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Dykens JA, Smith JS, Demment M, Marshall E, Schuh T, Peters K, Irwin T, McIntosh S, Sy A, Dye T. Evaluating the implementation of cervical cancer screening programs in low-resource settings globally: a systematized review. Cancer Causes Control 2020; 31:417-429. [PMID: 32185604 PMCID: PMC7105425 DOI: 10.1007/s10552-020-01290-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 02/27/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Cervical cancer disproportionately burdens low-resource populations where access to quality screening services is limited. A greater understanding of sustainable approaches to implement cervical cancer screening services is needed. METHODS We conducted a systematized literature review of evaluations from cervical cancer screening programs implemented in resource-limited settings globally that included a formal evaluation and intention of program sustainment over time. We categorized the included studies using the continuum of implementation research framework which categorizes studies progressively from "implementation light" to more implementation intensive. RESULTS Fifty-one of 13,330 initially identified papers were reviewed with most study sites in low-resource settings of middle-income countries (94.1%) ,while 9.8% were in low-income countries. Across all studies, visual inspection of the cervix with acetic acid (58.8%) was the most prevalent screening method followed by cytology testing (39.2%). Demand-side (client and community) considerations were reported in 86.3% of the articles, while 68.6% focused scientific inquiry on the supply side (health service). Eighteen articles (35.3%) were categorized as "Informing Scale-up" along the continuum of implementation research. CONCLUSIONS The number of cervical cancer screening implementation reports is limited globally, especially in low-income countries. The 18 papers we classified as Informing Scale-up provide critical insights for developing programs relevant to implementation outcomes. We recommend that program managers report lessons learnt to build collective implementation knowledge for cervical cancer screening services, globally.
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Affiliation(s)
- J Andrew Dykens
- University of Illinois at Chicago College of Medicine, Chicago, IL, USA.
| | - Jennifer S Smith
- University of North Carolina School of Public Health, Chapel Hill, NC, USA
| | - Margaret Demment
- University of Rochester Department of Obstetrics and Gynecology, Rochester, NY, USA
| | - E Marshall
- University of Illinois at Chicago Institute for Health Research and Policy, Chicago, IL, USA
| | - Tina Schuh
- University of Illinois at Chicago Institute for Health Research and Policy, Chicago, IL, USA
| | - Karen Peters
- University of Illinois at Chicago Institute for Health Research and Policy, Chicago, IL, USA
| | - Tracy Irwin
- University of Washington Department of Obstetrics and Gynecology, Seattle, WA, USA
| | - Scott McIntosh
- University of Rochester Department of Public Health Sciences, Rochester, NY, USA
| | - Angela Sy
- University of Hawaii John A Burns School of Medicine, Honolulu, HI, USA
| | - Timothy Dye
- University of Rochester Department of Obstetrics and Gynecology, Rochester, NY, USA
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de Fouw M, Oosting RM, Rutgrink A, Dekkers OM, Peters AAW, Beltman JJ. A systematic review and meta-analysis of thermal coagulation compared with cryotherapy to treat precancerous cervical lesions in low- and middle-income countries. Int J Gynaecol Obstet 2019; 147:4-18. [PMID: 31273785 DOI: 10.1002/ijgo.12904] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 05/09/2019] [Accepted: 07/03/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Thermal coagulation is gaining popularity for treating cervical intraepithelial neoplasia (CIN) in screening programs in low- and middle-income countries (LMICs) due to unavailability of cryotherapy. OBJECTIVES Assess the effectiveness of thermal coagulation for treatment of CIN lesions compared with cryotherapy, with a focus on LMICs. SEARCH STRATEGY Papers were identified from previous reviews and electronic literature search in February 2018 with publication date after 2010. SELECTION CRITERIA Publications with original data evaluating cryotherapy or thermal coagulation with proportion of cure as outcome, assessed by colposcopy, biopsy, cytology, and/or visual inspection with acetic acid (VIA), and minimum 6 months follow-up. DATA COLLECTION AND ANALYSIS Pooled proportions of cure are presented stratified per treatment modality, type of lesion, and region. MAIN RESULTS Pooled cure proportions for cryotherapy and thermal coagulation, respectively, were 93.8% (95% CI, 88.5-97.7) and 91.4% (95% CI, 84.9-96.4) for CIN 1; 82.6% (95% CI, 77.4-87.3) and 91.6% (95% CI, 88.2-94.5) for CIN 2-3; and 92.8% (95% CI, 85.6-97.7) and 90.1% (95% CI, 87.0-92.8) for VIA-positive lesions. For thermal coagulation of CIN 2-3 lesions in LMICs 82.4% (95% CI, 75.4-88.6). CONCLUSIONS Both cryotherapy and thermal coagulation are effective treatment modalities for CIN lesions in LMICs.
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Affiliation(s)
- Marlieke de Fouw
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, Netherlands
| | - Roos Marieke Oosting
- Department of BioMechanical Engineering, Delft University of Technology, Delft, Netherlands
| | - Amy Rutgrink
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, Netherlands
| | - Olaf Matthijs Dekkers
- Department of Clinical Epidemiology and Endocrinology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Jogchum Jan Beltman
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, Netherlands
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Ouedraogo Y, Furlane G, Fruhauf T, Badolo O, Bonkoungou M, Pleah T, Lankoande J, Bicaba I, Bazant ES. Expanding the Single-Visit Approach for Cervical Cancer Prevention: Successes and Lessons From Burkina Faso. GLOBAL HEALTH: SCIENCE AND PRACTICE 2018; 6:288-298. [PMID: 29959272 PMCID: PMC6024624 DOI: 10.9745/ghsp-d-17-00326] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 01/09/2018] [Indexed: 01/13/2023]
Abstract
The single-visit approach was implemented with strong attention to systems in 14 health facilities. In the 2 largest facilities, nearly 14,000 women screened for cervical cancer over 4 years. Of approximately 9% who screened positive, about 66% received same-day cryotherapy. Attention is needed to ensure local technicians can repair cryotherapy equipment, supplies are consistently in stock, and user fees are not prohibitive to accessing care. Background: Cervical cancer accounts for 23% of cancer incidence and 22% of cancer mortality among women in Burkina Faso. These proportions are more than 2 and 5 times higher than those of developed countries, respectively. Before 2010, cervical cancer prevention (CECAP) services in Burkina Faso were limited to temporary screening campaigns. Program Description: Between September 2010 and August 2014, program implementers collaborated with the Ministry of Health and professional associations to implement a CECAP program focused on coupling visual inspection with acetic acid (VIA) for screening with same-day cryotherapy treatment for eligible women in 14 facilities. Women with larger lesions or lesions suspect for cancer were referred for loop electrosurgical excision procedure (LEEP). The program trained providers, raised awareness through demand generation activities, and strengthened monitoring capacity. Methods: Data on program activities, service provision, and programmatic lessons were analyzed. Three data collection tools, an individual client form, a client registry, and a monthly summary sheet, were used to track 3 key CECAP service indicators: number of women screened using VIA, proportion of women who screened VIA positive, and proportion of women screening VIA positive who received same-day cryotherapy. Results: Over 4 years, the program screened 13,999 women for cervical cancer using VIA; 8.9% screened positive; and 65.9% received cryotherapy in a single visit. The proportion receiving cryotherapy on the same day started at a high of 82% to 93% when services were provided free of charge, but dropped to 51% when a user fee of $10 was applied to cover the cost of supplies. After reducing the fee to $4 in November 2012, the proportion increased again to 78%. Implementation challenges included difficulties tracking referred patients, stock-outs of key supplies, difficulties with machine maintenance, and prohibitive user fees. Providers were trained to independently monitor services, identify gaps, and take corrective actions. Conclusions: Following dissemination of the results that demonstrated the acceptability and feasibility of the CECAP program, the Burkina Faso Ministry of Health included CECAP services in its minimum service delivery package in 2016. Essential components for such programs include provider training on VIA, cryotherapy, and LEEP; provider and patient demand generation; local equipment maintenance; consistent supply stocks; referral system for LEEP; non-prohibitive fees; and a monitoring data collection system.
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Affiliation(s)
| | | | | | | | | | | | - Jean Lankoande
- Société de Gynécologues et Obstétriciens du Burkina, Ouagadougou, Burkina Faso
| | - Isabelle Bicaba
- Ministère de la Santé du Burkina Faso, Ouagadougou, Burkina Faso
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An Insight Into Cervical Cancer Screening and Treatment Capacity in Sub Saharan Africa. J Low Genit Tract Dis 2016; 20:31-7. [PMID: 26579842 DOI: 10.1097/lgt.0000000000000165] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Approximately 85% of cervical cancer cases and deaths occur in resource-constrained countries where best practices for prevention, particularly for women with HIV infection, still need to be developed. The aim of this study was to assess cervical cancer prevention capacity in select HIV clinics located in resource-constrained countries. MATERIALS AND METHODS A cross-sectional survey of sub-Saharan African sites of 4 National Institutes of Health-funded HIV/AIDS networks was conducted. Sites were surveyed on the availability of cervical cancer screening and treatment among women with HIV infection and without HIV infection. Descriptive statistics and χ or Fisher exact test were used as appropriate. RESULTS Fifty-one (65%) of 78 sites responded. Access to cervical cancer screening was reported by 49 sites (96%). Of these sites, 39 (80%) performed screening on-site. Central African sites were less likely to have screening on-site (p = .02) versus other areas. Visual inspection with acetic acid and Pap testing were the most commonly available on-site screening methods at 31 (79%) and 26 (67%) sites, respectively. High-risk HPV testing was available at 29% of sites with visual inspection with acetic acid and 50% of sites with Pap testing. Cryotherapy and radical hysterectomy were the most commonly available on-site treatment methods for premalignant and malignant lesions at 29 (74%) and 18 (46%) sites, respectively. CONCLUSIONS Despite limited resources, most sites surveyed had the capacity to perform cervical cancer screening and treatment. The existing infrastructure of HIV clinical and research sites may provide the ideal framework for scale-up of cervical cancer prevention in resource-constrained countries with a high burden of cervical dysplasia.
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Mexican Cervical Cancer Screening Study II: 6-month and 2-year follow-up of HR-HPV women treated with cryotherapy in a low-resource setting. J Low Genit Tract Dis 2015; 18:333-7. [PMID: 24977628 DOI: 10.1097/lgt.0000000000000029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the efficacy and tolerance of cryotherapy in a visual inspection with acetic acid (VIA) triage protocol after primary human papillomavirus (HPV) screening in a low-resource setting. MATERIALS AND METHODS This continuous series conducted over 2 years enrolled nonpregnant, high-risk HPV (HR-HPV)-positive women between the ages of 30 and 50 years, who resided in the state of Michoacán, Mexico, and had a history of no Pap smear screening or knowledge of Pap smear results within the last 3 years. These women were initially enrolled in the Mexican Cervical Cancer Screening Study II (MECCS II) trial and were treated with cryotherapy after VIA triage. They subsequently followed up at 6 months and 2 years for repeat VIA, colposcopy, and biopsy. RESULTS A total of 291 women were treated with cryotherapy, of whom 226 (78%) followed up at 6 months. Of these 226 women, 153 (68%) were HR-HPV-negative; there were no findings of cervical intraepithelial neoplasia grade 2 (CIN2) or worse. The remaining 73 women (32%) were HR-HPV-positive; of these women, 2 had CIN2 and 3 had CIN3. Only 137 women followed up at 2 years. Of these 137 women, 116 were HR-HPV-negative and 21 were HR-HPV-positive. Of the 21 women positive for HR-HPV, 9 had negative biopsy results, 11 had CIN1, and 1 had no biopsy. The clearance rate of HR-HPV was 83% (95% confidence interval: 0.78-0.87). There were no biopsy findings of CIN2 or worse at 2 years. Before cryotherapy, of the 226 women, 15 (6.6%) were positive for endocervical curettage (ECC) and 5 (2.2%) were referred for surgical management. Of these 15 ECC-positive women, 10 (67%) followed up at 6 months and it was shown that no patient was ECC positive at that time point. Moreover, of the 15 ECC-positive women, 11 (73%) followed up at 2 years and it was shown that no patient was ECC positive at that time point. In our study, VIA had a false-positive rate of 5%. CONCLUSIONS Cryotherapy was an effective, acceptable, and well-tolerated means of treating cervical dysplasia in a low-resource setting.
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Fallala MS, Mash R. Cervical cancer screening: Safety, acceptability, and feasibility of a single-visit approach in Bulawayo, Zimbabwe. Afr J Prim Health Care Fam Med 2015; 7:742. [PMID: 26245601 PMCID: PMC4564888 DOI: 10.4102/phcfm.v7i1.742] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 10/14/2014] [Accepted: 10/16/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Cervical cancer is the commonest cancer amongst African women, and yet preventative services are often inadequate. AIM The purpose of the study was to assess the safety, acceptability and feasibility of visual inspection with acetic acid and cervicography (VIAC) followed by cryotherapy or a loop electrical excision procedure (LEEP) at a single visit for prevention of cancer of the cervix. SETTING The United Bulawayo Hospital, Zimbabwe. METHODS The study was descriptive, using retrospective data extracted from electronic medical records of women attending the VIAC clinic. Over 24 months 4641 women visited the clinic and were screened for cervical cancer using VIAC. Cryotherapy or LEEP was offered immediately to those that screened positive. Treated women were followed up at three months and one year. RESULTS The rate of positive results on VIAC testing was 10.8%. Of those who were eligible, 17.0% received immediate cryotherapy, 44.1% received immediate LEEP, 1.9% delayed treatment, and 37.0% were referred to a gynaecologist. No major complications were recorded after cryotherapy or LEEP. Amongst those treated 99.5% expressed satisfaction with their experience. Only 3.2% of those treated at the clinic had a positive result on VIAC one year later. The service was shown to be feasible to sustain over time with the necessary consumables. There were no service-related treatment postponements and the clinic staff and facility were able to meet the demand for the service. CONCLUSION A single-visit approach using VIAC, followed by cryotherapy or LEEP, proved to be safe, acceptable and feasible in an urban African setting in Bulawayo, Zimbabwe. Outcomes a year later suggested that treatment had been effective.
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Affiliation(s)
| | - Robert Mash
- Division of Family Medicine and Primary Care, Stellenbosch University.
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Wesley RS, Muwonge R, Sauvaget C, Thara S, Sankaranarayanan R. Effectiveness of cryotherapy for histologically confirmed cervical intraepithelial neoplasia grades 1 and 2 in an Indian setting. Int J Gynaecol Obstet 2013; 123:16-20. [PMID: 23870419 DOI: 10.1016/j.ijgo.2013.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 04/22/2013] [Accepted: 06/24/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the effectiveness of cryotherapy for treating women who were histologically confirmed to have cervical intraepithelial neoplasia (CIN) in India. METHODS Data were analyzed retrospectively from screening projects that collected data from January 2001 to May 2008 in Trivandrum, India. Women with CIN were appropriately treated with cryotherapy by a trained nurse or physician and followed up for cure, adverse events, and complications. Cure was defined as absence of CIN during any follow-up visit at least 1 year after treatment. RESULTS Among 236 women identified with CIN and appropriately treated with cryotherapy, 173 (81.6%) were followed up (158 CIN 1 and 15 CIN 2 cases). The percentage cure for CIN 1 and 2 lesions was 93.0% and 86.7% respectively. An odds ratio of 0.2 (95% confidence interval, 0.0-0.9) was observed for treatment received more than 2 months after screening as compared with treatment received within 2 months. Complications were observed in 1.2% of treated women and adverse events (discharge and mild pain) in 26.6%. CONCLUSION The study affirms that trained mid-level providers can appropriately perform cryotherapy in primary healthcare services and that expanding such services in low-resource settings would increase the availability and accessibility of precancer treatment.
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Sauvaget C, Muwonge R, Sankaranarayanan R. Meta-analysis of the effectiveness of cryotherapy in the treatment of cervical intraepithelial neoplasia. Int J Gynaecol Obstet 2012; 120:218-23. [PMID: 23265830 DOI: 10.1016/j.ijgo.2012.10.014] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 10/01/2012] [Accepted: 11/23/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cryotherapy can be used for the ablation of cervical intraepithelial neoplasia (CIN). OBJECTIVES To provide an updated and comprehensive estimate of the efficacy of cryotherapy for CIN. SEARCH STRATEGY A literature search identified original studies (randomized controlled trials and clinical reports). SELECTION CRITERIA Studies reporting cure rates, acceptability, and safety of cryotherapy were included in the analysis. DATA COLLECTION AND ANALYSIS Number of persistent or recurrent lesions at follow-up, adverse events, and complications were recorded. Quality of the methodology was also assessed. Meta-analyses were performed according to CIN thresholds, geographic region, study year, setting, study design, presence of endocervical involvement, freezing method, duration of follow-up, and status of the cryotherapy provider. MAIN RESULTS A total of 146 articles were retrieved; 77 papers--equivalent to 28,827 cases of treated CIN--were included in the meta-analysis. Cryotherapy achieved cure rates of 94.0% (CIN1), 92.0% (CIN2), and 85.0% (CIN3). Use of the double-freeze method and absence of endocervical involvement significantly increased cure rates. Minimal complications were reported as adverse effects. CONCLUSIONS Cryotherapy is an effective, safe, and acceptable treatment for CIN. It has been shown to be successful in low-resource settings, enabling availability and accessibility of early detection services.
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Affiliation(s)
- Catherine Sauvaget
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France.
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Low cost versus other screening tests to detect cervical cancer or precancer in developing countries. Cochrane Database Syst Rev 2012; 2012:CD010186. [PMCID: PMC6457807 DOI: 10.1002/14651858.cd010186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows: To assess the accuracy of low cost screening tests (visual inspection of the cervix with VIA, VILI or VIAM and care HPV test) to detect underlying CIN2+, CIN3+ or cervical cancer among adult women in developing countries To assess the accuracy of comparator tests (cervical cytology and other HPV tests requiring established laboratory infrastructure) to detect underlying CIN2+, CIN3+ or cervical cancer among adult women in developing countries To assess the relative sensitivity and specificity of the low cost index tests compared to each other and to the comparator tests to detect CIN2+, CIN3+ or cervical cancer among adult women in developing countries
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Cytology versus visual inspection with acetic acid among women treated previously with cryotherapy in a low-resource setting. Int J Gynaecol Obstet 2010; 111:249-52. [DOI: 10.1016/j.ijgo.2010.06.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 06/21/2010] [Accepted: 07/20/2010] [Indexed: 11/20/2022]
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Belinson JL, Pretorius RG, Enerson C, Garcia F, Cruz EP, Belinson SE, Yeverino García E, Brainard J. The Mexican Cervical Cancer Screening Trial: self-sampling for human papillomavirus with unaided visual inspection as a secondary screen. Int J Gynecol Cancer 2009; 19:27-32. [PMID: 19258937 DOI: 10.1111/igc.0b013e318197f479] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The Mexican Cervical Cancer Screening (MECCS) study took place in the State of Michoacán. Primary screening was by self-sampling for high-risk human papillomavirus (HR-HPV). The objectives were to increase the specificity of primary HPV screening by requiring 2 positive HPV tests 1 year apart in women whose secondary screen was negative according to an acetic acid-aided visual inspection (VIA). In addition, we postulated that the sensitivity of VIA would be sufficient to identify large preinvasive lesions and cancers unsuitable for cryotherapy if applied in a see-and-treat algorithm.A total of 8621 women (aged 30-50 years) were screened, and 14.3% were positive for HR-HPV. In phase 1, 11.9% of the HPV-positive women were VIA-positive and were referred for colposcopy with directed and random biopsies. If VIA-negative, women repeated the self-sample 1 year later to detect persistent HR-HPV (25.2% were positive). If persistently HR-HPV-positive in phase 2, patients again had VIA, then all women (both VIA-positive and -negative) received directed and random biopsies. If cryotherapy had been used to treat HPV- and VIA-positive women in phase 1 or persistent HR-HPV-positive (phase 2), the potential risk of undertreatment would have been 4.1%, and 66.4% of the treated patients would have had normal or cervical intraepithelial neoplasia I on biopsy. The VIA triage would refer 0.73% of the patients to colposcopy owing to the lesion size, location, or the presence of a cancer. On the basis of this pilot study, we are encouraged to explore and evaluate a rapid, more sensitive, and more specific self-test.
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Affiliation(s)
- Jerome L Belinson
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA
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