Setting up a community-based cervical screening service in a low-income country: a pilot study from north-western Tanzania

Setting Up a Medical Oncology Educational Program in Sub-Saharan Africa

One of the major problems facing healthcare systems in countries with poor socio-economic conditions is the need to strengthen the system through the training of physicians, nurses and other healthcare operators. Partnering with more affluent countries is the key for hospitals in these areas, but such alliances are often based on limited educational exchanges. We present a retrospective study of our experience in building a collaborative relationship between our cancer institute in Italy and a Medical Center in sub-Saharan Africa (Tanzania). The main purpose is to see the changes in the clinical practice after educational interventions on health personnel in a Tanzanian cancer center.

Healthcare utilisation, cancer screening and potential barriers to accessing cancer care in rural South West Nigeria: a cross-sectional study

BACKGROUND/AIMS

Cancer burden is predicted to double by 2030 in sub-Saharan Africa; access to healthcare services for cancer management is a priority in the region. In Nigeria, National Cancer Control Plan aims to ensure >50% cancer screening of eligible populations by 2022 for all Nigerians. We describe healthcare utilisation, cancer screening activities and potential barriers to accessing cancer care within an understudied rural community-based adult population in South West Nigeria.

METHODS

In April 2018, we conducted a cross-sectional study of community-based adults (>18 years) ~130 km east of Ibadan, 250 km from Lagos in Osun State, South West Nigeria. Participants completed a face-to-face survey in local dialect. We used a questionnaire to assess demographics, health status, income, medical expenditures, doctor visits and cancer screening history.

RESULTS

We enrolled 346 individuals: with median age of 52 years and 75% women. Of the entire cohort, 4% had medical insurance. 46% reported a major medical cost in the last year. Cancer screening activities were infrequent in eligible participants: 1.5% reported having had cervical cancer screening, 3.3% mammogram and 5% colonoscopy screening. Cancer screening assessment was less frequent in those with less income and lower education levels. Using a multivariable logistic regression model including personal income, insurance status and education, higher personal income was associated with more cancer screening activity (OR 2.7, 95% CI 1.3 to 5.7, p<0.01). Despite this, most individuals had contact with a primary healthcare doctor (52% in the last year), and over 70% access to radio and TV suggesting the opportunity to expand community-based screening interventions and awareness exists.

CONCLUSIONS

Despite national increases in cancer cases, we highlight a deficiency in cancer screening and universal healthcare coverage within a community-based adult Nigerian population. Subject to availability of governmental resources, increasing financial risk protection, awareness and targeted resource allocation may help expand access in Nigeria.

Tanzanian women´s knowledge about Cervical Cancer and HPV and their prevalence of positive VIA cervical screening results. Data from a Prevention and Awareness Campaign in Northern Tanzania, 2017 - 2019

Background: 14.9 million women (≥15 years) in Tanzania are at risk of developing cervical cancer.

Limited cancer care facilities, prevention programs and sparse knowledge among community members and healthcare workers contribute to late-stage presentation leading to a high mortality rate.

Objective: This study aims to scientifically accompany prevention and awareness campaigns (PrevACamp) in northern Tanzania in its real-world settings to obtain (1) a better understanding about cervical cancer and HPV knowledge amongst female PrevACamp participants and (2) to determine the prevalence of pre-cancerous lesions among women undergoing cervical cancer VIA screening.

Method: Cross-sectional survey among PrevACamp attendees in two regions in Northern Tanzania. Two data collections tools were used: Questionnaires and clinical data from VIA screening. Data were collected from October 2017 to March 2019.

Results: 2,192 PrevACamp attendees were interviewed and 2,224 received VIA screening. There was significant nescience on cervical cancer regardless of education level, resident status, or number of children as well as nescience on HPV in all age groups, especially in urban areas and misconceptions about cancer. Screening revealed VIA positivity rate of 3.1%.

Conclusion: There is an alarming lack of knowledge about cervical cancer and, to a lesser Extent, about HPV among the study participants. Having health insurance influenced the level of knowledge significantly. Outreach programs in rural areas appear to target the population in need of health education. Low positive VIA screening results are paralleled with lower HIV rates among the women. We assume that the high density of primary health care coverage in northern Tanzania contributes to these findings..

An initiative to assess the quality of Tanzanian cervical cancer specimens for HPV and telomerase detection

The aim of our study was to assess the quality of Tanzanian cervical cancer specimens, evaluating telomerase alterations and human papilloma virus (HPV) infection in relation to histopathological characteristics since these biomarkers are not routinely analyzed. Thirty-two Tanzanian women with invasive cervical cancer were included in the study. Histopathological classification and all the analyses on tissue, including TERT immunohistochemistry, were performed at IRST IRCCS (Meldola, Italy). HPV typization was performed by pyrosequencing. FHACT™ was used to identify chromosomal aberrations. Nonparametric ranking statistics were used. The majority (75 %) of the cases analyzed were squamous carcinoma, while 12.5 % were adenocarcinoma. The presence of HPV infection was confirmed in 26/27 (96.3 %) cases. A high percentage of patients (88 %) were infected with HPV16 of whom 12 (44.4 %) with African type 1, and 4 (14.8 %) with African type 2. TERT expression evaluated in the entire case series showed a median H-score of 130 (range 3-270), with only one negative case. 88 % of the FISH-evaluable samples showed an amplification of the chromosomal region 3q26 (TERC) and/or 5p15, and 20q13, associated with a higher median expression of TERT (P = 0.0226). Despite pre-analytical problems in terms of sample fixation, we showed that the search for biomarkers such as HPV and telomerase is feasible in Tanzanian tissue. These markers could be important risk-stratification tools in this population.

Screening for cervical cancer in Africa: A proposal of a different combination of VIA test and cervical smear in Uganda

OBJECTIVE

To evaluate the efficacy of visual inspection with acetic acid (VIA) screening combined with a cervical smear in Uganda.

METHODS

Nine screening campaigns were held in Uganda between January 2011 and October 2019. In the last three campaigns, a new approach was used: the cervical smear was performed before the VIA test and, in case of a positive VIA test, the slide was sent for examination. The data collected were divided into two groups: the first six campaigns and the last three campaigns.

RESULTS

During the study period, 10 520 women were screened, of whom 911 had a positive VIA test. The VIA test showed 84.2% false positives. In the first group, the VIA test was positive in 516 women, of whom 93% were referred for further examinations. In the second group, the VIA test was positive in 395 women, but the cervical smear was positive in only 65 women. Thus, only 16.5% women were referred for further examinations.

CONCLUSION

Combining cervical smear, VIA test, and slide analysis in positive VIA tests may allow women who need treatment to be selected more effectively, while waiting for other more expensive solutions to become more affordable for this setting.

Evaluating the appropriateness of chemotherapy in a low-resource cancer centre in sub-Saharan Africa

Background

To evaluate the appropriateness of chemotherapy use at the Oncology Department of the Bugando Medical Centre of Mwanza, Tanzania.

Methods

The study was an observational prevalence‐based study designed to evaluate a single‐chemotherapy cycle during a defined time period for a cross‐section of patients at varying stages of their clinical history. The sample included 103 consecutive subjects who were treated during January‐March 2017 and had at least one previous cycle. Chemotherapy treatment omissions, cycle delays, and dose reductions and their causes were recorded using a standard form that included demographic, anthropometric, and clinical items. The data were analyzed descriptively.

Results

There were 59 males (57.3%) and 44 females (42.7%). Ninety‐four patients were aged ≥18 years. Considering cancer type/site, there were 23 distinct groups of patients. The recorded number of drugs in the chemotherapy regimens varied between one and five. The median cycle number was three (range: 2‐11). Sixty‐eight (66.0%) patients were treated in a standard fashion. For the remaining, cycle delay and dose reduction were the most common cause for nonstandard treatment. Hematologic toxicity was responsible for the greater part of cycle delays, whereas dose reductions were accounted for by a larger spectrum of causes. Overall, toxicity explained 21/35 (60.0%) patients receiving nonstandard treatment. The distribution of toxic events was skewed toward grade 1 and grade 2.

Conclusions

The observed level of appropriateness of chemotherapy was encouraging. The proportion of patients experiencing severe toxic effects was lower than expected.

Cervical cancer in Tanzania: A systematic review of current challenges in six domains

Cervical cancer is the most common cancer in Tanzania. After excluding human immunodeficiency virus, lower respiratory infections, malaria, diarrheal diseases, and tuberculosis, cervical cancer kills more women than any other form of illness in the country. Unfortunately, Tanzania has a low doctor-to-patient ratio (1:50,000) and nearly 7000 women die each year from this disease. The clinical problem is further magnified by the country's lack of resources and prevailing poverty, sporadic cervical cancer screening, prevalence of high-risk oncogenic human papillomavirus subtypes, and relatively high rates of human immunodeficiency virus co-infection. In recent years, addressing the cervical cancer problem has become a priority for the Tanzanian government. In this systematic review of 39 peer-reviewed publications that appeared in the PubMed/MEDLINE (NCBI) database from 2013 to 2018, we synthesize the growing body of literature to capture current trends in Tanzania's evolving cervical cancer landscape. Six domains were identified, including risk factors, primary prevention, barriers to screening, treatment, healthcare worker education, and sustainability. In addition to traditional risk factors associated with sexual behavior, acetowhite changes observed during visual inspection of the cervix with acetic acid, lower education, rural setting, and HIV positivity also have a noteworthy clinical impact.

A tailored within-community specimen collection strategy increased uptake of cervical cancer screening in a cross-sectional study in Ghana

Background

The implementation of cervical cancer screening strategies has reported different rates of success in different countries due to population specific factors that limit women’s participation. We report observations and the development of a community-based specimen collection strategy which resulted from interactions with women in the study communities, following an initial low response to a hospital based cervical cancer screening strategy.

Method

Women were recruited by a house survey and invited to report at a hospital either within a week or after a week for self and health-personnel specimen collections. However, due to the very low response and subsequent interactions with the women of the communities, another strategy was developed that required recruited women report at a central location within their respective communities for specimen collections at times that did not interfere with their daily routines.

Results

For specimen collection, of the 156 participants who opted to report after a week at the hospital, 60 (38.5%) reported. Of the 118 participants who opted to report within 1 week at the hospital, 55 (46.6%) reported. Of the 103 participants were invited to report at a specified location within the community, 98 (95.1%) reported. An overall response rate of 60.4% was attained. Almost 89.7% (226 of 253) of the women performed both self and health personnel sample collection.

Conclusion

The community-based strategy with self-specimen collection and HPV testing holds great potential for increasing women’s participation in cervical cancer screening in Ghana as compared to the hospital based strategy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4631-y) contains supplementary material, which is available to authorized users.