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Dorji T, Wangmo S, Dargay S, Dorji N, Dorjey Y, Pradhan B, Pema D, Dema C, Choden J, Dorji T, Mynak ML, Pempa, Jamphel K. Population-level cancer screening and cancer care in Bhutan, 2020-2023: a review. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 24:100370. [PMID: 38444883 PMCID: PMC10910341 DOI: 10.1016/j.lansea.2024.100370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/25/2024] [Accepted: 02/05/2024] [Indexed: 03/07/2024]
Abstract
Screening of cancers is an important intervention in reducing the incidence and mortality related to cancers. Bhutan is one small country that is witnessing an increasing incidence and mortality related to cancers. The government implemented a time-bound population-level screening for gastric, cervical and breast cancers from 2020 to 2023 with an overall coverage of 91.2% of the eligible population. Among 370,225 individuals screened for H pylori, 32.4% tested positive; among 53,182 who underwent upper gastrointestinal endoscopy and biopsy, 255 (0.07%) had gastric cancer. Among 10,749 tested for HPV DNA, 9.3% were positive; among 9887 evaluated with colposcopy and biopsy, 154 (0.13%) had cervical cancer. For breast cancer screening, 72,283 underwent clinical breast examination, 845 mammography and cancer was detected in 73 (0.10%) individuals. In this article, we review how Bhutan implemented a population-level cancer screening programme with on boarding of multiple stakeholders and the participation of people across all districts.
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Affiliation(s)
- Thinley Dorji
- Department of Internal Medicine, Central Regional Referral Hospital, Gelephu, Bhutan
| | - Sangay Wangmo
- Department of Surgery, Central Regional Referral Hospital, Gelephu, Bhutan
| | - Sonam Dargay
- Department of Surgery, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Namkha Dorji
- Department of Obstetrics and Gynaecology, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Yeshey Dorjey
- Department of Obstetrics and Gynaecology, Phuentsholing General Hospital, Phuentsholing, Bhutan
| | - Birendra Pradhan
- Department of Pathology and Laboratory Medicine, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Dechen Pema
- Department of Radiodiagnosis and Imaging, Central Regional Referral Hospital, Gelephu, Bhutan
| | - Choney Dema
- National Medical Services, Ministry of Health, Thimphu, Bhutan
| | - Jamyang Choden
- Department of Health Services, Ministry of Health, Thimphu, Bhutan
| | | | | | - Pempa
- Department of Health Services, Ministry of Health, Thimphu, Bhutan
| | - Kinga Jamphel
- Department of Health Services, Ministry of Health, Thimphu, Bhutan
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Ari ES, Dioso RIP, Sotunsa JO. Improving care seeking behavior toward cervical cancer screening participation among Gwafan community women, North-Central Nigeria. BMC Womens Health 2023; 23:356. [PMID: 37403114 DOI: 10.1186/s12905-023-02353-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/13/2023] [Indexed: 07/06/2023] Open
Abstract
INTRODUCTION Cervical cancer is the fourth most common cancer in women globally and the second most common cancer in low- to middle-income countries, and its screening rate is yet to reach the 70% WHO target. Most interventions that proved effective in improving screening participation in some communities did not achieve the desired behavioral outcome in some settings. AIM This study aimed to evaluate the effectiveness of care-seeking behavior interventions on cervical cancer screening participation. METHOD A pragmatic multiphase mixed methods design was adopted for this study, and three phases of the human-centered design process were used for data collection. Deductive thematic analysis was used for qualitative data, while SPSS was used for quantitative data analysis. RESULTS The findings show a significant relationship between participants' tribes p values (0.03) 0.05 and screening participation. Before the intervention, most (77.4%) were afraid of exposing their private parts; 75.9% were afraid of being diagnosed with cervical cancer; and the majority felt the procedure was embarrassing and painful. Free screening, awareness, and knowledge, offering transport, the use of influencers, and sample collection by a female care provider are among other facilitators to screening. Screening participation improved from 11.2% preintervention to 29.7% postintervention (average mean screening score from 1.890.316 to 1.70000.458). All participants who were screened postintervention said the procedure was not embarrassing or painful and that they were not afraid of the procedure or the screening environment. CONCLUSION In conclusion, screening habits in the community were low before intervention, as this may have resulted from women's feelings and past experiences with screening services. Sociodemographic variables may not directly predict screening participation. Care-seeking behavior interventions have significantly increased screening participation postintervention.
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Affiliation(s)
- Eunice Samuel Ari
- Faculty of Nursing, Lincoln University College, Kuala Lumpur, Malaysia
| | | | - John Obafemi Sotunsa
- Benjamin S. Carson (Snr) College of Health and Medical Sciences, Babcock University, Ilishan Remo, Ogun State, Nigeria
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Clifford GM, Baussano I, Heideman DAM, Tshering S, Choden T, Lazzarato F, Tenet V, Franceschi S, Darragh TM, Tobgay T, Tshomo U. Human papillomavirus testing on self-collected samples to detect high-grade cervical lesions in rural Bhutan: The REACH-Bhutan study. Cancer Med 2023; 12:11828-11837. [PMID: 36999740 PMCID: PMC10619475 DOI: 10.1002/cam4.5851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 01/09/2023] [Accepted: 03/13/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND "REACH-Bhutan" aimed to evaluate the feasibility and clinical performance of a community-based screening program for cervical cancer in rural Bhutan using self-collected samples for high-risk human papillomavirus (HR-HPV) testing. METHODS In April/May 2016, 2590 women aged 30-60 years were screened across rural Bhutan by providing a self-collected sample for careHPV testing. All careHPV-positive women, plus a random sample of careHPV-negative women, were recalled for colposcopy and biopsy. Self-samples also underwent GP5+/6+ polymerase chain reaction (PCR)-based HR-HPV DNA detection and genotyping. Cross-sectional screening indices were estimated against histological high-grade squamous intraepithelial lesions or worse (hHSIL+), including imputation of hHSIL+ in women without colposcopy. RESULTS HR-HPV positivity was 10.2% by careHPV and 14.8% by GP5+/6+ PCR. Twenty-two cases of hHSIL+ were histologically diagnosed, including one invasive cancer; an additional 7 hHSIL+ were imputed in women without colposcopy. HR-HPV testing by GP5+/6+ showed higher sensitivity for hHSIL+ (89.7%, 95% CI 72.6-97.8) than careHPV (75.9%, 95% CI 56.5-89.7). Negative predictive value was also slightly higher for GP5+/6+ (99.9%, 95% CI 99.6-100) than careHPV (99.7%, 95% CI 99.4-99.9). Specificity, however, was lower for GP5+/6+ (86.1%, 95% CI 84.6-87.4) than careHPV (90.6%, 95% CI 89.4-91.7), as was positive predictive value (6.9%, 95% CI 4.5-9.9 vs. 8.5%, 95% CI 5.4-12.6). Of 377 HR-HPV-positive women by GP5+/6+, 173 (45.9%) were careHPV-positive, including 54.7% HPV16-positive and 30.2% HPV18-positive women. CONCLUSIONS The final REACH-Bhutan results show that screening for cervical cancer with self-collection of samples and HR-HPV testing, in addition to our previous report of achieving high participation, can also perform well to detect women with hHSIL+.
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Affiliation(s)
- Gary M. Clifford
- Early Detection, Prevention and Infections BranchInternational Agency for Research on Cancer (IARC/WHO)LyonFrance
| | - Iacopo Baussano
- Early Detection, Prevention and Infections BranchInternational Agency for Research on Cancer (IARC/WHO)LyonFrance
| | - Daniëlle A. M. Heideman
- Department of PathologyAmsterdam UMC location Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Cancer Center Amsterdam, Imaging and BiomarkersAmsterdamThe Netherlands
| | - Sangay Tshering
- Department of Obstetrics & GynaecologyJigme Dorji Wangchuck National Referral HospitalThimphuBhutan
| | - Tashi Choden
- Department of Pathology & Laboratory MedicineJigme Dorji Wangchuck National Referral HospitalThimphuBhutan
| | - Fulvio Lazzarato
- Cancer Epidemiology Unit“Città della Salute e della Scienza” HospitalTurinItaly
| | - Vanessa Tenet
- Early Detection, Prevention and Infections BranchInternational Agency for Research on Cancer (IARC/WHO)LyonFrance
| | | | | | - Tashi Tobgay
- Department of Pathology & Laboratory MedicineJigme Dorji Wangchuck National Referral HospitalThimphuBhutan
| | - Ugyen Tshomo
- Department of Obstetrics & GynaecologyJigme Dorji Wangchuck National Referral HospitalThimphuBhutan
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Creagh NS, Boyd LAP, Bavor C, Zammit C, Saunders T, Oommen AM, Rankin NM, Brotherton JML, Nightingale CE. Self-Collection Cervical Screening in the Asia-Pacific Region: A Scoping Review of Implementation Evidence. JCO Glob Oncol 2023; 9:e2200297. [PMID: 36724416 PMCID: PMC10166429 DOI: 10.1200/go.22.00297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Although cervical cancer is a disease of inequity, it can be eliminated as a public health problem through vaccination, screening, and treatment. Human papillomavirus vaginal self-collection cervical screening is a high-performance test that can increase reach of screening. This review describes the different contexts and models of care used to pilot or implement self-collection within the Asia-Pacific, measures the extent that implementation outcome measures are reported and, where available, summarizes key implementation findings. METHODS A scoping review was conducted by searching five databases of the peer-reviewed literature on June 20, 2022. Two researchers assessed eligibility and extracted data independently to the model of care used and the Conceptual Framework for Implementation Outcomes. A mixed-method consolidation of findings (quantitative: count and frequencies; qualitative: content analysis) was undertaken to narratively report findings. RESULTS Fifty-seven articles, comprising 50 unique studies from 11 countries and two special autonomous regions, were included; 82% were conducted in trials. The implementation of self-collection was conducted in low- (2%), lower-middle- (32%), upper-middle- (32%), and high-income (35%) settings, with 10 different delivery models used; 80% delivered through practitioner-supported models with diversity in how samples were processed, and treatment was offered. Acceptability (73%) and appropriateness (64%) measures were most reported, followed by adoption (57%), feasibility (48%), and fidelity (38%). Only 7% of articles reported implementation cost or penetration measures. No articles reported sustainability measures. CONCLUSION The literature confirms that self-collection cervical screening has been implemented within the Asia-Pacific region, with evidence demonstrating that it is acceptable and appropriate from the user's perspective. Well-designed, high-quality implementation trials and real-world evaluations of self-collection that report the breadth of implementation outcomes can support the progression toward the elimination of cervical cancer.
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Affiliation(s)
- Nicola Stephanie Creagh
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lucy Ann Patricia Boyd
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Claire Bavor
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Claire Zammit
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Tessa Saunders
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Anu Mary Oommen
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.,Community Health Department, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nicole Marion Rankin
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Julia Mary Louise Brotherton
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.,Australian Centre for the Prevention of Cervical Cancer, Carlton, Victoria, Australia
| | - Claire Elizabeth Nightingale
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Villain P, Carvalho AL, Lucas E, Mosquera I, Zhang L, Muwonge R, Selmouni F, Sauvaget C, Basu P. Cross-sectional survey of the impact of the COVID-19 pandemic on cancer screening programs in selected low- and middle-income countries: Study from the IARC COVID-19 impact study group. Int J Cancer 2021; 149:97-107. [PMID: 33533501 PMCID: PMC8014228 DOI: 10.1002/ijc.33500] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/18/2021] [Accepted: 01/25/2021] [Indexed: 02/02/2023]
Abstract
We conducted a study to document the impact of COVID-19 pandemic on cancer screening continuum in selected low- and middle-income countries (LMICs). LMICs having an operational cancer control plan committed to screen eligible individuals were selected. Managers/supervisors of cancer screening programs were invited to participate in an online survey and subsequent in-depth interview. Managers/supervisors from 18 programs in 17 countries participated. Lockdown was imposed in all countries except Brazil. Screening was suspended for at least 30 days in 13 countries, while diagnostic-services for screen-positives were suspended in 9 countries. All countries except Cameroon, Bangladesh, India, Honduras and China managed to continue with cancer treatment throughout the outbreak. The participants rated service availability compared to pre-COVID days on a scale of 0 (no activities) to 100 (same as before). A rating of ≤50 was given for screening services by 61.1%, diagnostic services by 44.4% and treatment services by 22.2% participants. At least 70% participants strongly agreed that increased noncompliance of screen-positive individuals and staff being overloaded or overwhelmed with backlogs would deeply impact screening programs in the next 6 months at least. Although many of the LMICs were deficient in following the "best practices" to minimize service disruptions, at least some of them made significant efforts to improve screening participation, treatment compliance and program organization. A well-coordinated effort is needed to reinitiate screening services in the LMICs, starting with a situational analysis. Innovative strategies adopted by the programs to keep services on-track should be mutually shared.
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Affiliation(s)
| | | | - Eric Lucas
- International Agency for Research on Cancer, Lyon, France
| | | | - Li Zhang
- International Agency for Research on Cancer, Lyon, France
| | | | | | | | - Partha Basu
- International Agency for Research on Cancer, Lyon, France
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6
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Current Updates on Cancer-Causing Types of Human Papillomaviruses (HPVs) in East, Southeast, and South Asia. Cancers (Basel) 2021; 13:cancers13112691. [PMID: 34070706 PMCID: PMC8198295 DOI: 10.3390/cancers13112691] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/23/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022] Open
Abstract
Simple Summary Among the over 200 human papillomavirus (HPV) genotypes identified, approximately 15 of them can cause human cancers. In this review, we provided an updated overview of the distribution of cancer-causing HPV genotypes by countries in East, Southeast and South Asia. Besides the standard screening and treatment methods employed in these regions, we unravel HPV detection methods and therapeutics utilised in certain countries that differ from other part of the world. The discrepancies may be partly due to health infrastructure, socio-economy and cultural diversities. Additionally, we highlighted the area lack of study, particularly on the oncogenicity of HPV genotype variants of high prevalence in these regions. Abstract Human papillomavirus (HPV) infection remains one of the most prominent cancer-causing DNA viruses, contributing to approximately 5% of human cancers. While association between HPV and cervical cancers has been well-established, evidence on the attribution of head and neck cancers (HNC) to HPV have been increasing in recent years. Among the cancer-causing HPV genotypes, HPV16 and 18 remain the major contributors to cancers across the globe. Nonetheless, the distribution of HPV genotypes in ethnically, geographically, and socio-economically diverse East, Southeast, and South Asia may differ from other parts of the world. In this review, we garner and provide updated insight into various aspects of HPV reported in recent years (2015–2021) in these regions. We included: (i) the HPV genotypes detected in normal cancers of the uterine cervix and head and neck, as well as the distribution of the HPV genotypes by geography and age groups; (ii) the laboratory diagnostic methods and treatment regimens used within these regions; and (iii) the oncogenic properties of HPV prototypes and their variants contributing to carcinogenesis. More importantly, we also unveil the similarities and discrepancies between these aspects, the areas lacking study, and the challenges faced in HPV studies.
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Dorji T, Tshomo U, Gyamtsho S, Tamang ST, Wangmo S, Pongpirul K. Gender-neutral HPV elimination, cervical cancer screening, and treatment: Experience from Bhutan. Int J Gynaecol Obstet 2021; 156:425-429. [PMID: 33930178 DOI: 10.1002/ijgo.13728] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 11/10/2022]
Abstract
Cervical cancer is preventable and also curable when detected early and treated adequately, yet it remains a leading cause of morbidity and mortality among women. In Bhutan, cervical cancer is the most common cancer among women. Bhutan was the first country among the low- and middle-income economies to have instituted a national HPV vaccination program, in 2010, and has achieved >90% coverage. In 2019, Bhutan launched a cervical cancer elimination flagship program well ahead of WHO's launch of the global strategy for accelerated elimination of cervical cancer. Bhutan initiated vaccination of adolescent boys and adopted a gender-neutral vaccination program beginning September 2020 through its well-established network of primary healthcare centres. The flagship program aims to screen women aged 30-69 years with HPV testing using liquid-based cytology (LBC) as triaging for screen positive women. For women aged 25-29 years, LBC will be continued as per American Society of Colposcopy and Cervical Pathology guidelines. Colposcopy and treatment will be performed in camps to decrease loss of follow up of screen positive women. This program is also expected to improve early diagnosis of cervical cancer and provide timely and adequate cancer treatment and palliative care services. This article reviews the progress made and the challenges facing the 2030 cervical cancer elimination targets in Bhutan.
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Affiliation(s)
- Thinley Dorji
- Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan.,Kidu Mobile Medical Unit, His Majesty's People's Project, Thimphu, Bhutan
| | - Ugyen Tshomo
- Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Sonam Gyamtsho
- Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan.,Faculty of Postgraduate Medicine, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu
| | | | - Sangay Wangmo
- Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan.,Faculty of Postgraduate Medicine, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu
| | - Krit Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Kamath Mulki A, Withers M. Human Papilloma Virus self-sampling performance in low- and middle-income countries. BMC WOMENS HEALTH 2021; 21:12. [PMID: 33407355 PMCID: PMC7789658 DOI: 10.1186/s12905-020-01158-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/20/2020] [Indexed: 12/24/2022]
Abstract
Background Screening for HPV has led to significant reductions in cervical cancer deaths in high-income countries. However, the same results have not been achieved in low- and middle-income countries (LMICs). HPV self-sampling is a novel approach that could improve screening rates. Methods This study’s objective is to summarize the recent literature on HPV self-sampling in LMICs, focusing on sensitivity/specificity, and feasibility/acceptability of self-sampling compared to traditional screening methods. We conducted a PubMed search for articles published in English within the last 10 years on self-sampling in LMICs.
Results Fifty eligible articles from 26 countries were included, 19 of which came from sub-Saharan Africa and 18 from Latin America/Caribbean. Seven studies examined sensitivity, with five reporting rates higher than 91%. Six reported on specificity, which was also very high at 86–97.8%. Six studies examined self-sampling concordance with provider-collected sampling, with concordance rates ranging from 87 to 97.5%. A total of 38 studies examined the feasibility/acceptability of HPV self-sampling. Participation rates were very high in all studies, even when self-sampling was done at participants’ homes (over 89% participation). Overall, participants reported that HPV self-sampling was easy to perform (75–97%, 18 studies), painless (60–90%, nine studies), and preferred over provider-collected sampling (57–100%, 14 studies). Eight studies reported follow-up rates for participants who completed self-sampling; however, these rates varied widely-from 13.7 to 90%. The major benefits of self-sampling include convenience of screening from home, less embarrassment, and less travel. Improved education and awareness of self-sampling, combined with support from community health workers, could reduce perceptions of self-sampling being inferior to provider-collected sampling. Improving follow-up of abnormal results and improving linkages to treatment are also essential. Conclusion Our literature review highlights HPV self-sampling is a well-performing test that shows promise in terms of expanding screening efforts for the prevention of cervical cancer-related deaths in LMICs.
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Affiliation(s)
- Ashwini Kamath Mulki
- Department of Family Medicine, Lehigh Valley Health Network, 1730 Chew St, Allentown, PA, 18104, USA. .,Keck School of Medicine, University of Southern California, 2001 N Soto Street SSB 318G, Los Angeles, CA, 90032, USA.
| | - Mellissa Withers
- Keck School of Medicine, University of Southern California, 2001 N Soto Street SSB 318G, Los Angeles, CA, 90032, USA
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Lemp JM, De Neve JW, Bussmann H, Chen S, Manne-Goehler J, Theilmann M, Marcus ME, Ebert C, Probst C, Tsabedze-Sibanyoni L, Sturua L, Kibachio JM, Moghaddam SS, Martins JS, Houinato D, Houehanou C, Gurung MS, Gathecha G, Farzadfar F, Dryden-Peterson S, Davies JI, Atun R, Vollmer S, Bärnighausen T, Geldsetzer P. Lifetime Prevalence of Cervical Cancer Screening in 55 Low- and Middle-Income Countries. JAMA 2020; 324:1532-1542. [PMID: 33079153 PMCID: PMC7576410 DOI: 10.1001/jama.2020.16244] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 08/10/2020] [Indexed: 12/11/2022]
Abstract
Importance The World Health Organization is developing a global strategy to eliminate cervical cancer, with goals for screening prevalence among women aged 30 through 49 years. However, evidence on prevalence levels of cervical cancer screening in low- and middle-income countries (LMICs) is sparse. Objective To determine lifetime cervical cancer screening prevalence in LMICs and its variation across and within world regions and countries. Design, Setting, and Participants Analysis of cross-sectional nationally representative household surveys carried out in 55 LMICs from 2005 through 2018. The median response rate across surveys was 93.8% (range, 64.0%-99.3%). The population-based sample consisted of 1 136 289 women aged 15 years or older, of whom 6885 (0.6%) had missing information for the survey question on cervical cancer screening. Exposures World region, country; countries' economic, social, and health system characteristics; and individuals' sociodemographic characteristics. Main Outcomes and Measures Self-report of having ever had a screening test for cervical cancer. Results Of the 1 129 404 women included in the analysis, 542 475 were aged 30 through 49 years. A country-level median of 43.6% (interquartile range [IQR], 13.9%-77.3%; range, 0.3%-97.4%) of women aged 30 through 49 years self-reported to have ever been screened, with countries in Latin America and the Caribbean having the highest prevalence (country-level median, 84.6%; IQR, 65.7%-91.1%; range, 11.7%-97.4%) and those in sub-Saharan Africa the lowest prevalence (country-level median, 16.9%; IQR, 3.7%-31.0%; range, 0.9%-50.8%). There was large variation in the self-reported lifetime prevalence of cervical cancer screening among countries within regions and among countries with similar levels of per capita gross domestic product and total health expenditure. Within countries, women who lived in rural areas, had low educational attainment, or had low household wealth were generally least likely to self-report ever having been screened. Conclusions and Relevance In this cross-sectional study of data collected in 55 low- and middle-income countries from 2005 through 2018, there was wide variation between countries in the self-reported lifetime prevalence of cervical cancer screening. However, the median prevalence was only 44%, supporting the need to increase the rate of screening.
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Affiliation(s)
- Julia M. Lemp
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Hermann Bussmann
- Department of Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simiao Chen
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing
| | - Jennifer Manne-Goehler
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Michaela Theilmann
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Maja-Emilia Marcus
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Cara Ebert
- RWI–Leibniz Institute for Economic Research, Essen (Berlin office), Germany
| | - Charlotte Probst
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
| | | | - Lela Sturua
- Non-Communicable Disease Department, National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - Joseph M. Kibachio
- Division of Non-Communicable Diseases, Kenya Ministry of Health, Nairobi, Kenya
- Institute of Global Health, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland
| | - Sahar Saeedi Moghaddam
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Joao S. Martins
- Faculty of Medicine and Health Sciences, Universidade Nacional Timor Lorosa’e, Rua Jacinto Candido, Dili, Timor-Leste
| | - Dismand Houinato
- Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin
| | - Corine Houehanou
- Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin
| | - Mongal S. Gurung
- Health Research and Epidemiology Unit, Ministry of Health, Thimphu, Bhutan
| | - Gladwell Gathecha
- Division of Non-Communicable Diseases, Kenya Ministry of Health, Nairobi, Kenya
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Scott Dryden-Peterson
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Botswana Harvard AIDS Institute, Gaborone, Botswana
| | - Justine I. Davies
- MRC/Wits Rural Public Health and Health Transitions Research Unit, University of Witwatersrand School of Public Health, Johannesburg, South Africa
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Rifat Atun
- Department of Global Health and Population at the Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Global Health and Social Medicine at the Harvard Medical School, Boston, Massachusetts
| | - Sebastian Vollmer
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Department of Global Health and Population at the Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Africa Health Research Institute, Somkhele, South Africa
| | - Pascal Geldsetzer
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
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10
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Self-Collection for Cervical Screening Programs: From Research to Reality. Cancers (Basel) 2020; 12:cancers12041053. [PMID: 32344565 PMCID: PMC7226191 DOI: 10.3390/cancers12041053] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 12/16/2022] Open
Abstract
In 2018, there were an estimated 570,000 new cases of cervical cancer globally, with most of them occurring in women who either had no access to cervical screening, or had not participated in screening in regions where programs are available. Where programs are in place, a major barrier for women across many cultures has been the requirement to undergo a speculum examination. With the emergence of HPV-based primary screening, the option of self-collection (where the woman takes the sample from the vagina herself) may overcome this barrier, given that such samples when tested using a PCR-based HPV assay have similar sensitivity for the detection of cervical pre-cancers as practitioner-collected cervical specimens. Other advantages of HPV-based screening using self-collection, beyond the increase in acceptability to women, include scalability, efficiency, and high negative predictive value, allowing for long intervals between negative tests. Self-collection will be a key strategy for the successful scale up of cervical screening programs globally in response to the WHO call for all countries to work towards the elimination of cervical cancer as a public health problem. This review will examine self-collection for HPV-based cervical screening including the collection devices, assays and possible routine laboratory processes considering how they can be utilized in cervical screening programs.
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11
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Arbyn M, Smith SB, Temin S, Sultana F, Castle P. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. BMJ 2018; 363:k4823. [PMID: 30518635 PMCID: PMC6278587 DOI: 10.1136/bmj.k4823] [Citation(s) in RCA: 405] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of high-risk human papillomavirus (hrHPV) assays on self samples and the efficacy of self sampling strategies to reach underscreened women. DESIGN Updated meta-analysis. DATA SOURCES Medline (PubMed), Embase, and CENTRAL from 1 January 2013 to 15 April 2018 (accuracy review), and 1 January 2014 to 15 April 2018 (participation review). REVIEW METHODS Accuracy review: hrHPV assay on a vaginal self sample and a clinician sample; and verification of the presence of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) by colposcopy and biopsy in all enrolled women or in women with positive tests. Participation review: study population included women who were irregularly or never screened; women in the self sampling arm (intervention arm) were invited to collect a self sample for hrHPV testing; women in the control arm were invited or reminded to undergo a screening test on a clinician sample; participation in both arms was documented; and a population minimum of 400 women. RESULTS 56 accuracy studies and 25 participation trials were included. hrHPV assays based on polymerase chain reaction were as sensitive on self samples as on clinician samples to detect CIN2+ or CIN3+ (pooled ratio 0.99, 95% confidence interval 0.97 to 1.02). However, hrHPV assays based on signal amplification were less sensitive on self samples (pooled ratio 0.85, 95% confidence interval 0.80 to 0.89). The specificity to exclude CIN2+ was 2% or 4% lower on self samples than on clinician samples, for hrHPV assays based on polymerase chain reaction or signal amplification, respectively. Mailing self sample kits to the woman's home address generated higher response rates to have a sample taken by a clinician than invitation or reminder letters (pooled relative participation in intention-to-treat-analysis of 2.33, 95% confidence interval 1.86 to 2.91). Opt-in strategies where women had to request a self sampling kit were generally not more effective than invitation letters (relative participation of 1.22, 95% confidence interval 0.93 to 1.61). Direct offer of self sampling devices to women in communities that were underscreened generated high participation rates (>75%). Substantial interstudy heterogeneity was noted (I2>95%). CONCLUSIONS When used with hrHPV assays based on polymerase chain reaction, testing on self samples was similarly accurate as on clinician samples. Offering self sampling kits generally is more effective in reaching underscreened women than sending invitations. However, since response rates are highly variable among settings, pilots should be set up before regional or national roll out of self sampling strategies.
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Affiliation(s)
- Marc Arbyn
- Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, J Wytsmanstreet 14, B1050 Brussels, Belgium
| | - Sara B Smith
- Global Coalition Against Cervical Cancer, Durham, NC, USA
| | - Sarah Temin
- Department of Cancer Policy and Advocacy, American Society of Clinical Oncology, Alexandria, VA, USA
| | - Farhana Sultana
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
- Registries and Research, Victorian Cytology Service Registries, Victorian Cytology Service Ltd, Carlton South, Australia
| | - Philip Castle
- Global Coalition Against Cervical Cancer, Durham, NC, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
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12
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Franceschi S, Clifford GM, Baussano I. Options for design of real-world impact studies of single-dose vaccine schedules. Vaccine 2018; 36:4816-4822. [PMID: 29571973 PMCID: PMC6066174 DOI: 10.1016/j.vaccine.2018.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 01/12/2018] [Accepted: 02/01/2018] [Indexed: 11/25/2022]
Abstract
Based on existing evidence for efficacy, savings, and advantages in delivery, some countries may elect to pilot or roll out single-dose human papillomavirus (HPV) vaccination (instead of, or in combination with, two-dose) in advance of a WHO policy decision. Accelerated evidence of population-based effectiveness (hereafter referred to as overall effectiveness, OE) of one-dose vaccine programs could be gained through regular surveys of HPV prevalence in young women before and after vaccination introduction. In order to offer the earliest information on OE, one-dose HPV vaccination should target one or more birth cohorts as close as possible to the age when sexual activity most often starts in a given population. A catch-up one-dose vaccination program of girls up to 18 years of age who would have been too old to profit from the introduction of a routine HPV vaccination program in preadolescents would minimize the interval between vaccination and the possibility to monitor vaccination impact in young women. In addition, catch-up is especially desirable in low- and middle-income countries with little access to screening as "missed" cohorts may face high risk of cervical cancer death. HPV prevalence should be firstly monitored in age groups of women who may already be sexually active but still reluctant to admit it and to accept vaginal examination for the collection of cervical cells. Hence, HPV testing from urine samples, for which good concordance with cervical cells has been proven, offers a feasible approach to assess periodically vaccine OE in representative samples of 17-20 year-old women. This type of observational study would greatly benefit from the presence of a population census and the creation of a vaccination registry. A real-world demonstration of OE of the new schedule would complement the findings of ongoing clinical trials and immunogenicity studies on the efficacy of single-dose HPV vaccination.
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Affiliation(s)
- Silvia Franceschi
- Cancer Epidemiology Unit, Aviano National Cancer Institute IRCCS, Via Franco Gallini 2, 33081 Aviano (PN), Italy.
| | - Gary M Clifford
- International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon Cedex 08, France.
| | - Iacopo Baussano
- International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon Cedex 08, France.
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13
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Umulisa MC, Franceschi S, Baussano I, Tenet V, Uwimbabazi M, Rugwizangoga B, Heideman DAM, Uyterlinde AM, Darragh TM, Snijders PJF, Sayinzoga F, Clifford GM. Evaluation of human-papillomavirus testing and visual inspection for cervical cancer screening in Rwanda. BMC Womens Health 2018; 18:59. [PMID: 29699549 PMCID: PMC5921370 DOI: 10.1186/s12905-018-0549-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 04/09/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND A pilot screening campaign in Rwanda, based on careHPV-testing followed by visual inspection with acetic acid triage (careHPV+VIA triage), was evaluated against other WHO-recommended screening options, namely HPV screen-and-treat and VIA screen-and-treat. METHODS 764 women aged 30-69 underwent at visit 1: i) VIA, and cervical cell collection for ii) careHPV in Rwanda, and iii) liquid-based cytology and GP5+/6+ HR-HPV PCR in The Netherlands. All 177 women positive by VIA, careHPV and/or PCR were recalled, of whom 84% attended. At visit 2, VIA was again used to triage screen-positive women for treatment and to obtain biopsies from all women either from visible lesions or at 12 o'clock of the squamocolumnar junction. Cross-sectional screening indices were estimated primarily against histological high-grade squamous intraepithelial lesions or worse (hHSIL+), after imputation of missing histology data, based on 1-visit or 2-visit approaches. RESULTS In a 1-visit screen-and-treat approach, VIA had sensitivity and specificity of 41% and 96%, respectively, versus 71% and 88% for careHPV, and 88% and 86% for PCR. In a 2-visit approach (in which hHSIL+ imputed among women without visit 2 were considered untreated) careHPV sensitivity dropped to 59% due to loss of 13% of hHSIL+. For careHPV+VIA triage, sensitivity dropped further to 35%, as another 24% of hHSIL+ were triaged to no treatment. CONCLUSIONS CareHPV was not as sensitive as gold-standard PCR, but detected considerably more hHSIL+ than VIA. However, due to careHPV-positive hHSIL+ women being lost to follow-up and/or triaged to no treatment, 2-visit careHPV+VIA triage did not perform better than VIA screen-and-treat.
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Affiliation(s)
| | - Silvia Franceschi
- Cancer Epidemiology Unit, Aviano National Cancer Institute IRCCS, Aviano, Italy
| | - Iacopo Baussano
- International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon Cedex 08, France
| | - Vanessa Tenet
- International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon Cedex 08, France
| | | | - Belson Rugwizangoga
- Department of Pathology, University Teaching Hospital of Kigali, Kigali, Rwanda
- University of Rwanda School of Medicine and Pharmacy, Kigali, Rwanda
| | | | - Anne M. Uyterlinde
- Department of Pathology, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Peter J. F. Snijders
- Department of Pathology, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Gary M. Clifford
- International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon Cedex 08, France
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14
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Tshomo U, Franceschi S, Tshokey T, Tobgay T, Baussano I, Tenet V, Heideman DA, Snijders PJ, Clifford GM. Evaluation of cytology versus human papillomavirus-based cervical cancer screening algorithms in Bhutan. Oncotarget 2017; 8:72438-72446. [PMID: 29069800 PMCID: PMC5641143 DOI: 10.18632/oncotarget.19783] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 06/26/2017] [Indexed: 12/22/2022] Open
Abstract
To evaluate the performance of existing versus alternative cervical cancer screening protocols in Bhutan, cervical exfoliated cells were collected for cytology and high-risk human papillomavirus (HR-HPV) testing among 1,048 women aged 30-69 years. Conventional smears were prepared and read locally. HR-HPV was tested by GP5+/6+ polymerase chain reaction, followed by genotyping and human DNA methylation analysis among HR-HPV-positives, in Europe. Test positivity was 7.5% for ASCUS or worse (ASCUS+) cytology and 14.0% for HR-HPV. All women with ASCUS+ and/or HR-HPV positivity (n=192) were recalled for colposcopy, among whom a total of 29 cases of histologically confirmed cervical intraepithelial neoplasia grade 2 or worse (CIN2+) were identified. An additional 7 CIN2+ cases were imputed among women without colposcopy. Corrected sensitivities for CIN2+ and CIN3+ were 61% and 74% for ASCUS+, 86% and 96% for HR-HPV, and 47% and 70% for ASCUS+ triage of HR-HPV. Specificity varied from 88% for HR-HPV up to 98% for ASCUS+ triage of HR-HPV, similarly for CIN2+ and CIN3+. Among HR-HPV-positive women with biopsies, methylation analysis offered similar discrimination of CIN2/3 and cervical cancer as ASCUS+, and better than HPV16/18 genotyping alone, but sample sizes were limited. In conclusion, the performance of cytology in Bhutan is in the mid-range of that reported in other screening settings. HR-HPV testing has the potential to improve detection of CIN2+, albeit with a higher referral rate for colposcopy. Cytological triage of HR-HPV-positives (performed in the absence of knowledge of HR-HPV status) reduced referral but missed more than one third of CIN2+.
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Affiliation(s)
- Ugyen Tshomo
- Department of Obstetrics & Gynaecology, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | | | - Tshokey Tshokey
- Department of Pathology & Laboratory Medicine, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Tashi Tobgay
- Department of Pathology & Laboratory Medicine, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | | | - Vanessa Tenet
- International Agency for Research on Cancer, Lyon, France
| | | | - Peter J.F. Snijders
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands
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