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Sultanov M, van der Schans J, Koot JA, Greuter MJ, de Zeeuw J, Nakisige C, Beltman JJ, de Fouw M, Stekelenburg J, de Bock GH. Early evaluation of a screen-and-treat strategy using high-risk HPV testing for Uganda: Implications for screening coverage and treatment. J Glob Health 2024; 14:04157. [PMID: 39302149 DOI: 10.7189/jogh.14.04157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2024] Open
Abstract
Background Uganda has a high burden of cervical cancer and its current coverage of screening based on visual inspection with acetic acid (VIA) is low. High-risk HPV (hrHPV) testing is recommended by the World Health Organization as part of the global elimination strategy for cervical cancer. In this context, country-specific health economic evaluations can inform national-level decisions regarding implementation. We evaluated the recommended hrHPV screen-and-treat strategy to determine the minimum required levels of coverage and treatment adherence, as well as the maximum price level per test, for the strategy to be cost-effective in Uganda. Methods We conducted a headroom analysis to estimate potential room for spending on implementing the hrHPV screen-and-treat strategy at different levels of coverage and treatment adherence (from 10% to 100%) at each screening round, and at different price levels of the hrHPV test. We compared the strategy with the existing VIA-based screen-and-treat policy in Uganda. We calculated headroom as the product of number of life years gained by the strategy and the willingness-to-pay threshold, minus the incremental costs incurred by the strategy. Positive headroom was interpreted as an indication of cost-effectiveness. Results Compared with VIA-based screening with low 5% coverage, the hrHPV screen-and-treat strategy required at least 30% coverage and adherence for positive mean headroom, and compared with 30% VIA-based screening coverage, the minimum levels were 60%. At 60% coverage and adherence, the maximum acceptable price per hrHPV test was found to be between 15 and 30 international dollars. Conclusions The hrHPV-based screen-and-treat strategy could be cost-effective in Uganda if the screening coverage and treatment adherence are at least 30% in each screening round, and if the price per test is set below 30 international dollars. The minimum required levels of screening coverage and adherence to treatment provide potential starting points for decision-makers in planning the rollout of hrHPV testing. The headroom estimates can guide the planning costs of screening infrastructure and campaigns to achieve the required coverage and treatment adherence in Uganda.
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Affiliation(s)
- Marat Sultanov
- Global Health Unit, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jurjen van der Schans
- Global Health Unit, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Economics, Econometrics and Finance, Faculty of Economics and Business, University of Groningen, Groningen, Netherlands
| | - Jaap Ar Koot
- Global Health Unit, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Marcel Jw Greuter
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Janine de Zeeuw
- Global Health Unit, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | | | - Jogchum J Beltman
- Department of Gynecology, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Marlieke de Fouw
- Department of Gynecology, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Jelle Stekelenburg
- Global Health Unit, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Geertruida H de Bock
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Vahabi M, Mishra G, Pimple S, Wong JPH, Khan M, Prakash V, Anand K, Narushima M, Lofters AK. Effectiveness of family-centred sexual health education and HPV self-sampling in promoting cervical cancer screening among hard-to-reach indian women in rural and tribal areas: a community-based pilot study. BMC Public Health 2023; 23:671. [PMID: 37041530 PMCID: PMC10088194 DOI: 10.1186/s12889-023-15602-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/04/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND While cervical cancer deaths have declined steeply in high-income countries due to the widespread use of the Papanicolaou test (Pap test), the same trend has not emerged in low or middle-income countries (LMICs). Access to screening in LMICs like India is limited due to barriers such as limited healthcare infrastructures, lack of sexual health education, and stigma demarcating sexually transmitted infections (STIs). HPV self-sampling (HPV-SS), a woman-centered and at-home method for screening, can be utilized as a unique screening tool to overcome some of these barriers. Our study examined the effectiveness of HPV-SS, supported by family-centred arts-based sexual health literacy on the uptake of cervical cancer screening among hard-to-reach women in rural and remote areas in India. METHODS Our community-based mixed methods pilot study recruited 240 participants (120 women and 120 male partners or family members) through female Accredited Social Health Activists (ASHA) across 3 Indian villages of Shirgoan, Khodala, and Jamsar in Palghar district. Inclusion criteria included women ages 30-69 who were under or never screened (UNS) and their male partners/family members aged 18 or over. Knowledge and attitudes about cervical cancer and screening and their perceived stigma surrounding STI were assessed using validated scales prior to and after attending a 2-hour arts-based sexual health education (SHE). In addition, participants' uptake of cervical cancer screening was assessed after attendance in SHE. FINDINGS Results revealed significant improvement in knowledge and attitudes about cervical cancer and screening, and a reduction in the STI stigma after participation in SHE sessions (overall mean difference in Knowledge: z = 6.1 ± 2.4, P < 0.001; attitudes about Pap-test and VIA: z = 2.2 ± 8.4, P < 0.001 and z = 2.9 ± 8.2, P < 0.001; STI stigma: z = 2.8 ± 12.4, P < 0.001). 118 out of 120 female participants chose to be screened and 115 opted for HPV-SS. CONCLUSIONS The implementation of HPV-SS coupled with family-centered arts-based and culturally appropriate SHE is highly promising in promoting cervical cancer screening among hard-to-reach women. Evidence from our study can be used to advance public health policies and inform the scale-up of similar initiatives in other villages and states across rural India and other LMICs.
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Affiliation(s)
- Mandana Vahabi
- Daphne Cockwell School of Nursing, Ryerson University, 4 Josephine Pui-Hing Wong, 350 Victoria Street, M5B 2K3, Toronto, ON, Canada.
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
| | - Gauravi Mishra
- Department of Preventive Oncology, Centre for Cancer Epidemiology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), R. No. 314, 3rd Floor, Service Block, E Borges Marg, Mumbai, 400012, Maharashtra, India
| | - Sharmila Pimple
- Department of Preventive Oncology, Centre for Cancer Epidemiology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), R. No. 314, 3rd Floor, Service Block, E Borges Marg, Mumbai, 400012, Maharashtra, India
| | - Josephine Pui-Hing Wong
- Daphne Cockwell School of Nursing, Ryerson University, 4 Josephine Pui-Hing Wong, 350 Victoria Street, M5B 2K3, Toronto, ON, Canada
- Dalla Lana School of Public Health (Cross-appointed), University of Toronto, Toronto, ON, Canada
| | - Momina Khan
- Daphne Cockwell School of Nursing, Ryerson University, 4 Josephine Pui-Hing Wong, 350 Victoria Street, M5B 2K3, Toronto, ON, Canada
| | - Vijayshree Prakash
- Daphne Cockwell School of Nursing, Ryerson University, 4 Josephine Pui-Hing Wong, 350 Victoria Street, M5B 2K3, Toronto, ON, Canada
| | - Kavita Anand
- Department of Preventive Oncology, Centre for Cancer Epidemiology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), R. No. 314, 3rd Floor, Service Block, E Borges Marg, Mumbai, 400012, Maharashtra, India
| | | | - Aisha K Lofters
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Department of Family & Community Medicine, University of Toronto, St. Catharines, Canada
- Women's College Hospital Research Institute, Peter Gilgan Centre for Women's Cancers, Toronto, Canada
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3
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Joseph J, Demke O, Ameyan L, Bitilinyu-Bango J, Bourgoin B, Diop M, Guèye B, Kama J, Lubega M, Madzima B, Maparo T, Mhizha T, Musoke A, Nabadda S, Phiri T, Tchereni T, Wiwa O, Hariharan K, Peter T, Khan S. Human papillomavirus testing using existing nucleic acid testing platforms to screen women for cervical cancer: implementation studies from five sub-Saharan African countries. BMJ Open 2023; 13:e065074. [PMID: 36609331 PMCID: PMC9827237 DOI: 10.1136/bmjopen-2022-065074] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 12/02/2022] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To demonstrate acceptability and operational feasibility of introducing human papillomavirus (HPV) testing as a principal cervical cancer screening method in public health programmes in sub-Saharan Africa. SETTING 45 primary and secondary health clinics in Malawi, Nigeria, Senegal, Uganda and Zimbabwe. PARTICIPANTS 15 766 women aged 25-54 years presenting at outpatient departments (Senegal only, general population) or at antiretroviral therapy clinics (all other countries, HIV-positive women only). Eligibility criteria followed national guidelines for cervical cancer screening. INTERVENTIONS HPV testing was offered to eligible women as a primary screening for cervical cancer, and HPV-positive women were referred for visual inspection with acetic acid (VIA), and if lesions identified, received treatment or referral. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcomes were the proportion of HPV-positive women who received results and linked to VIA and the proportion of HPV-positive and VIA-positive women who received treatment. RESULTS A total of 15 766 women were screened and tested for HPV, among whom 14 564 (92%) had valid results and 4710/14 564 (32%) were HPV positive. 13 837 (95%) of valid results were returned to the clinic and 3376 (72%) of HPV-positive women received results. Of women receiving VIA (n=2735), 715 (26%) were VIA-positive and 622 (87%) received treatment, 75% on the same day as VIA. CONCLUSIONS HPV testing was found to be feasible across the five study countries in a public health setting, although attrition was seen at several key points in the cascade of care, namely results return to women and linkage to VIA. Once women received VIA, if eligible, the availability of on-site cryotherapy and thermal ablation allowed for same-day treatment. With sufficient resources and supportive infrastructure to ensure linkage to treatment, use of HPV testing for cervical cancer screening as recommended by WHO is a promising model in low-income and middle-income countries.
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Affiliation(s)
- Jessica Joseph
- Global Health Sciences, Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Owen Demke
- Global Diagnostics Team, Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Lola Ameyan
- Cervical Cancer, Clinton Health Access Initiative, Abuja, Nigeria
| | | | | | - Mamadou Diop
- Cancer Institute of Cheikh Anta Diop University, Aristide Le Dantec Hospital, Dakar, Senegal
| | - Babacar Guèye
- Disease Control, Ministère de la Santé et de l'Action Sociale, Dakar, Senegal
| | - Jibrin Kama
- Laboratory Access Program, Clinton Health Access Initiative, Abuja, Nigeria
| | - Marvin Lubega
- Laboratory Access Program, Clinton Health Access Initiative, Kampala, Uganda
| | - Bernard Madzima
- Family Health, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Tatenda Maparo
- Laboratory Access Program, Clinton Health Access Initiative, Harare, Zimbabwe
| | - Tasimba Mhizha
- Laboratory Access Program, Clinton Health Access Initiative, Harare, Zimbabwe
| | | | - Susan Nabadda
- National Health Laboratory and Diagnostic Services, Ministry of Health, Kampala, Uganda
| | | | - Timothy Tchereni
- Sexual, Reproductive, Maternal and Newborn Health, Clinton Health Access Initiative, Lilongwe, Malawi
| | - Owens Wiwa
- Clinton Health Access Initiative, Abuja, Nigeria
| | - Karen Hariharan
- Global Cervical Cancer and Nutrition, Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Trevor Peter
- Global Diagnostics Team, Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Shaukat Khan
- Global Diagnostics Team, Clinton Health Access Initiative, Boston, Massachusetts, USA
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Herrick T, Thomson KA, Shin M, Gannon S, Tsu V, de Sanjosé S. Acting on the call for cervical cancer elimination: Planning tools for low- and middle- income countries to increase the coverage and effectiveness of screening and treatment. BMC Health Serv Res 2022; 22:1246. [PMID: 36241993 PMCID: PMC9563118 DOI: 10.1186/s12913-022-08423-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 08/04/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Accessible planning tools tailored for low-and middle-income countries can assist decision makers in comparing implementation of different cervical cancer screening approaches and treatment delivery scenarios in settings with high cervical cancer burden. Methods The Cervical Precancer Planning Tool (CPPT) was developed by PATH for users to explore and compare the accuracy of screening approaches, what treatment equipment to procure, and how best to deploy treatment equipment in a given country. The CPPT compares four screening approaches: 1) visual inspection with acetic acid (VIA), 2) HPV testing, 3) HPV testing followed by a VIA triage, and 4) HPV testing followed by an enhanced triage test. Accuracy of screening outcomes (e.g., true positives, false positives) is based on published sensitivity and specificity of tests to detect cervical precancerous lesions. The CPPT compares five scenarios for deploying ablative treatment equipment: 1) cervical precancer equipment at every location a woman is screened (single visit approach), 2) equipment only at a hospital level, 3) a single unit of equipment in each district, 4) allowing two districts to share a single unit of equipment, and 5) equipment placed at select district hospitals paired with mobile outreach. Users can customize the CPPT by adjusting pre-populated baseline values and assumptions, including population estimates, screening age range, screening frequency, HPV and HIV prevalence, supply costs, and health facility details. Results The CPPT generates data tables and graphs that compare the results of implementing each of the four screening and five treatment scenarios disaggregated by HIV status. Outputs include the number and outcomes of women screened, cost of each screening approach, provider time and cost saved by implementing self-sampling for HPV testing, number of women treated, treatment equipment needed by type, and the financial and economic costs for each equipment deployment scenario. Conclusion The CPPT provides practical information and data to compare tradeoffs of patient access and screening accuracy as well as efficient utilization of equipment, skilled personnel, and financial resources. Country decision makers can use outputs from the CPPT to guide the scale-up of cervical cancer screening and treatment while optimizing limited resources.
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Affiliation(s)
- Tara Herrick
- Market Dynamics, PATH, 2201, Westlake Ave Suite 200, Seattle, WA, 98121, USA.
| | - Kerry A Thomson
- Sexual and Reproductive Health Program, PATH, 2201 Westlake Ave, Suite 200, Seattle, WA, 98121, USA.
| | - Michelle Shin
- Department of Global Health, University of Washington, Seattle, USA
| | - Sarah Gannon
- Market Dynamics, PATH, 2201, Westlake Ave Suite 200, Seattle, WA, 98121, USA
| | - Vivien Tsu
- Department of Global Health, University of Washington, Seattle, USA
| | - Silvia de Sanjosé
- Sexual and Reproductive Health Program, PATH, 2201 Westlake Ave, Suite 200, Seattle, WA, 98121, USA
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5
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Shastri SS, Temin S, Almonte M, Basu P, Campos NG, Gravitt PE, Gupta V, Lombe DC, Murillo R, Nakisige C, Ogilvie G, Pinder LF, Poli UR, Qiao Y, Woo YL, Jeronimo J. Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Guideline Update. JCO Glob Oncol 2022; 8:e2200217. [PMID: 36162041 PMCID: PMC9812449 DOI: 10.1200/go.22.00217] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To update resource-stratified, evidence-based recommendations on secondary prevention of cervical cancer globally. METHODS American Society of Clinical Oncology convened a multidisciplinary, multinational Expert Panel to produce recommendations reflecting four resource-tiered settings. A review of existing guidelines, formal consensus-based process, and modified ADAPTE process to adapt existing guidelines was conducted. Other experts participated in formal consensus. RESULTS This guideline update reflects changes in evidence since the previous update. Five existing guidelines were identified and reviewed, and adapted recommendations form the evidence base. Cost-effectiveness analyses provided indirect evidence to inform consensus, which resulted in ≥ 75% agreement. RECOMMENDATIONS Human papillomavirus (HPV) DNA testing is recommended in all resource settings; visual inspection with acetic acid may be used in basic settings. Recommended age ranges and frequencies vary by the following setting: maximal: age 25-65 years, every 5 years; enhanced: age 30-65 years, if two consecutive negative tests at 5-year intervals, then every 10 years; limited: age 30-49 years, every 10 years; basic: age 30-49 years, one to three times per lifetime. For basic settings, visual assessment is used to determine treatment eligibility; in other settings, genotyping with cytology or cytology alone is used to determine treatment. For basic settings, treatment is recommended if abnormal triage results are obtained; in other settings, abnormal triage results followed by colposcopy is recommended. For basic settings, treatment options are thermal ablation or loop electrosurgical excision procedure; for other settings, loop electrosurgical excision procedure or ablation is recommended; with a 12-month follow-up in all settings. Women who are HIV-positive should be screened with HPV testing after diagnosis, twice as many times per lifetime as the general population. Screening is recommended at 6 weeks postpartum in basic settings; in other settings, screening is recommended at 6 months. In basic settings without mass screening, infrastructure for HPV testing, diagnosis, and treatment should be developed.Additional information is available at www.asco.org/resource-stratified-guidelines.
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Affiliation(s)
| | - Sarah Temin
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | - Nicole G Campos
- Harvard University T.H. Chan School of Public Health, Boston, MA
| | | | | | - Dorothy C Lombe
- Regional Cancer Treatment Services, MidCentral District Health Board, Palmerston North, New Zealand
| | | | | | | | | | - Usha R Poli
- India Institute of Public Health, Hyderabad, India
| | - Youlin Qiao
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Nguyen DTN, Simms KT, Keane A, Mola G, Bolnga JW, Kuk J, Toliman PJ, Badman SG, Saville M, Kaldor J, Vallely A, Canfell K. Towards the elimination of cervical cancer in low-income and lower-middle-income countries: modelled evaluation of the effectiveness and cost-effectiveness of point-of-care HPV self-collected screening and treatment in Papua New Guinea. BMJ Glob Health 2022; 7:bmjgh-2021-007380. [PMID: 35241461 PMCID: PMC8896000 DOI: 10.1136/bmjgh-2021-007380] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/23/2021] [Indexed: 01/22/2023] Open
Abstract
Introduction WHO has launched updated cervical screening guidelines, including provisions for primary HPV screen-and-treat. Papua New Guinea (PNG) has a high burden of cervical cancer, but no national cervical screening programme. We recently completed the first field trials of a screen-and-treat algorithm using point-of-care self-collected HPV and same-day treatment (hereafter self-collected HPV S&T) and showed this had superior clinical performance and acceptability to visual inspection of the cervix with acetic acid (VIA). We, therefore, evaluated the effectiveness, cost-effectiveness and resource implications of a national cervical screening programme using self-collected HPV S&T compared with VIA in PNG. Methods An extensively validated platform (‘Policy1-Cervix’) was calibrated to PNG. A total of 38 strategies were selected for investigation, and these incorporated variations in age ranges and screening frequencies and allowed for the identification of the optimal strategy across a wide range of possibilities. A selection of strategies that were identified as being the most effective and cost-effective were then selected for further investigation for longer-term outcomes and budget impact estimation. In the base case, we assumed primary HPV testing has a sensitivity to cervical intraepithelial neoplasia 2 (CIN2+) + of 91.8% and primary VIA of 51.5% based on our earlier field evaluation combined with evidence from the literature. We conservatively assumed HPV sampling and testing would cost US$18. Costs were estimated from a service provider perspective based on data from local field trials and local consultation. Results Self-collected HPV S&T was more effective and more cost-effective than VIA. Either twice or thrice lifetime self-collected HPV S&T would be cost-effective at 0.5× gross domestic product (GDP) per capita (incremental cost-effectiveness ratio: US$460–US$656/life-years saved; 1GDPper-capita: US$2829 or PGK9446 (year 2019)) and could prevent 33 000–42 000 cases and 23 000–29 000 deaths in PNG over the next 50 years, if scale-up reached 70% coverage from 2023. Conclusion Self-collected HPV S&T was effective and cost-effective in the high-burden, low-resource setting of PNG, and, if scaled-up rapidly, could prevent over 20 000 deaths over the next 50 years. VIA screening was not effective or cost-effective. These findings support, at a country level, WHO updated cervical screening guidelines and indicate that similar approaches could be appropriate for other low-resource settings.
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Affiliation(s)
| | - Kate T Simms
- Daffodil Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Adam Keane
- Daffodil Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Glen Mola
- Department of Reproductive Health, Obstetrics and Gynecology, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, CND, Papua New Guinea.,Department of Obstetrics and Gynecology, Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | - John Walpe Bolnga
- Department of Obstetrics and Gynecology, Modilion Hospital, Mango, Madang, Papua New Guinea
| | - Joseph Kuk
- Department of Obstetrics and Gynecology, Mt Hagen Provincial Hospital, Mt Hagen, Western Highlands Province, Papua New Guinea
| | - Pamela J Toliman
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Steven G Badman
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Marion Saville
- Australian Centre for the Prevention of Cervical Cancer, Melbourne, Victoria, Australia
| | - John Kaldor
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Vallely
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Karen Canfell
- Daffodil Centre, The University of Sydney, Sydney, New South Wales, Australia
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Torres KL, Rondon HHDMF, Martins TR, Martins S, Ribeiro A, Raiol T, Marques CP, Corrêa F, Migowski A, Minuzzi-Souza TTCE, Schiffman M, Rodriguez AC, Gage JC. Moving towards a strategy to accelerate cervical cancer elimination in a high-burden city-Lessons learned from the Amazon city of Manaus, Brazil. PLoS One 2021; 16:e0258539. [PMID: 34662368 PMCID: PMC8523067 DOI: 10.1371/journal.pone.0258539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 09/29/2021] [Indexed: 11/19/2022] Open
Abstract
The World Health Organization Call to Eliminate Cervical Cancer resonates in cities like Manaus, Brazil, where the burden is among the world's highest. Manaus has offered free cytology-based screening since 1990 and HPV immunization since 2013, but the public system is constrained by many challenges and performance is not well-defined. We obtained cervical cancer prevention activities within Manaus public health records for 2019 to evaluate immunization and screening coverage, screening by region and neighborhood, and the annual Pink October screening campaign. We estimated that among girls and boys age 14-18, 85.9% and 64.9% had 1+ doses of HPV vaccine, higher than rates for age 9-13 (73.4% and 43.3%, respectively). Of the 90,209 cytology tests performed, 24.9% were outside the target age and the remaining 72,230 corresponded to 40.1% of the target population (one-third of women age 25-64). The East zone had highest screening coverage (49.1%), highest high-grade cytology rate (2.5%) and lowest estimated cancers (38.1/100,000) compared with the South zone (32.9%, 1.8% and 48.5/100,000, respectively). Largest neighborhoods had fewer per capita screening locations, resulting in lower coverage. During October, some clinics successfully achieved higher screening volumes and high-grade cytology rates (up to 15.4%). Although we found evidence of some follow-up within 10 months post-screening for 51/70 women (72.9%) with high-grade or worse cytology, only 18 had complete work-up confirmed. Manaus has successfully initiated HPV vaccination, forecasting substantial cervical cancer reductions by 2050. With concerted efforts during campaigns, some clinics improved screening coverage and reached high-risk women. Screening campaigns in community locations in high-risk neighborhoods using self-collected HPV testing can achieve widespread coverage. Simplifying triage and treatment with fewer visits closer to communities would greatly improve follow-up and program effectiveness. Achieving WHO Cervical Cancer Elimination goals in high-burden cities will require major reforms for screening and simpler follow-up and treatment.
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Affiliation(s)
- Kátia Luz Torres
- Amazon State Oncology Control Foundation (FCECON), Manaus, Amazonas, Brazil
- Post Graduation Program in Health Sciences and Basic and Applied Immunology at The Federal University of Amazonas (UFAM), Manaus, Amazonas, Brazil
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
| | - Heidy Halanna de Melo Farah Rondon
- Post Graduation Program in Health Sciences and Basic and Applied Immunology at The Federal University of Amazonas (UFAM), Manaus, Amazonas, Brazil
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
| | - Toni Ricardo Martins
- Tropical Medicine Institute, São Paulo University, Virology Laboratory (LIM52) (USP-SP) - São Paulo, São Paulo, Brazil
| | - Sandro Martins
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
| | - Ana Ribeiro
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
- Department of Pharmacy, Faculty of Health Sciences, University of Brasília (UNB), Brasília, Federal District, Brazil
| | - Taina Raiol
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
| | - Carla Pintas Marques
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
- Collective Health, Universidade de Brasília (UnB), Brasília, Federal District, Brazil
| | - Flavia Corrêa
- Cancer Early Detection Division, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Arn Migowski
- Cancer Early Detection Division, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Thais Tâmara Castro e Minuzzi-Souza
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
- National Immunization Program, Health Surveillance Secretariat (SVS), Ministry of Health, Brasília, Federal District, Brazil
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland, United States of America
| | - Ana Cecilia Rodriguez
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland, United States of America
| | - Julia C. Gage
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland, United States of America
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8
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Mremi A, Linde DS, Mchome B, Mlay J, Schledermann D, Blaakaer J, Rasch V. Acceptability and feasibility of self-sampling and follow-up attendance after text message delivery of human papillomavirus results: A cross-sectional study nested in a cohort in rural Tanzania. Acta Obstet Gynecol Scand 2021; 100:802-810. [PMID: 33555038 DOI: 10.1111/aogs.14117] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The objective was to determine if self-collection of vaginal samples for human papillomavirus (HPV) testing was acceptable and feasible in rural Tanzania and to assess the extent of attendance at a follow-up appointment among women who tested HPV-positive after delivery of HPV results via text messages. MATERIAL AND METHODS A combined cross-sectional and cohort study was conducted among women aged 25-60 years from rural Kilimanjaro, Tanzania. Women were offered HPV self-sampling or traditional visual inspection of the cervix with acetic acid. If HPV self-sampling was preferred, participants received instructions on self-collection with an Evalyn Brush. A questionnaire was used to assess the acceptability and feasibility of the self-sampling procedure for the participants and delivery of HPV results via text messages. A mobile text message platform was used to send private text messages with the screening results to the participants. RESULTS A total of 1108 women were enrolled and self-collected an HPV sample; 11.8% tested positive for high-risk HPV. The majority (98.9%) agreed that they had no trouble in understanding the instructions on how to perform the self-collection and that they would recommend it to a friend (94.5%) or as a standard screening method in Tanzania (95.5%). A minority of women experienced bleeding (2.4%) or pain (6%) while collecting the sample, while some were worried that they would get hurt (12.7%) or felt embarrassed (3.5%). The majority (98.4%) of women would like to receive the screening test results via text messages. Eighty-two per cent of those who tested positive for high-risk HPV attended the follow-up appointment after receiving a text message reminder and an additional 16% attended after receiving both a text message and a phone call reminder whereas 2% did not attend follow up at all. Attendance was not influenced by age, marital status, education level, parity, or HIV status. CONCLUSIONS Human papillomavirus self-sampling and text-message feedback delivery are generally well-perceived and accepted among rural Tanzanian women, and the majority of HPV-positive women attended a follow-up appointment after receiving their HPV results and follow-up appointment via text messages. This screening method may have potential to be transferrable to other low-income countries with a high incidence of cervical cancer and so improve cervical cancer screening attendances.
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Affiliation(s)
- Alex Mremi
- Department of Pathology, Kilimanjaro Christian Medical Center, Moshi, Tanzania.,Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Ditte S Linde
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark.,Odense Patient Data Explorative Network (OPEN, Odense University Hospital, Odense, Denmark.,Department of Public Health, University of Southern Denmark, Esbjerg, Denmark
| | - Bariki Mchome
- Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Joseph Mlay
- Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | - Jan Blaakaer
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - Vibeke Rasch
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
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Megersa BS, Bussmann H, Bärnighausen T, Muche AA, Alemu K, Deckert A. Community cervical cancer screening: Barriers to successful home-based HPV self-sampling in Dabat district, North Gondar, Ethiopia. A qualitative study. PLoS One 2020; 15:e0243036. [PMID: 33306681 PMCID: PMC7732077 DOI: 10.1371/journal.pone.0243036] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 11/15/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To explore the barriers to successful home-based human papillomavirus (HPV) self-sampling in North Gondar, Ethiopia. METHODS The study participants were women who had previously participated in a community-wide home-based HPV self-sampling pilot study, community health workers, women's development army leaders, and the sample collectors of the home-based HPV self-sampling pilot study. A community based qualitative descriptive study was conducted. We applied purposive and convenience sampling. In total, 47 women participated in the study (in-depth interviews n = 22, four focus group discussions n = 25, 6-7 participants each). The study employed thematic analysis for clustering the emerged themes. RESULTS Husband disapproval was identified as the main barrier to the acceptance of home-based HPV self-sampling. Social influence, lack of knowledge about cervical cancer and screening, lack of health education on cervical cancer and HPV-based screening, feeling healthy, and religious influence were identified as additional barriers. Fear of using Evalyn brush® for self-sampling was found to be the main barrier to the provision of a quality sample. The inability of the sample collectors to check the proper utilization of Evalyn brush® and the difficulty in understanding the instructions did also contribute to the low-quality. Providing health education concerning cervical cancer and HPV self-sapling to women, male involvement in the screening program, and linking the screening service to existing local health facilities were suggested to guarantee the success of home-based HPV self-sampling. CONCLUSIONS Educating women regarding cervical cancer and HPV testing, providing clear instructions on how to collect self-sample, and male involvement in the screening program are prerequisites for a successful implementation of home-based HPV testing. Women empowerment should also be focused to overcome the identified sociocultural barriers. Furthermore, the screening program should guarantee the timely provision of the test results and offering women follow-up examinations and treatment for abnormal findings.
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Affiliation(s)
- Bikila Soboka Megersa
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- * E-mail:
| | - Hermann Bussmann
- Department of Applied Tumor Biology, Institute of Pathology, Heidelberg University, Heidelberg, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Achenef Asmamaw Muche
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Kassahun Alemu
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Andreas Deckert
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
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10
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Jatho A, Tran BT, Cambia JM, Nanyingi M, Mugisha NM. Cancer Risk Studies and Priority Areas for Cancer Risk Appraisal in Uganda. Ann Glob Health 2020; 86:78. [PMID: 32704483 PMCID: PMC7350938 DOI: 10.5334/aogh.2873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Research into aetiologies and prevention of the commonest cancers and implementation of primary and secondary prevention can reduce cancer risk and improve quality of life. Moreover, monitoring the prevalence of cancer risk factors in a specific population helps guide cancer prevention and early detection efforts and national cancer control programming. Objective This article aims to provide the scope and findings of cancer risk studies conducted in Uganda to guide researchers, health-care professionals, and policymakers. Methods Between November 2019 to January 2020, we searched peer-reviewed published articles in Pubmed, EMBASE and Cochrane Library (Cochrane central register of controlled trials-CENTRAL). We followed the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - the PRISMA. The primary focus was to identify cancer risk and prevention studies conducted in Uganda and published in peer-reviewed journals from January 2000 and January 2020. We used key Boolean search terms with their associated database strings. Results We identified 416 articles, screened 269 non-duplicate articles and obtained 77 full-text articles for review. Out of the 77 studies, we identified one (1%) randomized trial, two (2.5%) retrospective cohort studies and 14 (18%) case-control studies, 46 (60%) cross-sectional studies, five (6.4%) ecological studies, three panel studies (4%) and six (8%) qualitative studies. Cervical cancer was the most studied type of cancer in Uganda (23.4%, n = 18 studies), followed by lymphomas - both Hodgkin and Non-Hodgkin sub-types (20.7%), n = 16 studies) and breast cancer (15.6%, n = 12 studies). In lymphoma studies, Burkitt lymphoma was the most studied type of lymphoma (76%, n = 13 studies). The studies concentrated on specific cancer risk awareness, risk perceptions, attitudes, uptake of screening, uptake of human papillomavirus vaccination, the prevalence of some of the known cancer risk factors and obstacles to accessing screening services. Conclusion The unmet need for comprehensive cancer risk and prevention studies is enormous in Uganda. Future studies need to comprehensively investigate the known and putative cancer risk factors and prioritize the application of the higher-hierarchy evidence-generating epidemiological studies to guide planning of the national cancer control program.
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Affiliation(s)
- Alfred Jatho
- Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, KR
- Uganda Cancer Institute, Kampala, UG
| | - Binh Thang Tran
- Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, KR
- Institute of Research and Development, Duy Tan University, Da Nang, VN
| | - Jansen Marcos Cambia
- Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, KR
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Malone C, Barnabas RV, Buist DSM, Tiro JA, Winer RL. Cost-effectiveness studies of HPV self-sampling: A systematic review. Prev Med 2020; 132:105953. [PMID: 31911163 PMCID: PMC7219564 DOI: 10.1016/j.ypmed.2019.105953] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/06/2019] [Accepted: 12/16/2019] [Indexed: 02/06/2023]
Abstract
HPV self-sampling (HPV-SS) can increase cervical cancer screening participation by addressing barriers in high- and low- and middle-income settings. Successful implementation of HPV-SS programs will depend on understanding potential costs and health effects. Our objectives were to summarize the methods and results of published HPV-SS cost and cost-effectiveness studies, present implications of these results for HPV-SS program implementation, and identify knowledge gaps. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. One reviewer searched online databases for articles published through June 12, 2019, identified eligible studies, and extracted data; a second reviewer checked extracted data for accuracy. Eligible studies used an economic model to compare HPV-SS outreach strategies to standard-of-care tests. Of 16 eligible studies, 14 reported HPV-SS could be a cost-effective strategy. Studies differed in model type, HPV-SS delivery methods, triage strategies for positive results, and target populations. Most (9/16) modeled HPV-SS in European screening programs, 6/16 targeted women who were underscreened for cervical cancer, and 5/16 modeled HPV-SS in low- and middle-income countries. The most commonly identified driver of HPV-SS cost-effectiveness was the level of increase in cervical cancer screening attendance. Lower HPV-SS material and testing costs, higher sensitivity to detect cervical precancer, and longer duration of underscreening among HPV-SS users were also associated with increased cost-effectiveness. Future HPV-SS models in high-income settings should explore the effect of widespread vaccination and new triage strategies such as partial HPV genotyping. Knowledge gaps remain about the cost-effectiveness of HPV-SS in low- and middle-income settings.
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Affiliation(s)
- Colin Malone
- Department of Epidemiology, University of Washington, Box 359933, 325 9th Ave, Seattle, WA 98104, USA.
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Box 359931, 325 9th Ave, Seattle, WA 98104, USA.
| | - Diana S M Buist
- Kaiser Permanente Washington Health Research Institute,1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA.
| | - Jasmin A Tiro
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Rachel L Winer
- Department of Epidemiology, University of Washington, Box 359933, 325 9th Ave, Seattle, WA 98104, USA; Kaiser Permanente Washington Health Research Institute,1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA.
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12
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Campos NG, Alfaro K, Maza M, Sy S, Melendez M, Masch R, Soler M, Conzuelo-Rodriguez G, Gage JC, Alonzo TA, Castle PE, Felix JC, Cremer M, Kim JJ. The cost-effectiveness of human papillomavirus self-collection among cervical cancer screening non-attenders in El Salvador. Prev Med 2020; 131:105931. [PMID: 31765712 DOI: 10.1016/j.ypmed.2019.105931] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 01/17/2023]
Abstract
Cervical cancer screening with human papillomavirus (HPV) DNA testing has been incorporated into El Salvador's national guidelines. The feasibility of home-based HPV self-collection among women who do not attend screening at the clinic (i.e., non-attenders) has been demonstrated, but cost-effectiveness has not been evaluated. Using cost and compliance data from El Salvador, we informed a mathematical microsimulation model of HPV infection and cervical carcinogenesis to conduct a cost-effectiveness analysis from the societal perspective. We estimated the reduction in cervical cancer risk, lifetime cost per woman (2017 US$), life expectancy, and incremental cost-effectiveness ratio (ICER, 2017 US$ per year of life saved [YLS]) of a program with home-based self-collection of HPV (facilitated by health promoters) for the 18% of women reluctant to screen at the clinic. The model was calibrated to epidemiologic data from El Salvador. We evaluated health and economic outcomes of the self-collection intervention for women aged 30 to 59 years, alone and in concert with clinic-based HPV provider-collection. Home-based self-collection of HPV was projected to reduce population cervical cancer risk by 14% and cost $1210 per YLS compared to no screening. An integrated program reaching 99% coverage with both provider- and home-based self-collection of HPV reduced cancer risk by 74% (compared to no screening), and cost $1210 per YLS compared to provider-collection alone. Self-collection facilitated by health promoters is a cost-effective strategy for increasing screening uptake in El Salvador.
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Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA.
| | - Karla Alfaro
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Mauricio Maza
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Stephen Sy
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA
| | - Mario Melendez
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Rachel Masch
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Montserrat Soler
- Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | | | - Julia C Gage
- Department of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, USA
| | - Todd A Alonzo
- University of Southern California, 222 East Huntington Drive, Suite 100, Monrovia, CA 91016, USA
| | | | - Juan C Felix
- Department of Pathology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI, USA
| | - Miriam Cremer
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA; Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Jane J Kim
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA
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13
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Mezei AK, Pedersen HN, Sy S, Regan C, Mitchell-Foster SM, Byamugisha J, Sekikubo M, Armstrong H, Rawat A, Singer J, Ogilvie GS, Kim JJ, Campos NG. Community-based HPV self-collection versus visual inspection with acetic acid in Uganda: a cost-effectiveness analysis of the ASPIRE trial. BMJ Open 2018; 8:e020484. [PMID: 29895648 PMCID: PMC6009460 DOI: 10.1136/bmjopen-2017-020484] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 04/12/2018] [Accepted: 04/18/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cervical cancer is the leading cause of cancer death for women in Uganda, despite the potential for prevention through organised screening. Community-based self-collected human papillomavirus (HPV) testing has been proposed to reduce barriers to screening. OBJECTIVE Our objective was to evaluate the cost-effectiveness of the Advances in Screening and Prevention of Reproductive Cancers (ASPIRE) trial, conducted in Kisenyi, Uganda in April 2014 (n=500). The trial compared screening uptake and compliance with follow-up in two arms: (1) community-based (ie, home or workplace) self-collected HPV testing (facilitated by community health workers) with clinic-based visual inspection with acetic acid (VIA) triage of HPV-positive women ('HPV-VIA') and (2) clinic-based VIA ('VIA'). In both arms, VIA was performed at the local health unit by midwives with VIA-positive women receiving immediate treatment with cryotherapy. DESIGN We informed a Monte Carlo simulation model of HPV infection and cervical cancer with screening uptake, compliance and retrospective cost data from the ASPIRE trial; additional cost, test performance and treatment effectiveness data were drawn from observational studies. The model was used to assess the cost-effectiveness of each arm of ASPIRE, as well as an HPV screen-and-treat strategy ('HPV-ST') involving community-based self-collected HPV testing followed by treatment for all HPV-positive women at the clinic. OUTCOME MEASURES The primary outcomes were reductions in cervical cancer risk and incremental cost-effectiveness ratios (ICERs), expressed in dollars per year of life saved (YLS). RESULTS HPV-ST was the most effective and cost-effective screening strategy, reducing the lifetime absolute risk of cervical cancer from 4.2% (range: 3.8%-4.7%) to 3.5% (range: 3.2%-4%), 2.8% (range: 2.4%-3.1%) and 2.4% (range: 2.1%-2.7%) with ICERs of US$130 (US$110-US$150) per YLS, US$240 (US$210-US$280) per YLS, and US$470 (US$410-US$550) per YLS when performed one, three and five times per lifetime, respectively. Findings were robust across sensitivity analyses, unless HPV costs were more than quadrupled. CONCLUSIONS Community-based self-collected HPV testing followed by treatment for HPV-positive women has the potential to be an effective and cost-effective screening strategy.
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Affiliation(s)
- Alex K Mezei
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Heather N Pedersen
- Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Stephen Sy
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Catherine Regan
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Sheona M Mitchell-Foster
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda
- Department of Obstetrics and Gynecology, Mulago National Referral Hospital, Kampala, Uganda
| | - Musa Sekikubo
- Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda
- Department of Obstetrics and Gynecology, Mulago National Referral Hospital, Kampala, Uganda
| | - Heather Armstrong
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Angeli Rawat
- Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Gina S Ogilvie
- Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Jane J Kim
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nicole G Campos
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Campos NG, Tsu V, Jeronimo J, Mvundura M, Kim JJ. Evidence-based policy choices for efficient and equitable cervical cancer screening programs in low-resource settings. Cancer Med 2017; 6:2008-2014. [PMID: 28707435 PMCID: PMC5548874 DOI: 10.1002/cam4.1123] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 05/25/2017] [Indexed: 01/25/2023] Open
Abstract
Women in developing countries disproportionately bear the burden of cervical cancer. The availability of prophylactic vaccines against human papillomavirus (HPV) types 16 and 18, which cause approximately 70% of cervical cancers, provides reason for optimism as roll-out begins with support from Gavi, the Vaccine Alliance. However, for the hundreds of millions of women beyond the target age for HPV vaccination, cervical cancer screening to detect and treat precancerous lesions remains the only form of prevention. Here we describe the challenges that confront screening programs in low-resource settings, including (1) optimizing screening test effectiveness; (2) achieving high screening coverage of the target population; and (3) managing screen-positive women. For each of these challenges, we summarize the tradeoffs between resource utilization and programmatic attributes. We then highlight opportunities for efficient and equitable programming, with supporting evidence from recent mathematical modeling analyses informed by data from the PATH demonstration projects in India, Nicaragua, and Uganda.
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Affiliation(s)
- Nicole G. Campos
- Center for Health Decision ScienceHarvard T.H. Chan School of Public Health718 Huntington AvenueBostonMassachusetts
| | - Vivien Tsu
- PATHReproductive Health ProgramSeattleWashington
| | | | | | - Jane J. Kim
- Center for Health Decision ScienceHarvard T.H. Chan School of Public Health718 Huntington AvenueBostonMassachusetts
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