misconceptions included beliefs that BC can be prevented (87%), obesity does not increase the risk of BC (49%), and deodorant causes BC (17%). CC misconceptions included that pap smears should not be performed while sexually active (64%), vaginal pain is an early sign of CC (44%), and only women contract human papilloma virus (33%). Overall, 29% (303) were identified as at risk and needed a screening test, with 32% (98) successfully screened.

DISCUSSION

mApps can identify women at risk for BC and/or CC, detect barriers to early cancer detection, and help coordinate screening test(s). This technology has widespread applications and may be useful in other underserved communities.

Factors associated with delays in time to treatment initiation in Colombian women with cervical cancer: A cross-sectional analysis

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Cervical cancer is one of the leading causes of morbidity and mortality in Colombia.

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Delays in time to treatment initiation have been associated with poor prognosis.

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Only 12.41% of women were treated within the 30 days from diagnosis.

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Median time to treatment initiation was longer in women under chemotherapy.

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Social disparities were associated with delays in time to treatment initiation.

Cervical cancer (CC) is one of the leading causes of morbidity in upper-middle income countries such as Colombia. Several studies have reported poor prognosis when treatment is delayed. We aimed to describe the factors associated with delays in time to treatment initiation (TTI) in Colombian women with CC. Cross-sectional analysis including newly diagnosed cases of CC during 2018 and reported to the National Administrative Cancer Registry. TTI was defined as days from diagnosis to the first treatment (chemotherapy, radiation, or surgery). Linear and multinomial logistic regression models were estimated to analyze the association of interest. 1,249 new cases of CC were analyzed (26.98% in-situ and 40.11% locally advanced). The median age was 46 years (IQR: 36–58). Median TTI was 71 days (IQR: 42–105), varying from 70 days (IQR: 43–106) among the surgery group to 76 days (IQR: 41–118) in women under chemotherapy. Only 12.41% were treated within 30 days from diagnosis. TTI was significantly longer in women with state insurance (β = 18.95 days, 95% CI: 11.77–26.13) compared with those insured by the third payer. Women from the Pacific and Eastern regions also had a significantly longer TTI than those living in the capital of Colombia. Age, health insurance, region of residence, and stage at diagnosis were associated with TTI longer than 45 days in the multinomial model. We concluded that demographic variables (age, region of residence, and health insurance) which are proxies of social disparities and poor access to quality health care services, were associated with delays in TTI.

Conceptual Framework to Guide Early Diagnosis Programs for Symptomatic Cancer as Part of Global Cancer Control

Diagnosing cancer earlier can enable timely treatment and optimize outcomes. Worldwide, national cancer control plans increasingly encompass early diagnosis programs for symptomatic patients, commonly comprising awareness campaigns to encourage prompt help-seeking for possible cancer symptoms and health system policies to support prompt diagnostic assessment and access to treatment. By their nature, early diagnosis programs involve complex public health interventions aiming to address unmet health needs by acting on patient, clinical, and system factors. However, there is uncertainty regarding how to optimize the design and evaluation of such interventions. We propose that decisions about early diagnosis programs should consider four interrelated components: first, the conduct of a needs assessment (based on cancer-site-specific statistics) to identify the cancers that may benefit most from early diagnosis in the target population; second, the consideration of symptom epidemiology to inform prioritization within an intervention; third, the identification of factors influencing prompt help-seeking at individual and system level to support the design and evaluation of interventions; and finally, the evaluation of factors influencing the health systems' capacity to promptly assess patients. This conceptual framework can be used by public health researchers and policy makers to identify the greatest evidence gaps and guide the design and evaluation of local early diagnosis programs as part of broader cancer control strategies.