The burden of travelling for cervical cancer treatment in Uganda: A mixed-method study

Views on cervical cancer screening among female caregivers at the Uganda cancer Institute

Patients admitted to Uganda Cancer Institute (UCI) have their non-medical needs provided by caregivers called "attendants" who are predominantly female family members. This provides a unique opportunity to provide free screening among attendants during their free time at the hospital. The objective of this qualitative focus group study was to understand knowledge of and facilitators and barriers to cervical cancer screening among attendants at the UCI. The goal is to use these data to inform a future opportunistic intervention. Female attendants 25 years of age or older were included in this focus group study. The focus group discussions explored knowledge of cervical cancer and screening modalities, health information sources, barriers and facilitators for cervical cancer screening, and potential use of mobile phone technology to share cervical cancer screening information among one's social community. Data were analyzed using an inductive approach and thematic analysis. Results showed moderate understanding of risk factors for cervical cancer, supplemented by misinformation. Knowledge of symptoms of advanced cervical cancer was high. Most participants were aware that cervical cancer screening exists but knew little about screening modalities. Responses were mixed regarding preferred information sources, and included healthcare workers and facilities, radio and family members. Participants were enthusiastic about mobile phone messaging to provide information about screening but emphasized a need to catch their attention and incentivize screening with promise of good such as sugar, demonstrating prioritization of immediate needs over future cancer risk. These results will inform an intervention which aims to connect female caregivers with free screening available at the adjacent cancer prevention clinic.

High-risk human papillomavirus testing for cervical cancer screening in Uganda: Considering potential harms and benefits in a low-resource setting

OBJECTIVES

The World Health Organization supports both the screen-and-treat (ST) approach and the screen, triage and treat (STT) approach to cervical cancer screening using high-risk human papillomavirus (hrHPV) testing. For Uganda, the sequence of hrHPV-ST and hrHPV-STT could be similar, with visual inspection with acetic acid (VIA) after positive hrHPV tests in both. To consider potential tradeoffs (overtreatment in ST versus missed cancer cases in STT), we compared hrHPV-STT with VIA triage (STT-VIA), and STT with HPV 16/18 genotyping risk stratification, to hrHPV-ST for Uganda, in terms of overtreatment, cervical cancer incidence, and life years, for the general female population of Uganda.

METHODS

A microsimulation model of cervical cancer was adapted. Incremental benefit-harm ratios of STT were calculated as ratios of prevented overtreatment to reduced life years, and to increased cancer cases. Additional scenarios with 20% difference in intra- and inter-screening follow-up between ST and STT were modeled.

RESULTS

Both STT strategies resulted in life year losses on average compared to ST. STT-VIA prevented more overtreatment but led to increased cervical cancer incidence and life year losses. STT-G-VIA resulted in better harm-benefit ratios and additional costs. With better follow-up, STT prevented overtreatment and improved outcomes.

DISCUSSION

For Uganda, the STT approach appears preferrable, if the screening sequences of hrHPV-based ST and STT are similar in practice. While VIA triage alone would reduce overtreatment the most, it could also result in more cancer cases. Risk stratification via genotyping could improve STT. Potential follow-up differences and resource availability should be considered by decision-makers when planning Uganda's hrHPV-based screening strategy.