Evidence-based improvisation: Facing the challenges of cervical cancer care in Uganda

Serum levels of stearic and dihomo-γ-linolenic acids can be used to diagnose cervical cancer and cervical intraepithelial neoplasia

Despite widespread cervical cancer (CC) screening programs, low participation has led to high morbidity and mortality rates, especially in developing countries. Because early-stage CC often has no symptoms, a non-invasive and convenient diagnostic method is needed to improve disease detection. In this study, we developed a new approach for differentiating both CC and cervical intraepithelial neoplasia (CIN)2/3, a precancerous lesion, from healthy individuals by exploring CC fatty acid metabolic reprogramming. Analysis of public datasets suggested that various fatty acid metabolizing enzymes were expressed at higher levels in CC tissues than in normal tissues. Correspondingly, 11 free fatty acids (FFAs) showed significantly different serum levels in CC patient samples compared with healthy donor samples. Nine of these 11 FFAs also displayed significant alterations in CIN2/3 patients. We then generated diagnostic models using combinations of these FFAs, with the optimal model including stearic and dihomo-γ-linolenic acids. Receiver operating characteristic curve analyses suggested that this diagnostic model could detect CC and CIN2/3 more accurately than using serum squamous cell carcinoma antigen level. In addition, the diagnostic model using FFAs was able to detect patients regardless of clinical stage or histological type. Overall, the serum FFA diagnostic model developed in this study could be a powerful new tool for the non-invasive early detection of CC and CIN2/3.

Exploring global barriers to optimal ovarian cancer care: thematic analysis

OBJECTIVE

To explore the barriers to ovarian cancer care, as reported in the open ended responses of a global expert opinion survey, highlighting areas for improvement in global ovarian cancer care. Potential solutions to overcome these barriers are proposed.

METHODS

Data from the expert opinion survey, designed to assess the organization of ovarian cancer care worldwide, were analyzed. The survey was distributed across a global network of physicians. We examined free text, open ended responses concerning the barriers to ovarian cancer care. A qualitative thematic analysis was conducted to identify, analyze, and report meaningful patterns within the data.

RESULTS

A total of 1059 physicians from 115 countries completed the survey, with 438 physicians from 93 countries commenting on the barriers to ovarian cancer care. Thematic analysis gave five major themes, regardless of income category or location: societal factors, inadequate resources in hospital, economic barriers, organization of the specialty, and need for early detection. Suggested solutions include accessible resource stratified guidelines, multidisciplinary teamwork, public education, and development of gynecological oncology training pathways internationally.

CONCLUSIONS

This analysis provides an international perspective on the main barriers to optimal ovarian cancer care. The themes derived from our analysis highlight key target areas to focus efforts to reduce inequalities in global care. Future regional analysis involving local representatives will enable country specific recommendations to improve the quality of care and ultimately to work towards closing the care gap.

Public health concern-driven insights and response of low- and middle-income nations to the World health Organization call for cervical cancer risk eradication

The heart shattering impact afflicted by the notorious cervical cancer is rising rapidly as it emerges as the second most prevalent cancer among women in the developing countries. There was an anticipated 604,127 observed reports and 341,831 fatalities reported worldwide in 2020. The mortality rate was 7.2 deaths per 100,000 women-years, while the age-standardized incidence rate was 13.3 cases per 100,000 women annually. In less developed countries, the accountability was around 87-90% of mortality and roughly 84% of newly diagnosed cases. Resource limitations, inadequate public awareness, and late-stage diagnosis aggravate the complications of cancer mitigation in these regions, compared to the higher income nations. While primary and secondary interventions come off as an enticing solution, international collaborations and the integration of technology also emerge as promising avenues for enhancing cancer care accessibility. This study aims to assess the progress of developing countries in meeting the World Health Organization's mandate to eliminate cervical cancer by scrutinizing the prevalence of cervical cancer incidence and mortality rates, evaluating the impact and execution of HPV vaccination initiatives, and analyzing proposals for cervical cancer eradication within these nations, our objective is to accelerate advancements towards the ultimate goal of eradicating cervical cancer.

Implementation strategies of cervical cancer screening in South Asia: A systematic review

BACKGROUND

Cervical cancer is a preventable cancer by screening, vaccination and timely management of preinvasive cervical lesions. However, about 90% of the global burden of cervical cancer is reported from developing countries.

OBJECTIVE

This systematic review aimed to analyze the strategies implemented for cervical cancer screening in South Asia.

SEARCH STRATEGY

An electronic search of PubMed/MEDLINE, Scopus and Google Scholar was carried out for articles published in English, evaluating the implementation of cervical cancer screening between December 2000 and June 2023 in South Asia using appropriate search terms.

SELECTION CRITERIA

Cross-sectional studies, randomized control trials (RCTs) or non-randomized controlled trials evaluating different cervical screening strategies were included.

DATA COLLECTION AND ANALYSIS

A three-stage selection process was performed using a validated proforma including the title, author, year of publication, objective, country, study design, screening methods, strategies and outcomes, and results. The systematic review was designed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The risk of bias was evaluated with the National Heart, Lung, and Blood Institute's (NHLBI) Quality Assessment Tools.

MAIN RESULTS

Out of the initial 1135 articles reviewed systematically, 23 studies met the inclusion criteria and were included in the qualitative synthesis of results. The implementation outcomes measured were acceptability (n = 23 100%), feasibility (n = 22, 95.7%), fidelity (n = 14, 60.9%), sustainability (n = 7, 30.4%), coverage (n = 4, 17.4%) and cost (n = 1, 4.3%).

CONCLUSION

Cervical cancer screening can be effectively implemented by restructuring the ongoing programs.

Late Stage at Diagnosis of Cervical Cancer and Its Correlates at a Large Regional Referral Hospital in Uganda: A Cross-Sectional Study

Background The stage of disease at diagnosis is one of the major determinants of survival in women with cervical cancer. Most women with cervical cancer in low- and middle-income countries (LMICs) present to hospitals with advanced stages, thus reducing their survivorship following the diagnosis. Factors correlated with late-stage disease at diagnosis are not completely explored. This study aimed to describe the association between sociodemographic, clinical, and metabolic characteristics with late-stage disease at diagnosis in women with cervical cancer attending the Mbarara Regional Referral Hospital in Southwestern Uganda. Methodology We conducted a cross-sectional study of women with histological diagnoses of invasive cervical cancer between November 2022 and August 2023. Women who presented to the hospital with the International Federation of Gynecology and Obstetrics stage IIb and above were considered to have late-stage cervical cancer while those with stage IIa and below were considered to have early-stage disease. We used modified Poisson regression to determine the factors independently associated with the outcome. Results We enrolled 157 women. The average age of the participants was 52.4 years. The majority of the participants (83.4%) had late-stage disease at diagnosis. Women with adenocarcinoma (adjusted prevalence ratio (aPR) = 1.18, 95% confidence interval (CI) = 1.10-1.38) and those with lymphovascular space involvement on histology (aPR = 1.30, 95% CI = 1.05-1.60) were more likely to have late-stage disease at diagnosis while women living with human immunodeficiency virus (aPR = 0.83, 95% CI = 0.71-0.97) were less likely to present with late-stage disease at diagnosis. None of the sociodemographic and metabolic characteristics were associated with late-stage disease at diagnosis. Conclusions The number of women presenting with late-stage cervical cancer is high. Efforts to increase the availability and uptake of cervical cancer screening services in LMICs should be reinforced. Cervical cancer treatment services should be decentralized to increase accessibility.

Outcomes of neoadjuvant chemotherapy and radical hysterectomy for locally advanced cervical cancer at Kigali University Teaching Hospital, Rwanda: a retrospective descriptive study

BACKGROUND

Half of countries in Africa lack access to radiation (RT), which is essential for standard treatment of locally advanced cervical cancers. We evaluated outcomes for patients treated with neoadjuvant chemotherapy (NACT) followed by radical hysterectomy in settings where no RT is available.

METHODS

We performed a retrospective descriptive study of all patients with FIGO stage IB2-IIA2 and some exceptional stage IIB cases who received NACT and surgery at Kigali University Teaching Hospital in Rwanda. Patients were treated with NACT consisting of carboplatin and paclitaxel once every 3 weeks for 3-4 cycles before radical hysterectomy. We calculated recurrence rates and overall survival (OS) rate was determined by Kaplan-Meier estimates.

RESULTS

Between May 2016 and October 2018, 57 patients underwent NACT and 43 (75.4%) were candidates for radical hysterectomy after clinical response assessment. Among the 43 patients who received NACT and surgery, the median age was 56 years, 14% were HIV positive, and FIGO stage distribution was: IB2 (32.6%), IIA1 (7.0%), IIA2 (51.2%) and IIB (9.3%). Thirty-nine (96%) patients received 3 cycles and 4 (4%) received 4 cycles of NACT. Thirty-eight (88.4%) patients underwent radical hysterectomy as planned and 5 (11.6%) had surgery aborted due to grossly metastatic disease. Two patients were lost to follow up after surgery and excluded from survival analysis. For the remaining 41 patients with median follow-up time of 34.4 months, 32 (78%) were alive with no evidence of recurrence, and 8 (20%) were alive with recurrence. One patient died of an unrelated cancer. The 3-year OS rate for the 41 patients who underwent NACT and surgery was 80.8% with a recurrence rate of 20%.

CONCLUSIONS

Neoadjuvant chemotherapy with radical hysterectomy is a feasible treatment option for locally advanced cervical cancer in settings with limited access to RT. With an increase in gynecologic oncologists skilled at radical surgery, this approach may be a more widely available alternative treatment option in countries without radiation facilities.

Identifying the optimal deep learning architecture and parameters for automatic beam aperture definition in 3D radiotherapy

PURPOSE

Two-dimensional radiotherapy is often used to treat cervical cancer in low- and middle-income countries, but treatment planning can be challenging and time-consuming. Neural networks offer the potential to greatly decrease planning time through automation, but the impact of the wide range of hyperparameters to be set during training on model accuracy has not been exhaustively investigated. In the current study, we evaluated the effect of several convolutional neural network architectures and hyperparameters on 2D radiotherapy treatment field delineation.

METHODS

Six commonly used deep learning architectures were trained to delineate four-field box apertures on digitally reconstructed radiographs for cervical cancer radiotherapy. A comprehensive search of optimal hyperparameters for all models was conducted by varying the initial learning rate, image normalization methods, and (when appropriate) convolutional kernel size, the number of learnable parameters via network depth and the number of feature maps per convolution, and nonlinear activation functions. This yielded over 1700 unique models, which were all trained until performance converged and then tested on a separate dataset.

RESULTS

Of all hyperparameters, the choice of initial learning rate was most consistently significant for improved performance on the test set, with all top-performing models using learning rates of 0.0001. The optimal image normalization was not consistent across architectures. High overlap (mean Dice similarity coefficient = 0.98) and surface distance agreement (mean surface distance < 2 mm) were achieved between the treatment field apertures for all architectures using the identified best hyperparameters. Overlap Dice similarity coefficient (DSC) and distance metrics (mean surface distance and Hausdorff distance) indicated that DeepLabv3+ and D-LinkNet architectures were least sensitive to initial hyperparameter selection.

CONCLUSION

DeepLabv3+ and D-LinkNet are most robust to initial hyperparameter selection. Learning rate, nonlinear activation function, and kernel size are also important hyperparameters for improving performance.

Human papillomavirus vaccination in low- and middle-income countries: progression, barriers, and future prospective

Human papillomavirus (HPV) is a viral infection that, if does not go away, can cause health problems like genital warts and cancer. The national immunization schedules for individuals before sexual debut, significantly decreased HPV-associated mortality and it will be affordable. However, immunization programs remain vulnerable to macroeconomic factors such as inflation, fiscal policy, employment levels, and national income. This review aims to investigate the association between national income in lower-middle-income countries to explore recent advances and potential issues, as well as how to deal with challenges.

Advancing cervical cancer diagnosis and screening with spectroscopy and machine learning

INTRODUCTION

In the UK alone, the incidence of cervical cancer is increasing, hence an urgent need for early and rapid detection of cancer before it develops. Spectroscopy in conjunction with machine learning offers a disruptive technology that promises to be pick up cancer early as compared to the current diagnostic techniques used.

AREAS COVERED

This review article explores the different spectroscopy techniques that have been used for the analysis of cervical cancer. Along with the extensive description of spectroscopic techniques, the various machine learning techniques are also described as well as the applications that have been explored in the diagnosis of cervical cancer. This review delimits the literature specifically associated with cervical cancer studies performed solely with the use of a spectroscopy technique, and machine learning.

EXPERT OPINION

Although there are several methods and techniques to detect cervical cancer, the clinical sector requires to introduce new diagnostic technologies that help improving the quality of life of patient. These innovative technologies involve spectroscopy as a qualitative method and machine learning as a quantitative method. In this article, both the techniques and methodologies that allow and promise to be a new screening tool for the detection of cervical cancer is covered.

Initiatives to reduce the waiting time to initiate oncological treatment: a scoping literature review

Objective.

To identify the managerial actions proposed and employed to reduce the waiting time to initiate oncological treatments in the public health system and its application in Latin America.

Method.

We searched seven databases in December 2020. Search terms were conceptualized into three groups: waiting time, cancer, and terms related to public sector. The eligibility criteria included theoretical or empirical academic articles written in English, Spanish, or Portuguese, that focused on managerial solutions to face oncological healthcare queues' dilemma.

Results.

The search returned 1 255 articles, and 20 were selected and analysed in this review. Results show that most of the proposals are related to the process and people dimensions. The actions related to the process dimension were mainly associated with programming new treatment pathways and integrating cancer systems. People's dimension initiatives referred mostly to task forces and groups of specialists. Some initiatives were related to implementing technological solutions and the technology dimension, mainly concerning radiotherapy devices' acquisition.

Conclusion.

Few studies focus on analysing actions to minimize waiting time to initiate oncological treatments. The prevalence of conceptual and illustrative case studies indicates the lack of research maturity on this theme. Future studies should focus on setting the field's theoretical foundations, considering the existing paradigms, or developing new ones. There is a need for empirical studies applying a multidisciplinary approach to face the oncological treatment waiting time challenge and proposing new and innovative initiatives.

Patient experiences of living with cancer before interaction with palliative care services in Zimbabwe: A qualitative secondary data analysis

OBJECTIVE

Cancer patients in Zimbabwe typically access health services with advanced disease, limiting treatment choices and lessening the likelihood of positive treatment outcomes. We outline experiences of patients with advanced cancer prior to interaction with palliative care services to identify targets for future intervention development to enhance care delivery in Zimbabwe.

METHODS

Participants were purposively sampled adult patients with advanced cancer. We adopted a thematic approach to guide a qualitative secondary data analysis exploring factors influencing support sought by participants, external factors influencing decision making across the disease trajectory and the process for seeking and accessing palliative care.

RESULTS

Participants reported fragmented and uncoordinated care, from initial symptom experience and throughout disease progression. A recurring notion of disjuncture was present through participants' experiences of gaps, breaks and discontinuity across the disease trajectory. Each step had a beginning and end without clear routes for transition with movement between steps as a result of happenstance or informal encounters.

CONCLUSION

Targets for intervention development at the patient and family level exist that may reduce the disjuncture currently experienced between need and care provision. A holistic response that incorporates engagement with policy actors is critical to addressing prominent financial constraints for patients.

Prognostic Value of Evaluating Platelet Role, Count and Indices in Laboratory Diagnosis of Different Types of Solid Malignancies

Platelets are associated with the processes that aid in tumour growth and progression. Platelet Count (PLT) and platelet indices like Mean Platelet Volume (MPV), Platelet Large Cell Ratio (P-LCR), Plateletcrit (PCT) and Platelet Distribution Width (PDW) are markers that are linked with platelet activities in cancer. This review involves the evaluation of PLT, MPV and PCT in different cancers. Platelets actions should be always monitored during several diseases, as their potential exceeds the classical function in preventing bleeding. Vast roles of platelets were discovered in several biological functions. Therefore, studying their indices can be effective in the diagnosis of several disorders including cancer.

Breast Cancer Diagnostics, Therapy, and Outcomes in Sub-Saharan Africa: A Population-Based Registry Study

BACKGROUND

Breast cancer (BC) is the most common cancer in sub-Saharan Africa (SSA). However, little is known about the actual therapy received by women with BC and their survival outcome at the population level in SSA. This study aims to describe the cancer-directed therapy received by patients with BC at the population level in SSA, compare these results with the NCCN Harmonized Guidelines for SSA (NCCN Harmonized Guidelines), and evaluate the impact on survival.

METHODS

Random samples of patients with BC (≥40 patients per registry), diagnosed from 2009 through 2015, were drawn from 11 urban population-based cancer registries from 10 countries (Benin, Congo, Cote d'Ivoire, Ethiopia, Kenya, Mali, Mozambique, Namibia, Uganda, and Zimbabwe). Active methods were used to update the therapy and outcome data of diagnosed patients ("traced patients"). Excess hazards of death by therapy use were modeled in a relative survival context.

RESULTS

A total of 809 patients were included. Additional information was traced for 517 patients (63.8%), and this proportion varied by registry. One in 5 traced patients met the minimum diagnostic criteria (cancer stage and hormone receptor status known) for use of the NCCN Harmonized Guidelines. The hormone receptor status was unknown for 72.5% of patients. Of the traced patients with stage I-III BC (n=320), 50.9% received inadequate or no cancer-directed therapy. Access to therapy differed by registry area. Initiation of adequate therapy and early-stage diagnosis were the most important determinants of survival.

CONCLUSIONS

Downstaging BC and improving access to diagnostics and care are necessary steps to increase guideline adherence and improve survival for women in SSA. It will also be important to strengthen health systems and facilities for data management in SSA to facilitate patient follow-up and disease surveillance.

Cervical cancer treatment in Rwanda: Resource-driven adaptations, quality indicators, and patient outcomes

OBJECTIVE

Most cervical cancer cases and deaths occur in low- and middle-income countries, yet clinical research from these contexts is significantly underrepresented. We aimed to describe the treatment quality, resource-driven adaptations, and outcomes of cervical cancer patients in Rwanda.

METHODS

A retrospective cohort study was conducted of all patients with newly diagnosed cervical cancer enrolled between April 2016 and June 2018. Data were abstracted from medical records and analyzed using descriptive statistics, Kaplan Meier methods, and Cox proportional hazards regression.

RESULTS

A total of 379 patients were included; median age 54 years, 21% HIV-infected. A majority (55%) had stage III or IV disease. Thirty-four early-stage patients underwent radical hysterectomy. Of 254 patients added to a waiting list for chemoradiation, 114 ultimately received chemoradiation. Of these, 30 (26%) received upfront chemoradiation after median 126 days from diagnosis, and 83 (73%) received carboplatin/paclitaxel while waiting, with a median 56 days from diagnosis to chemotherapy and 207 days to chemoradiation. There was no survival difference between the upfront chemoradiation and prior chemotherapy subgroups. Most chemotherapy recipients (77%) reported improvement in symptoms. Three-year event-free survival was 90% with radical hysterectomy (95% CI 72-97%), 66% with chemoradiation (95% CI 55-75%), and 12% with chemotherapy only (95% CI 6-20%).

CONCLUSIONS

Multi-modality treatment of cervical cancer is effective in low resource settings through coordinated care and pragmatic approaches. Our data support a role for temporizing chemotherapy if delays to chemoradiation are anticipated. Sustainable access to gynecologic oncology surgery and expanded access to radiotherapy are urgently needed.

Women's lived experiences of advanced cervical cancer: a descriptive qualitative study

AIM

To explore the lived experiences of women with advanced incurable cervical cancer attending a palliative care service in Uganda.

METHODS

This qualitative and exploratory study was conducted at Mobile Hospice Mbarara in South Western Uganda. The target population was a convenience sample of all patients with a confirmed histological diagnosis of advanced cervical cancer; stage 2B to 4B, and clinically advanced disease. Demographic data were collected prior to conducting semi-structured audio-taped interviews. Transcripts were read and re-read, coded and codes were then abstracted into emergent broad-based meaningful themes by consensus.

RESULTS

A total of 10 participants, average age of 53.4, age range 40-71, cancer staging 2B to 4 and average duration of illness 3.5 years were interviewed. Six themes emerged from the data: socio-demographic profiles of the women; road to cancer diagnosis; effects of disease on women's quality of life; experiences with main stream medicine; adapting to having cancer and needs of the women.

CONCLUSIONS

Living with advanced incurable cervical cancer is associated with significant disruptions in all domains of life. Good palliative care enables patients to achieve an optimal quality life. Poverty and a lack of knowledge about cervical cancer among women and health workers are the strongest predictors of a patient receiving a late advanced diagnosis.

Meeting the Global Need for Radiation Therapy in Cervical Cancer-An Overview

Cervical cancer is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women. The discrepancy in cervical cancer incidence and mortality between developed and developing nations has become increasingly apparent with 84% of the incidence and 88% of the mortality of cervical cancer occurring in low income countries. Access to comprehensive cancer care is a challenge and in particular the radiotherapy facilities. The radiotherapy infrastructure requirement is grossly inadequate with only 30% of the needs available and is even worst in LIC's with only 3% facilities. Additionally, lack of brachytherapy facilities and expertise in LIC's and LMIC's compounds the issue further. Even with continued HPV vaccination programs, there will still be a substantial burden of cervical cancer patients for treatment. Introspection and review in international and national policies, augmentation of (i) infrastructure - affordable & sustainable, (ii) manpower and rigorous training in accessible regions would be vital. International and National collaborative efforts among global organizations and societies, periodic peer reviews, resource stratified treatment guidelines and research, and health education would contribute further to women health. The amalgamation of palliative and hospice care services and radiotherapy facilities seamlessly would be a major step for comprehensive management of cervical cancer patients.

Long Noncoding RNA LINC00899/miR-944/ESR1 Axis Regulates Cervical Cancer Cell Proliferation, Migration, and Invasion

Cervical cancer (CC) is a common malignancy in women. Long noncoding RNA LINC00899 plays a role in cancer, but its effects in CC are unknown. Our experiment aims to investigate the specific effects of LINC00899 in CC. LINC00899 was lowly expressed in CC tissues and cells, and overexpressed LINC0089 inhibited the viability, proliferation, migration, and invasion of CC cells, whereas silencing of LINC00899 had the opposite effect. There is a targeting relationship between LINC0089 and miR-944. It was found that miR-944 could competitively bind with LINC00899, and LINC00899 in turn, could downregulate expression of miR-944. Moreover, estrogen receptor 1 (ESR1) was the target gene of miR-944. Overexpressed miR-944 inhibited ESR1 expression, yet enhanced the migration and invasion of CC cells and promoted the expression levels of N-cadherin and Vimentin while inhibiting the expression of E-cadherin. However, overexpressed ESR1 reversed the effect of miR-944 overexpression on CC cells. LINC00899/miR-944/ESR1 axis regulates the proliferation, migration, and invasion of CC cells by regulating the expression levels of related proteins.

Surgical candidacy and treatment initiation among women with cervical cancer at public referral hospitals in Kampala, Uganda: a descriptive cohort study

OBJECTIVES

This study aimed to report the proportion of women with a new diagnosis of cervical cancer recommended for curative hysterectomy as well as associated factors. We also report recommended treatments by stage and patterns of treatment initiation.

DESIGN

This was an observational cohort study. Inperson surveys were followed by a phone call.

SETTING

Participants were recruited at the two public tertiary care referral hospitals in Kampala, Uganda.

PARTICIPANTS

Adult women with a new diagnosis of cervical cancer were eligible: 332 were invited to participate, 268 met the criteria and enrolled, and 255 completed both surveys.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The primary outcome of interest was surgical candidacy; a secondary outcome was treatment initiation. Descriptive and multivariate statistical analyses examined the associations between predictors and outcomes. Sensitivity analyses were performed to examine outcomes in subgroups, including stage and availability of radiation.

RESULTS

Among 268 participants, 76% were diagnosed at an advanced stage (IIB-IVB). In total, 12% were recommended for hysterectomy. In adjusted analysis, living within 15 km of Kampala (OR 3.10, 95% CI 1.20 to 8.03) and prior screening (OR 2.89, 95% CI 1.22 to 6.83) were significantly associated with surgical candidacy. Radiotherapy availability was not significantly associated with treatment recommendations for early-stage disease (IA-IIA), but was associated with recommended treatment modality (chemoradiation vs primary chemotherapy) for locally advanced stage (IIB-IIIB). Most (67%) had started treatment. No demographic or health factor, treatment recommendation, or radiation availability was associated with treatment initiation. Among those recommended for hysterectomy, 55% underwent surgery. Among those who had initiated treatment, 82% started the modality that was recommended.

CONCLUSION

Women presented to public referral centres in Kampala with mostly advanced-stage cervical cancer and few were recommended for surgery. Most were able to initiate treatment. Lack of access to radiation did not significantly increase the proportion of early-stage cancers recommended for hysterectomy.

Perceptions of key informants on the provision of cervical cancer prevention and control programme in Uganda: implication for cervical cancer policy

Background

Uganda has one of the highest burdens of cervical cancer globally. In 2010 the Ugandan Ministry of Health launched the Strategic Plan for Cervical Cancer Prevention and Control with the hope of developing cervical cancer policy in Uganda. This study explored the beliefs of senior key informants in Uganda about cervical cancer prevention, the control programme, and the relevance of cervical cancer policy.

Methods

We conducted 15 key informant interviews with participants from six organisations across Northern and Central Uganda. Participants were drawn from district local government health departments, St. Mary’s Hospital Lacor, Uganda Nurses and Midwifery Council, non-governmental organisations (NGOs) and Ministry of Health in Kampala, Uganda. The interview recordings were transcribed and analysed using thematic analysis.

Results

Seven themes emerged relating to the cervical cancer prevention and control programmes in Uganda: (1) policy frameworks for cervical cancer, (2) operationalising cervical cancer prevention and control, (3) financial allocation and alignment, (4) human resources and capability, (5) essential supplies and vaccines, (6) administrative data and resource distribution, and (7) cervical cancer services.

Conclusions

The key informants perceive that the lack of a cervical cancer policy in Uganda is hindering cervical cancer prevention and control programmes. Therefore, the Ministry of Health and stakeholders need to work together in coming up with an effective policy framework that will accelerate efforts towards cervical cancer prevention and control in Uganda.

Cervical cancer in low and middle-income countries

Cervical cancer is a malignant tumour that occurs in the cervix and is classified into two histological types, adenocarcinoma and squamous cell carcinoma (SCC); SCC is more common and accounts for 70% of all cases. In 2018 there were ~569,000 new cases of cervical cancer diagnosed worldwide and ~311,000 deaths were attributed to cervical cancer. Of these, between 84 and 90% occurred in low- and middle-income countries (LMICs) such as South Africa, India, China and Brazil. The most common cause of cervical cancer is persistent infection caused by the sexually transmitted human papilloma virus. Other factors that contribute to the incidence of cervical cancer include geography, traditional practices and beliefs, the screening levels, socioeconomic status, healthcare access, public awareness, use of oral contraceptives, smoking and co-infection with HIV. An estimated 11 million women from LMICs will be diagnosed with cervical cancer in the next 10-20 years. The aim of this review was to explore various types of genetic and epigenetic factors that influence the development, progression or suppression of cervical cancer.