Cervical cancer screening uptake and challenges in Malawi from 2011 to 2015: retrospective cohort study

The impact of DNA tumor viruses in low-to-middle income countries (LMICS): A literature review

DNA viruses are common in the human population and act as aetiological agents of cancer on a large scale globally. They include the human papillomaviruses (HPV), Epstein-Barr virus (EBV), Kaposi sarcoma-associated herpesvirus (KSHV), hepatitis viruses, and human polyomaviruses. Oncogenic viruses employ different mechanisms to induce cancer. Notably, cancer only develops in a minority of individuals who are infected, usually following protracted years of chronic infection. The human papillomaviruses (HPVs) are associated with the highest number of cancer cases, including cervical cancer and other epithelial malignancies. Hepatitis B virus (HBV) and the RNA virus hepatitis C (HCV) are significant contributors to hepatocellular cancer (HCC). Other oncoviruses include Epstein-Barr virus (EBV), Kaposi sarcoma-associated herpes virus (KSHV), human T-cell leukemia virus (HTLV-I), and Merkel cell polyomavirus (MCPyV). The identification of these infectious agents as aetiological agents for cancer has led to reductions in cancer incidence through preventive interventions such as HBV and HPV vaccination, HPV-DNA based cervical cancer screening, antiviral treatments for chronic HBV and HCV infections, and screening of blood for transfusion for HBV and HCV. Successful efforts to identify additional oncogenic viruses in human cancer may provide further understanding of the aetiology and development of cancer, and novel approaches for prevention and treatment. Cervical cancer, caused by HPV, is the leading gynaecological malignancy in LMICs, with high age-standardised incidence and mortality rates, HCC due to HBV is an important cause of cancer deaths, and the burden of other cancer attributable to infections continues to rise globally. Hence, cancers attributable to DNA viruses have become a significant global health challenge. These viruses hence warrant continued attention and interrogation as efforts to understand them further and device further preventive interventions are critical.

Men's perceptions and perceived acceptability of their female partner's use of self-administered intravaginal therapies for treatment of cervical precancer in Kenya

Background

Cervical cancer continues to be a major health issue in low- and middle-income countries (LMICs). Despite increasing access to screening, access to precancer treatment remains a significant challenge in LMICs, highlighting a need for innovative, accessible and resource-appropriate treatment approaches, including self-administered therapies.

Methods

A cross-sectional mixed-methods study was conducted among men aged 25-65 with a current female partner in Kisumu County, Kenya. Participants were sequentially recruited and surveyed to evaluate their understanding of human papillomavirus and cervical cancer, their views on screening and treatment and their attitudes toward self-administered therapies. Focus group discussions (FGDs) with a subset of the survey participants further explored their treatment preferences and perceptions.

Results

Two hundred fourteen men participated in the survey, and 39 men participated in FGDs. The median age was 39 years, and 51% had a primary school education or less. Most (96%) were in a committed relationship, and 74% earned $10 or less daily. There was strong support for self-administered topical therapies, with 98% willing to support their partners using such treatments if available. Additionally, most participants were open to supporting necessary abstinence or condom use, though 76% believed their partners might hesitate to request condom use. When given an option, most preferred their partner to self-administer such therapies at home compared to provider administration at a health facility, citing convenience, cost-effectiveness and privacy. Preferences varied between two potential therapies, 5-Fluorouracil and Artesunate, based on their administration frequency, duration and abstinence requirements. Qualitative findings largely supported the quantitative analysis.

Conclusion

The study demonstrates strong support for self-administered topical therapies for cervical precancer among Kenyan men. Additional research on acceptability, feasibility and efficacy in different LMICs could pave the way for these therapies to help bridge current cervical precancer treatment gaps in these settings.

Cervical cancer prevention in Southern Africa: A review of national cervical cancer screening guidelines in the Southern African development community

BACKGROUND

Cervical cancer poses a significant burden, particularly in low-and-middle income countries (LMIC) with limited access to healthcare. High-income countries have made progress in prevention, while LMIC face unacceptably high incidence and mortality rates, often lacking official screening recommendations. We analysed the presence and content of cervical cancer screening guidelines for the secondary prevention of cervical cancer in the Southern African Development Community (SADC) and compared it to the current World Health Organization (WHO) guidelines for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention.

METHODS

A review of national cervical cancer guidelines across the SADC region was conducted. Data was obtained from government websites, international cancer control platforms, and WHO resources. Search terms included "cervical cancer" and "cervical cancer control guidelines", amongst others. There were no limitations on publication years, and the most recent versions of the guidelines were analysed, regardless of language. Each guideline was assessed for specific screening and treatment recommendations, in relation to the current WHO guidelines. Points were assigned for each data element.

RESULTS

While most countries contributed data to this analysis there was a notable absence of adherence to the WHO guidelines. The most common screening method was naked eye visual inspection. There was a consensus on the age of screening initiation. Most countries recommended treatment by cryotherapy and loop excision.

CONCLUSION

Effective cervical cancer screening programmes, guided by evidence-based recommendations, can enhance early intervention and outcomes. This study highlights the need for standardized and evidence-based cervical cancer screening guidelines in the SADC region, to reduce the burden of cervical cancer and improve the health outcomes of women in these areas.

Prevalence and trends of cervical cancer screening among women in Fiji from 2014 to 2018

Introduction

Cervical cancer is the third most common cancer in women both in developed and developing countries. This study aimed to determine the prevalence of cervical cancer and the trends of cervical cancer screening among women who had cervical cancer screening in Suva, Fiji between 2014 and 2018.

Materials and method

This study applied a 5-year retrospective electronic chart review of data from all women attending the Women's Wellness Clinic (WWC) in Suva, Fiji. The women who were selected for this study and screened for cervical cancer were Fijian citizens above 18 years of age and were registered in 2014-2018. A data collection form was used to collect data. The data was analyzed using Statistical Package for Social Sciences (SPSS) version 24; p <0.05 % was considered as the level of significance.

Results

Among the 39,579 women who attended WWC for other family planning services, 12,074 women screened for cervical cancer with a prevalence of 30.5 %. The overall mean age for women screened for cervical cancer was 37.6 (SD ± 11.2). Two-thirds (76.4 %) of the women screened for cervical cancer were less than 46 years of age and 53.9 % were I-taukei. The number of women who came for Pap smear increased in 2015, however, a slight decline was observed in 2016 which was later improved to 35.1 % in 2018. Malignancy was more common in the age range of 42-49 respectively. In this study, women of 46 years and above had an OR of 0.51 (95 % CI: 0.36, 0.72), other ethnicity OR was 1.73 (95 % CI: 1.27, 2.35), and the Muslim religion OR recorded was 1.44 (95 % CI: 1.03, 2.01) which was comparatively considered a high-risk group. Women who are widowed 1.57 (95 % CI: 0.798, 3.11), single 1.29 (95 % CI: 0.87, 1.92) or divorced 1.08 (95 % CI: 0.59, 1.99), employed 1.01 (95 % CI: 0.83, 1.24) and are living in rural areas 1.19 (95 % CI: 0.82, 1.73) are also associated with higher odds of having abnormal results.

Conclusion

Cervical cancer is listed as the first and most common type of cancer in women which is noticeably increasing in Fiji. Even though cervical cancer screening has improved over the years, adequate surveillance systems and ongoing programs should be designed and implemented to increase awareness and monitor the trend of cervical cancer screening in order to reduce cervical cancer prevalence and mortality rates.

Mobile health-delivered narrative intervention to increase cervical cancer screening among Malawian women living with HIV: A pilot randomized controlled trial

Objective

This study aimed to develop and evaluate a mobile health (mHealth)-delivered, theory-guided, culturally tailored storytelling narrative (STN) intervention to increase cervical cancer screening among Malawian women living with human immunodeficiency virus (HIV).

Methods

This study involved two phases: Phase 1: development of a theory-guided and culturally adapted STN intervention and Phase 2: a pilot randomized controlled trial was conducted. Participants were randomly assigned to one of three arms: Arm 1: tablet-based video (mHealth) with STN (n = 60); Arm 2: mHealth with a video of nonnarrative educational materials (n = 59); and Arm 3: control group with only reading nonnarrative educational materials in person (n = 60). Cervical cancer screening was measured using visual inspection with acetic acid (VIA) uptakes by self-report and health passport record review at 2 and 6 months after intervention.

Results

Both arms 1 and 2 had nearly twice the rate of VIA uptakes than those in Arm 3 (51.0% and 50.0%, respectively, vs. 35.0%, P = 0.01) at 2 months follow-up, but there were no differences among groups from 2- to 6-month follow-ups. All groups demonstrated significant improvement of knowledge about risk factors, intention, and VIA uptakes.

Conclusions

The findings demonstrate the preliminary effectiveness of the intervention on cervical cancer screening behavior and the feasibility of the study regarding recruitment, retention, treatment fidelity, and acceptability of the single 30-min session. The feasibility and the preliminary results of the effectiveness of the proposed study indicate scaling up the STN intervention to a larger population of women to increase cervical cancer screening uptake to prevent deaths due to cervical cancer in Malawi.

Cost-effectiveness of single-visit cervical cancer screening in KwaZulu-Natal, South Africa: a model-based analysis accounting for the HIV epidemic

Introduction

Women living with human immunodeficiency virus (WLHIV) face elevated risks of human papillomavirus (HPV) acquisition and cervical cancer (CC). Coverage of CC screening and treatment remains low in low-and-middle-income settings, reflecting resource challenges and loss to follow-up with current strategies. We estimated the health and economic impact of alternative scalable CC screening strategies in KwaZulu-Natal, South Africa, a region with high burden of CC and HIV.

Methods

We parameterized a dynamic compartmental model of HPV and HIV transmission and CC natural history to KwaZulu-Natal. Over 100 years, we simulated the status quo of a multi-visit screening and treatment strategy with cytology and colposcopy triage (South African standard of care) and six single-visit comparator scenarios with varying: 1) screening strategy (HPV DNA testing alone, with genotyping, or with automated visual evaluation triage, a new high-performance technology), 2) screening frequency (once-per-lifetime for all women, or repeated every 5 years for WLHIV and twice for women without HIV), and 3) loss to follow-up for treatment. Using the Ministry of Health perspective, we estimated costs associated with HPV vaccination, screening, and pre-cancer, CC, and HIV treatment. We quantified CC cases, deaths, and disability-adjusted life-years (DALYs) averted for each scenario. We discounted costs (2022 US dollars) and outcomes at 3% annually and calculated incremental cost-effectiveness ratios (ICERs).

Results

We projected 69,294 new CC cases and 43,950 CC-related deaths in the status quo scenario. HPV DNA testing achieved the greatest improvement in health outcomes, averting 9.4% of cases and 9.0% of deaths with one-time screening and 37.1% and 35.1%, respectively, with repeat screening. Compared to the cost of the status quo ($12.79 billion), repeat screening using HPV DNA genotyping had the greatest increase in costs. Repeat screening with HPV DNA testing was the most effective strategy below the willingness to pay threshold (ICER: $3,194/DALY averted). One-time screening with HPV DNA testing was also an efficient strategy (ICER: $1,398/DALY averted).

Conclusions

Repeat single-visit screening with HPV DNA testing was the optimal strategy simulated. Single-visit strategies with increased frequency for WLHIV may be cost-effective in KwaZulu-Natal and similar settings with high HIV and HPV prevalence.

Cervical cancer screening outcomes for HIV-positive women in the Lubombo and Manzini regions of Eswatini-Prevalence and predictors of a positive visual inspection with acetic acid (VIA) screen

This study aimed to describe the prevalence and predictors of a positive VIA (visual inspection with acetic acid) cervical cancer screening test in women living with human immunodeficiency virus (HIV). We retrospectively analysed data from women aged ≥15 who accessed VIA screening from health facilities in the Lubombo and Manzini regions of Eswatini. Sociodemographic and clinical data from October 2020 to June 2023 were extracted from the client management information system (CMIS). VIA screening outcome was categorised into negative, positive, or suspicious. A logistic regression model estimated the adjusted odds ratio (AOR) of the predictors of a positive VIA screen at p<0.05 with 95% confidence intervals. Of 23,657 participants, 60.8% (n = 14,397) were from the Manzini region. The mean age was 33.3 years (standard deviation 7.0), and 33% (n = 7,714) were first-time screens. The prevalence of a positive VIA was 2.6% (95% CI: 2.2%, 3.0%): 2.8% (95% CI: 2.2%, 3.5%) in Lubombo and 2.4% (95% CI: 2.0%, 2.9%) in Manzini (p = 0.096). Screening at mission-owned (AOR 1.40; p = 0.001), NGO-owned (AOR 3.08; p<0.001) and industrial/workplace-owned health facilities (AOR 2.37; p = 0.044) were associated with increased odds of a positive VIA compared to government-owned health facilities. Compared to those aged 25-34, the odds of a positive VIA increased by 1.26 for those in the 35-44 age group (AOR 1.26; p = 0.017). Predictors with lower odds for a positive VIA test were: being on anti-retroviral therapy (ART) for 5-9 years (AOR 0.76; p = 0.004) and ≥10 years (AOR 0.66; p = 0.002) compared to <5 years; and having an undetectable viral load (AOR 0.39; p<0.001) compared to unsuppressed. Longer duration on ART and an undetectable viral load reduced the odds, while middle-aged women and screening at non-public health facilities increased the odds of a positive VIA screen.

Barriers Associated with Adherence to Cervical Cancer Screening Among Women Living with HIV in Nkhatabay District, Malawi: A Mixed-Methods Study

Background

Cervical cancer (CC) incidence among Women Living with HIV (WLHIV) is high compared to the general population of women. As such, the Malawi National CC guideline recommends yearly screening among WLHIV. However, only 15.9% of WLHIV were screened nationally using Visual Inspection with Acetic Acid (VIA) by 2015 and there is no data regarding adherence and barriers to yearly screening. This study assessed adherence levels and associated barriers to yearly Cervical Cancer screening (CCS) among WLHIV.

Methods

A cross-sectional concurrent mixed-method study was conducted at Nkhatabay District Hospital (NBDH) and Chintheche Rural Hospital (CRH) in Malawi. A sample of 205 WLHIV participated in quantitative strand and in-depth interviews were conducted with 10 health care workers and 10 WLHIV. Quantitative data were analysed using STATA version 16. Pearson's chi-square test and Multivariate logistic regression analysis were performed. P value was set at 0.05. Qualitative data were analysed deductively following six steps of thematic analysis.

Results

Only 5.4% (n=11) of the participants had been screened as required. Women aged ≥45 had 4 times the odds of being screened for CC compared to ≤30 (OR 4.18, 95% CI 0.65-26.8). WLHIV on ART > 10 years had more than 5 times the odds of being screened (OR 5.9, 95% CI 1.08-33.19) compared with those on ART <3 years. Use of male service providers (p =< 0.001), fear of the VIA procedure (p = <0.001) and lack of interest (p = <0.015) were significant barriers to adherence. Qualitative findings revealed a lack of knowledge regarding CCS protocol and the use of male providers.

Conclusion

WLHIV face many challenges in accessing CCS and adherence to yearly CCS is very low. There is urgent need for targeted community awareness, scaling up of HPV tests and incorporation of CCS into routine integrated outreach services.

"There is nothing that can prevent me from supporting her:" men's perspectives on their involvement and support of women's use of topical therapy for cervical precancer treatment in Kenya

Purpose

Cervical cancer disproportionately impacts women in low- and middle-income countries (LMICs). The World Health Organization's (WHO) 90/70/90 strategy aims to eliminate cervical cancer by 2030 by increasing HPV vaccination coverage to 90%, screening 70% of eligible women, and effectively treating 90% of those with abnormal results by 2030, potentially preventing 62 million deaths in LMICs. LMICs, however, struggle with limited access to cervical precancer treatment, in part due to a lack of trained professionals and weak health systems. Effective non-surgical, self-administered, which have demonstrated efficacy in high-income countries, could bridge the treatment gap in LMICs and may be more scalable and cost-effective than provider-administered therapies. To inform feasibility studies in LMICs, data are needed on the role of male partners in influencing the acceptability and uptake of self-administered topical therapies, including their support of recommended abstinence and contraception guidelines associated with these therapies.

Methods

Between November 2022 and April 2023, we conducted five focus group discussions (FGDs) with men aged 25 to 65 years in Kenya to explore their perspective and perceived support regarding their female partners using topical self-administered therapies for cervical precancer treatment. The FGDs were moderated by local qualitative research assistants and conducted in local languages, transcribed, coded, and analyzed using qualitative description.

Results

Thirty-nine male participants meeting the eligibility criteria participated in five FGDs. The mean age of participants was 42.5 years. Most participants, 79.5%, had a female partner with a history of cervical precancer treatment, 5.1% did not, and 15.4% were unsure of their female partner's prior precancer treatment history. The study aimed to assess men's support of their female partners' use of topical therapies for treating cervical precancer. We find that male participants strongly express acceptance and willingness to support their wives or partners in using such therapies, if available. Reported supportive behavior included permitting the use of the therapies and support of maintaining abstinence during the recommended times. Additionally, participants desired male involvement in clinic and community-based education about topical therapies to facilitate widespread support.

Conclusion

The use of self-administered topical therapies for cervical precancer treatment, if supported by efficacy studies in LMICs, may support achieving the WHO's 2030 goal of 90% treatment access. We find that with adequate education, men express overwhelming support of their female partner's use of topical therapies, including adherence to abstinence and contraception guidelines.

Experiences of women participating in a human papillomavirus-based screen-triage-and treat strategy for cervical cancer prevention in Malawi

Objective

To explore the experiences of Malawian women who underwent a human papillomavirus (HPV)-based screen-triage-treat algorithm for cervical cancer (CxCa) prevention. This algorithm included GeneXpert® HPV testing of self-collected vaginal samples, visual inspection with acetic acid (VIA) and colposcopy for HPV-positive women, and thermal ablation of ablation-eligible women.

Method

In-depth interviews were conducted with participants of a trial that evaluated the feasibility of a HPV-based screen-triage-treat algorithm among women living with HIV and HIV negative women in Lilongwe, Malawi. Participants were recruited from 3 groups: 1) HPV-negative; 2) HPV-positive/VIA-negative; 3) HPV-positive/VIA-positive and received thermal ablation. Interviews explored baseline knowledge of CxCa and screening, attitudes towards self-collection, and understanding of test results. Content analysis was conducted using NVIVO v12.

Results

Thematic saturation was reached at 25 interviews. Advantages of HPV self-collection to participants were convenience of sampling, same-day HPV results and availability of same-day treatment. There was confusion surrounding HPV-positive/VIA-negative results, as some participants still felt treatment was needed. Counseling, and in particular anticipatory guidance, was key in helping participants understand complex screening procedures and results. Overall, participants expressed confidence in the HPV screen-triage-treat strategy.

Discussion

HPV testing through self-collected samples is a promising tool to increase CxCa screening coverage. A multi-step screening algorithm utilizing HPV self-testing, VIA triage and thermal ablation treatment requires proper counseling and anticipatory guidance to improve patient understanding. Incorporating thorough counseling in CxCa screening programs can change women's perspectives about screening, build trust in healthcare systems, and influence healthcare seeking behavior towards routine screening and prevention.

State of the Science of Scale-Up of Cancer Prevention and Early Detection Interventions in Low- and Middle-Income Countries: A Scoping Review

PURPOSE

Cancer deaths in low- and middle-income countries (LMICs) will nearly double by 2040. Available evidence-based interventions (EBIs) for cancer prevention and early detection can reduce cancer-related mortality, yet there is a lack of evidence on effectively scaling these EBIs in LMIC settings.

METHODS

We conducted a scoping review to identify published literature from six databases between 2012 and 2022 that described efforts for scaling cancer prevention and early detection EBIs in LMICs. Included studies met one of two definitions of scale-up: (1) deliberate efforts to increase the impact of effective intervention to benefit more people or (2) an intervention shown to be efficacious on a small scale expanded under real-world conditions to reach a greater proportion of eligible population. Study characteristics, including EBIs, implementation strategies, and outcomes used, were summarized using frameworks from the field of implementation science.

RESULTS

This search yielded 3,076 abstracts, with 24 studies eligible for inclusion. Included studies focused on a number of cancer sites including cervical (67%), breast (13%), breast and cervical (13%), liver (4%), and colon (4%). Commonly reported scale-up strategies included developing stakeholder inter-relationships, training and education, and changing infrastructure. Barriers to scale-up were reported at individual, health facility, and community levels. Few studies reported applying conceptual frameworks to guide strategy selection and evaluation.

CONCLUSION

Although there were relatively few published reports, this scoping review offers insight into the approaches used by LMICs to scale up cancer EBIs, including common strategies and barriers. More importantly, it illustrates the urgent need to fill gaps in research to guide best practices for bringing the implementation of cancer EBIs to scale in LMICs.

Cervical cancer screening among female health workers: Evidence from a secondary health facility in Northern Malawi

Cervical cancer is preventable and curable if identified early. Although health workers have a critical role in influencing beliefs and practices of the entire population, some studies have shown paradoxical efforts among female health workers themselves-a threat towards attainment of the triple-intervention strategy as propagated by the World Health Organization (WHO). The study aimed to assess knowledge, attitudes and practices of cervical cancer screening among female health workers. The study used a descriptive cross-sectional design. Data entry and analysis were carried out using IBM Statistical Package for Social Scientists (SPSS) version 20.0 (SPSS, Michigan Avenue, Chicago, IL, USA). The response rate was 65.4 % and mean age of 32 years with standard deviation=±8.397. The majority of participants were nurses n = 31 (43.3). There was poor knowledge on signs/symptoms and risk factors as only 15.7 % were aware of multiple sexual partners, 7.1 % for each early sexual encounter and uncircumcised men as risk factors. Regarding willingness, 77.1 % were willing to have the screening test. Their practices were rated poor as only 35.7 % (n = 25) had ever undergone screening within the past 6 years. There was poor knowledge, fair attitudes and poor practices of cervical cancer screening among female health workers. As part of the efforts to achieve sustainable development goal (SDG) target 3.4 and the attainment of WHO 90-70-90 target by 2030; this study recommends scaling up health education, social mobilization and Human Papillomavirus (HPV) vaccinations to support awareness, detection and treatment of cervical cancer. Acceptability of the current screening methods must be further explored.

Lessons in Cultural Adaptations: Translation of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Cervical Cancer Module From English to Chichewa in Malawi

INTRODUCTION

To complete a culturally appropriate translation of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Cervical Cancer module (QLQ-CX24) from English to Chichewa (one of the official languages of Malawi) in preparation for postsurgical outcomes research in rural Malawian cervical cancer patients.

METHODS

Following the EORTC translation procedure manual, two distinct forward translations from English were reconciled into a preliminary Chichewa translation, followed by two distinct back-translations to English. The English back-translation was reconciled and the translation report sent for discussion and proofreading by EORTC; this was followed by pilot testing. All translators were physicians fluent in English and Chichewa.

RESULTS

Of 24 questions in QLQ-CX24, three had prior translations available; all three required revision to clarify tense or wording. Three discussion exchanges with EORTC refined the translation and ensured faithfulness to the original English meaning; proofreaders contributed minor changes. Pilot testing was completed on 10 female patients (three with cervical cancer, four suspicious cervical lesions, and three screening only). Three patients were illiterate. During pilot testing, translation of question 46 (Q46) was misunderstood as referring to vaginal discharge instead of feeling "feminine". The remaining questions were understood, with minor feedback for six questions. Final revision of Q46 yielded a phrase describing "feminine" as "appearance or activities as a woman". Concepts comparable to "feminine" were absent in the Chichewa language/regional Malawian culture. The final revision of Q46 was pilot-tested on five patients (three illiterate) and found acceptable.

CONCLUSIONS

Translation of the QLQ-CX24 module was completed successfully and revealed absence of the modern concept of femininity in Chichewa language and regional Malawian culture. Care should be taken when creating and translating healthcare-related documents for surgical research to ensure broad applicability across cultures.

Exploring COVID-19 from the perspectives of healthcare personnel in Malawi

Background

The Coronavirus 2019 disease (COVID-19) brought many healthcare systems around the world to the point of collapse all the while putting the lives of healthcare workers at risk. This study forgoes an institutional look at healthcare to center individual healthcare personnel in Malawi to better understand (1) how the worldviews of healthcare workers impact their work in the context of COVID-19, (2) how COVID-19 impacted healthcare workers, and (3) the unique conditions faced by being a healthcare worker in a low-income nation.

Methods

This research uses a hermeneutic phenomenological approach to qualitative methodology involving in-depth interviews (n = 15) with healthcare workers, traditional healers, and hospital leadership. The data collected were inductively coded and analyzed using the framework method, producing rich descriptions on how COVID-19 impacted the lifeworlds of healthcare workers in Malawi.

Results

The findings reveal many of the struggles healthcare workers faced due to misaligned government policy and perceived proximity to COVID-19; outline their needs such as wanting better resources, funds, wages, and public health communication; and, exemplify the significant role that personal biases, worldviews, and sense of fear played in how healthcare workers perceived and interacted with COVID-19.

Conclusion

Much of what was said echoes beyond borders, reflecting common global sentiments felt by healthcare personnel, and offers directions to explore building policies, strategies, and plans in preparation for any future disease outbreaks.

Screening Guidelines and Programs for Cervical Cancer Control in Countries of Different Economic Groups: A Narrative Review

Screening guidelines and practices differ according to resource availability and continually update as scientific developments take place. In this article, we have reviewed screening guidelines and programs for cervical cancer prevention in selected countries belonging to different economic groups viz high income, middle income, and low income. We have selected six countries - the United States of America (USA), the United Kingdom (UK), India, South Africa, Bangladesh, and Malawi. Considerable differences are observed across the health systems. Countries with established screening guidelines complemented by organised nationwide programs or insurance practices have much better screening rates. Human Papilloma Virus (HPV) DNA testing is currently the test of choice in the majority of settings for cervical cancer screening due to its higher sensitivity (up to 90-100%) and longer screening intervals (three to five years). It is also cost-effective, less dependent on operator expertise, and suitable for all settings as compared to a Pap smear test or visual inspection with acetic acid (VIA). Self-sampling of HPV can further help to improve screening coverage by increasing opportunities of reaching to women who would otherwise not participate in screening programs. Resource-constrained countries recommend VIA-based screening in their national programs due to its low cost. The share of cervical cancer is higher in middle and low-income countries as they have lower screening coverage, compared to high-income countries. The main barriers faced in the implementation of the program in low-income countries (LICs) are pertaining to the health system, patient-specific challenges, and healthcare provider-specific challenges.

Results from Two HPV-Based Cervical Cancer Screening-Family Planning Integration Models in Malawi: A Cluster Randomized Trial

We conducted a cluster randomized trial of two models for integrating HPV self-collection into family-planning (FP) services at 16 health facilities in Malawi between March 2020-December 2021. Model 1 involved providing only clinic-based HPV self-collection, whereas Model 2 included both clinic-based and community-based HPV self-collection. An endline household survey was performed in sampled villages and households between October-December 2021 in the catchment areas of the health facilities. We analyzed 7664 surveys from 400 villages. Participants from Model 2 areas were more likely to have ever undergone cervical cancer screening (CCS) than participants from Model 1 areas, after adjusting for district, facility location (urban versus rural), and facility size (hospital versus health center) (adjusted odds ratio = 1.73; 95% CI: 1.29, 2.33). Among participants who had ever undergone CCS, participants from Model 2 were more likely to report having undergone HPV self-collection than participants from Model 1 (50.5% versus 22.8%, p = 0.023). Participants from Model 2 were more likely to be using modern FP (adjusted odds ratio = 1.01; 95% CI: 1.41, 1.98) than Model 1 participants. The integration of FP and HPV self-collection in both the clinic and community increases CCS and modern FP uptake more than integration at the clinic-level alone.

Socio-demographic determinants of cervical cancer screening uptake among women of child-bearing age in Mangochi, Malawi: a facility-based cross-sectional study

Background

Cervical cancer (CC) is the number one leading cause of death among women in Malawi. However, it is generally viewed as preventable and treatable if diagnosed in an early stage. Despite the burden, Malawi registers low uptake of cervical cancer screening (CCS). This study examined the socio-demographic determinants of CCS uptake among women of child-bearing age (WCBA) in Mangochi district.

Methods

A cross-sectional quantitative study was conducted in five health facilities. A total of 482 women between the ages of 18–49 participated and were sampled using a multi-stage sampling method. An interviewer administered structured questionnaire was used to collect data from June to July, 2019. Multivariate logistic regression model was used to identify determinants of CCS uptake among WCBA.

Results

Few respondents (13.1%) had ever done CCS. Compared to respondents in the age-group of 18–24 years, those in the age-groups of 25–35 years and 36–49 years were 2.63 and 3.90 times more likely to undergo CCS (AOR = 2.63, 95% CI 1.30–5.31 and AOR = 3.90, 95% CI 1.62–9.38), respectively. Respondents who practiced Christianity were 2.77 times more likely to undergo CCS than those who practiced Islam (AOR = 2.77, 95% CI 1.23–6.22). Respondents of the Chewa ethnic group were 71% less likely to undergo CCS as compared to those of Yao ethnicity (AOR = 0.29, 95% CI 0.09–0.95). Respondents who lived in semi-urban areas were 2.57 times more likely to go for CCS than those who were village residents (AOR = 2.57, 95% CI 1.19–5.55).

Conclusion

Our study showed that CCS uptake was low in Mangochi and the results suggested that age, religion, ethnicity and place of residence were determinants of CCS uptake. We recommend that comprehensive health education on CC should specifically target the young women and Muslim women in places where they meet. We call upon the district health authorities to scale up CCS provision in all Antiretroviral Therapy (ART) and outreach clinics to improve CCS uptake among women residing in the villages and those of the Chewa ethnicity. We, further, call upon all CC program implementers to design programs that address the highlighted socio-demographic determinants of CCS uptake among WCBA in the district.

Application of the hub and spokes model in improving access to cervical cancer screening in Ghana

OBJECTIVE

To examine the contribution of lower-level health facilities in increasing access to cervical cancer screening in the North Tongu District.

DESIGN

A descriptive cross-sectional study design was used. The Cervical Cancer Prevention and Training Centre (CCPTC) of the Catholic Hospital, Battor, served as the hub, and six health facilities (3 health centres and 3 CHPS compounds) served as the spokes. From April 2018 to September 2019, the well-resourced CCPTC trained 6 nurses at selected Community-based Health Planning and Services (CHPS) / Health Centres (HCs) (spokes) to provide cervical cancer screening services. The nurses, after training, started screening with VIA and HPV DNA testing.

PARTICIPANTS

A total of 3,451women were screened by the trained nurses. This comprised 1,935 (56.1%) from the hub and 1,516 (43.9%) from the spokes.

MAIN OUTCOME MEASURE

The detection of screen positives.

RESULTS

The screen positives were 19.4% (375/1935) at the hub and 4.9% (74/1516) at the spokes.

CONCLUSION

We have demonstrated that a hub and spokes model for cervical cancer screening is possible in limited resource settings. Designating and resourcing a 'hub' that supports a network of 'spokes' could increase women's access to cervical cancer screening. This approach could create awareness about cervical cancer screening services and how they can be accessed.

FUNDING

None declared.

Explaining socioeconomic inequality in cervical cancer screening uptake in Malawi

Background

Cervical cancer is a prevalent public health concern and is among the leading causes of death among women globally. Malawi has the second highest cervical cancer prevalence and burden in the world. Due to the cervical cancer burden, the Malawi government scaled up national cancer screening services in 2011, which are free for all women. This paper is the first study to examine the socioeconomic inequality in cervical cancer screening uptake using concentration indices, in Malawi. Furthermore, it decomposes the concentration index to examine how each factor contributes to the level of inequality in the uptake of cervical cancer screening.

Methods

The data used in this paper were obtained from the nationally representative Malawi Population HIV Impact Assessment (MPHIA) household survey, which was conducted in 2015. Concentration curves were constructed to explore whether there was any socioeconomic inequality in cervical cancer screening and, if so, its extent. This was complemented by concentration indices that were computed to quantify the magnitude of socioeconomic inequality. A decomposition analysis was then conducted to examine the factors that explained/were associated with greater socioeconomic inequality in cervical cancer screening. The methodology in this paper followed that of previous studies found in the literature and used the wealth index to measure socioeconomic status.

Results

The results showed that the concentration curves lay above the line of equality, implying a pro-rich inequality in cervical cancer screening services. Confirming the results from the concentration curves, the overall concentration index was positive and significant (0.142; %95 CI = 0.127, 0.156; p < 0.01). The magnitude was lower in rural areas (0.075; %95CI = 0.059, 0.090; p < 0.01) than in urban areas (0.195; %95CI = 0.162, 0.228 p < 0.001). After undertaking a decomposition of the concentration index, we found that age, education, rural or urban location, and wealth status account for more than 95% of the socioeconomic inequality in cervical cancer uptake.

Conclusion

Despite the national scale-up of free cancer care at the point of use, cervical cancer screening uptake in Malawi remains pro rich. There is a need to implement parallel demand-side approaches to encourage uptake among poorer groups. These may include self-testing and mobile screening centres, among others.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13750-4.

Cervical cancer screening among HIV-positive women in urban Uganda: a cross sectional study

Background

Women living with Human Immunodeficiency Virus (HIV) are at a high risk for early development of cervical cancer. Adherence to cervical cancer prevention strategies in this population is vital for the early detection and treatment of cervical cancer. This study aimed to determine the prevalence and factors associated with cervical cancer screening among HIV-positive women attending an urban HIV care center in Uganda.

Methods

This cross-sectional study included 205 HIV-positive women receiving care at an urban HIV care center. An interviewer-administered questionnaire was used to capture sociodemographic information, history of screening for cervical cancer, and reproductive health characteristics. Logistic regression analysis was used to determine the factors associated with cervical cancer screening.

Results

Of the 205 HIV-positive women with a mean age of 37.5 ± 8.87 that participated in the study, majority (n = 201, 98%) were aware of cervical cancer screening. Ninety participants (44%) had ever been screened for cervical cancer and only 33 (16.1%) had been screened in the past year. Obtaining information about cancer of the cervix and cervical cancer screening from health care professionals was significantly associated with higher levels of cervical cancer screening (adjusted odds ratio = 5.61, 95% confidence interval: 2.50–12.61, p value < 0.001).

Conclusion

This study highlights the low prevalence of cervical cancer screening among HIV-positive women and underscores the role of health professionals as an effective source of information on cervical cancer and cervical cancer screening. Patient education programs in HIV prevention and care facilities should emphasize cervical cancer screening messages to enhance the uptake of screening services.

Prevalence of traditional, complementary, and alternative medicine (TCAM) among adult cancer patients in Malawi

PURPOSE

The objective of this study is to document the prevalence of traditional, complementary, and alternative medicine (TCAM) use by adult cancer patients at a national teaching hospital in Malawi. We aim to document the products/therapies used, the reason for use, as well as patient-reported satisfaction with TCAM practitioners and modalities.

METHODS

We conducted investigator-administered interviews with adult cancer patients presenting to the Kamuzu Central Hospital (KCH) Cancer Clinic in Lilongwe, Malawi between January and July 2018. The KCH is a national teaching hospital in the capital of Lilongwe, which serves patients with cancer from the northern half of Malawi. Descriptive statistics were used to describe TCAM use and logistic regression was applied to identify predictors of TCAM.

RESULTS

A total of 263 participants completed the survey, of which 70% (n = 183) were female and average age was 45 (SD 14) years old. The prevalence of overall TCAM use was 84% (n = 222), and 60% (n = 157) of participants reported combining TCAM with conventional cancer treatment. The majority of patients used TCAM to directly treat their cancer versus for symptom management. Patients reported using faith-based healing (64%, n = 168), herbal medicine (56%, n = 148), diet change (46%, n = 120), and vitamins/minerals (23%, n = 61). Participants reported the highest satisfaction for physicians among practitioners and diet change for modalities. Female gender was found to be a predictor of TCAM with conventional treatment use, no other significant predictors were observed.

CONCLUSION

There is a high prevalence of TCAM use among an adult population with cancer in Malawi, and a wide variety in the TCAM modalities used among patients. Additional studies are needed to identify risks and benefits of TCAM use to assist with policy and public health, patient safety, and holistically address the global burden of cancer.

Support for lowering cervical cancer screening age to 25 for women living with HIV: retrospective cross-sectional programmatic data from Botswana

BACKGROUND

Women living with human immunodeficiency virus (HIV) tend to develop cervical cancer at a younger age than women without HIV. The World Health Organization's (WHO) 2021 guidelines for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention include a conditional recommendation for initiating screening at age 25 for women living with HIV (WLWH). This recommendation is based on low-certainty evidence, and WHO calls for additional data. We describe the association of age and HIV status with visual inspection with acetic acid (VIA) positivity and cervical intraepithelial neoplasia grade two or higher (CIN2+) in Botswana.

METHODS

This was a retrospective cross-sectional study of 5714 participants aged 25 to 49 years who underwent VIA screening in a clinic mainly serving WLWH. VIA-positive women received cryotherapy if eligible or were referred for colposcopy and excisional treatment. Known cervical cancer risk factors, screening outcome, and histological results were extracted from the program database. We compared the proportions and association of VIA positivity and CIN2+ by age and HIV status.

RESULTS

The median age was 35 years [IQR 31-39], and 18% of the women were aged 25-29. Ninety percent were WLWH; median CD4 count was 250 cells/µL [IQR 150-428], and 34.2% were on anti-retroviral treatment (ART). VIA-positivity was associated with younger age (OR 1.48, CI 1.28, 1.72 for 25-29 years vs. 30-49 years), and HIV-positivity (OR 1.85, CI 1.51, 2.28). CIN2+ was only associated with HIV-positivity (OR 6.12, CI 3.39, 11.10), and proportions of CIN2+ were similar for both age groups in WLWH (69.1% vs. 68.3%).

CONCLUSIONS

Younger WLWH in Botswana had a significant burden of CIN2+. This finding further supports lowering the screening age for WLWH from 30 to 25.

A novel cervical cancer screen-triage-treat demonstration project with HPV self-testing and thermal ablation for women in Malawi: Protocol for a single-arm prospective trial

Cervical cancer is the leading cause of cancer mortality among Malawian women, despite being preventable through screening and preventive therapy. In 2004, Malawi implemented a national screening program, using visual inspection with acetic acid (VIA) and cryotherapy, but its success has been limited due to equipment and human resources challenges. Since the development of that program, new technologies for screening and treatment that are less resource-intensive and more scalable have become available. GeneXpert systems provide fast, accurate HPV results and are increasingly available in low-income countries. Self-collection for human papillomavirus (HPV) testing is a validated method for screening and improves uptake. Thermal ablation provides an alternative ablative treatment that is simpler to use than cryotherapy and can be performed with portable devices. Meanwhile, urine HPV testing methods provide promising options for primary screening. We designed a single-arm prospective study to investigate a novel HPV screen-triage-treat strategy among 1250 women in Lilongwe, Malawi. Our proposed strategy consists of (1) Xpert HPV testing of self-collected samples, (2) VIA and colposcopy for HPV-positive women, and (3) thermal ablation for HPV-positive/ablation-eligible women. We will collect cervical biopsies, Pap smears, and endocervical samples to validate the HPV results and VIA/colposcopy findings against endpoints of high-grade cervical intraepithelial neoplasia or cancer (CIN2+). We will evaluate same-day completion of our algorithm, its performance in triaging women for treatment, and 24-week treatment efficacy of thermal ablation. We will also explore the performance of HPV and methylation tests in urine samples, as compared to provider- and self-collected cervicovaginal samples.

Histopathological profile of cervical biopsies in northern Malawi: a retrospective cross-sectional study

OBJECTIVES

According to the WHO (2014), cervical cancer is the second most common cancer in women globally. More than 85% of the global cervical cancer morbidity and mortality occur in low-income and middle-income countries and the highest risk region is in Eastern and Southern Africa. Malawi has the highest age-standardised rate of cervical cancer in the world. This study was carried out to determine the histopathological profile of cervical biopsies in a public tertiary hospital in Mzuzu, northern region of Malawi.

SETTING

A public tertiary hospital in Mzuzu, northern region of Malawi.

PARTICIPANTS

This was a retrospective study of all cervical biopsy specimen reports received in a public tertiary hospital in northern Malawi over a period of 5 years from July 2013 to June 2018. Demographic, clinical and diagnostic data were obtained from original histopathology reports.

RESULTS

A total of 500 cervical biopsy reports were reviewed during the study period. The mean age of the patients was 41.99±12.5. Age ranged from 15 to 80 years. Cervicitis accounted for 46.0% (n=162) of the total non-malignant lesions seen, followed by cervical intraepithelial neoplasm, at 24.4% (n=86) and endocervical polyp, at 20.5% (n=72). Squamous cell carcinoma (SCC) accounted for 15.6% (n=78) of the total cervical biopsies studied and 85.7% of all total malignant lesions. Adenocarcinoma and undifferentiated carcinoma were 8.8% and 4.4%, respectively of the total malignant diagnosis. All patients with malignant lesions had HIV.

CONCLUSION

Our study shows that cervicitis and SCC were most common among non-malignant and malignant cervical biopsies, respectively. Since the frequency of cervical cancer is high, there is a need to have well detailed national policies to be put in place to increase detection of preinvasive lesions in order to reduce the prevalence of cervical cancer.

Cancer Statistics and Anticancer Potential of Peganum harmala Alkaloids: A Review

Cancer is one of the most common diseases in the world. Although it develops in various organs and tissues, some species maintain a stable position in the ranking. Although the cancer causes are different, the specific grounds for each type are also noted. Sometimes the increase in incidents and mortality is associated with geographical reasons. Increases in statistics, expensive and chemotherapeutic methods focus on plant-based substances. One of such potential plants is Peganum harmala, which contains alkaloids such as harmine, harmaline, harmol, and harmalol. The effects of these compounds on many cancer cells have been tested, and positive results have been obtained. This fact reinforces the claim that more in-depth research on noted alkaloids is needed.

Cervical cancer screening coverage and its related knowledge in southern Malawi

Background

Cervical cancer (CC) is the fourth most common cancer among women worldwide and Malawi has the world’s highest rate of cervical cancer related mortality. Since 2016 the National CC Control Strategy has set a screening coverage target at 80% of 25-49-year-old women. The Ministry of Health and Médecins Sans Frontières (MSF) set up a CC program in Blantyre City, as a model for urban areas, and Chiradzulu District, as a model for rural areas. This population-based survey aimed to estimate CC screening coverage and to understand why women were or were not screened.

Methods

A population-based survey was conducted in 2019. All resident consenting eligible women aged 25-49 years were interviewed (n = 1850) at households selected by two-stage cluster sampling. Screening and treatment coverage and facilitators and barriers to screening were calculated stratified by age, weighted for survey design. Chi square and design-based F tests were used to assess relationship between participant characteristics and screening status.

Results

The percentage of women ever screened for CC was highest in Blantyre at 40.2% (95% CI 35.1-45.5), 38.9% (95% CI 32.8-45.4) in Chiradzulu with supported CC screening services, and lowest in Chiradzulu without supported CC screening services at 25.4% (95% CI 19.9-31.8). Among 623 women screened, 49.9% (95% CI 44.0-55.7) reported that recommendation in the health facility was the main reason they were screened and 98.5% (95% CI 96.3-99.4) recommended CC screening to others. Among 1227 women not screened, main barriers were lack of time (26.0%, 95% CI 21.9-30.6), and lack of motivation (18.3%, 95% CI 14.1-23.3). Overall, 95.6% (95% CI 93.6-97.0) of women reported that they had some knowledge about CC. Knowledge of CC symptoms was low at 34.4% (95% CI 31.0-37.9) and 55.1% (95% CI 51.0-59.1) of participants believed themselves to be at risk of CC.

Conclusion

Most of the survey population had heard about CC. Despite this knowledge, fewer than half of eligible women had been screened for CC. Reasons given for not attending screening can be addressed by programs. To significantly reduce mortality due to CC in Malawi requires a comprehensive health strategy that focuses on prevention, screening and treatment.

Perceptions of cervical cancer and motivation for screening among women in Rural Lilongwe, Malawi: A qualitative study

INTRODUCTION

Cervical cancer is the leading cause of cancer death among women in Malawi. Low awareness of cervical cancer and negative perceptions of screening can prevent women from participating in preventative strategies. We sought to explore perceptions and motivations for screening among women who participated in a cervical cancer screen-and-treat pilot study in rural Malawi.

MATERIALS AND METHODS

We conducted a qualitative sub-study of a community-based cervical cancer screen-and-treat pilot study in rural Lilongwe between July-August 2017. From October 2017-February 2018, 17 women who underwent screening using visual inspection with acetic acid (VIA) and same-day thermal ablation treatment were recruited at their 12-week follow-up visit post treatment to participate in this qualitative sub-study. Semi-structured interview guides that explored baseline knowledge of cervical cancer, perceptions, and motivation for screening were used for in-depth interviews (IDIs). IDIs were conducted in the local language, Chichewa, translated and transcribed to English. Data was analyzed using NVivo® V12.0.

RESULTS

Findings included fatalistic views on cancer, but limited knowledge specific to cervical cancer. Misconceptions of cervical cancer screening were common; however, there was a unique understanding of screening as prevention (i.e., finding and treating early disease to prevent progression to worsening disease). This understanding appeared to stem from HIV prevention concepts known to the community. Motivations for screening included desire to know one's health status, convenience of community-based screening, and peer encouragement.

CONCLUSION

Despite limited knowledge of cervical cancer and misconceptions of screening, the concept of screening for prevention, desire to know one's health status, convenient access, and peers' influence were motivators for participation in screening. Cervical cancer screen-and-treat programs in high HIV prevalence areas should consider utilizing language that parallels HIV prevention language to communicate the need for cervical cancer screening and treatment and utilize prevention concepts that may already be familiar to women living there.

Implementation research to accelerate scale-up of national screen and treat strategies towards the elimination of cervical cancer

BACKGROUND

Cervical cancer is a significant public health problem, with 570,000 new cases and 300,000 deaths of women per year globally, mostly in low- and middle-income countries. In 2018 the WHO Director General made a call to action for the elimination of cervical cancer as a public health problem.

MAIN BODY

New thinking on programmatic approaches to introduce emerging technologies and screening and treatment interventions of cervical precancer at scale is needed to achieve elimination goals. Implementation research (IR) is an important yet underused tool for facilitating scale-up of evidence-based screening and treatment interventions, as most research has focused on developing and evaluating new interventions. It is time for countries to define their specific IR needs to understand acceptability, feasibility, and cost-effectiveness of interventions as to design and ensure effective implementation, scale-up, and sustainability of evidence-based screening and treatment interventions. WHO convened an expert advisory group to identify priority IR questions for HPV-based screening and treatment interventions in population-based programmes. Several international organizations are supporting large scale introduction of screen-and-treat approaches in many countries, providing ideal platforms to evaluate different approaches and strategies in diverse national contexts.

CONCLUSION

For reducing cervical cancer incidence and mortality, the readiness of health systems, the reach and effectiveness of new technologies and algorithms for increasing screening and treatment coverage, and the factors that support sustainability of these programmes need to be better understood. Answering these key IR questions could provide actionable guidance for countries seeking to implement the WHO Global Strategy towards cervical cancer elimination.

Association of HIV status and treatment characteristics with VIA screening outcomes in Malawi: A retrospective analysis

Background

Although evidence from high-resource settings indicates that women with HIV are at higher risk of acquiring high-risk HPV and developing cervical cancer, data from cervical cancer “screen and treat” programs using visual inspection with acetic acid (VIA) in lower-income countries have found mixed evidence about the association between HIV status and screening outcomes. Moreover, there is limited evidence regarding the effect of HIV-related characteristics (e.g., viral suppression, treatment factors) on screening outcomes in these high HIV burden settings.

Methods

This study aimed to evaluate the relationship between HIV status, HIV treatment, and viral suppression with cervical cancer screening outcomes. Data from a “screen and treat” program based at a large, free antiretroviral therapy (ART) clinic in Lilongwe, Malawi was retrospectively analyzed to determine rates of abnormal VIA results and suspected cancer, and coverage of same-day treatment. Multivariate logistic regression assessed associations between screening outcomes and HIV status, and among women living with HIV, viremia, ART treatment duration and BMI.

Results

Of 1405 women receiving first-time VIA screening between 2017–2019, 13 (0.9%) had suspected cancer and 68 (4.8%) had pre-cancerous lesions, of whom 50 (73.5%) received same-day lesion treatment. There was no significant association found between HIV status and screening outcomes. Among HIV+ women, abnormal VIA was positively associated with viral load ≥ 1000 copies/mL (aOR 3.02, 95% CI: 1.22, 7.49) and negatively associated with ART treatment duration (aOR 0.88 per additional year, 95% CI: 0.80, 0.98).

Conclusion

In this population of women living with HIV with high rates of ART coverage and viral suppression, HIV status was not significantly associated with abnormal cervical cancer screening results. We hypothesize that ART treatment and viral suppression may mitigate the elevated risk of cervical cancer for women living with HIV, and we encourage further study on this relationship in high HIV burden settings.

Comparative assessment of test characteristics of cervical cancer screening methods for implementation in low-resource settings

Cervical cancer disproportionately affects low-resource settings. Papanicolaou, human papillomavirus (HPV), and visual inspection of cervix with acetic acid (VIA) testing, each with different characteristics, will reduce cervical cancer burden. We conducted a critical literature review using PubMed, Cochrane, WHO, and grey literature from 1994 to 2020. We examined efficacy, harms, and comparative effectiveness of screening methods by age, human immunodeficiency virus, provider characteristics, and assessed implementation challenges in low-resource settings. Comprehensive data on utility and efficacy of screening tests indicates that each screening has strengths and shortcomings but all confer acceptable performance. HPV and VIA appear more promising. Primary HPV test-and-treat, self-testing, and co-testing have been studied but data on triage plans, cost, support system, implementation and sustainability is unclear in low-resource settings. HPV testing could help target subgroups of older or higher risk women. VIA offers local capacity-building and scalability. Quality VIA technique after HPV testing is still required to guide post-screening treatments. VIA competencies decline gradually with current standard trainings. Stationary cervicography improves VIA quality but isn't scalable. Affordable smartphones eliminate this barrier, enhance training through mentorship, and advance continuing education and peer-to-peer training. Smartphone-based VIA facilitates cervical image storage for patient education, health promotion, record-keeping, follow-up care, remote expert support, and quality control to improve VIA reliability and reproducibility and reduce mis-diagnoses and burden to health systems. Rather than ranking screening methods using test characteristics alone in study or higher-resource settings, we advocate for scalable strategies that maximize reliability and access and reduce cost and human resources.

Lessons learned from a rural, community-based cervical cancer screen-and-treat pilot study in Malawi

Objectives

Invasive cervical cancer (ICC) is the leading cause of cancer-related death among women in Malawi. Barriers to screening for ICC in Malawi, such as long distances to health facilities and lack of public education about ICC, have hindered participation of women in ICC prevention programs. Given the burden of disease and barriers to screening, we implemented a community-based ICC screen-and-treat pilot study and present its successes and challenges.

Study design

This study was a screen-and-treat pilot study using Visual Inspection with Acetic acid (VIA) for screening and same-day thermal ablation for treatment of pre-cancerous lesions. The pilot was implemented in four rural community settings in Lilongwe District, Malawi.

Methods

With consultation from local leaders, as well as the UNC Project-Malawi Community Department and the Community Advisory Board, a team of researchers designed a rural, community-based ICC screen-and-treat pilot study. Over a 5-week period, we travelled to four rural communities to provide information about and screening for ICC and HIV through our study. The four selected rural locations were about an hour drive from Lilongwe City, Malawi. Detailed field notes were taken by study staff and then later analyzed and categorized as either strengths or challenges.

Results

Successes included support from local leaders, high uptake of screening (408 women underwent VIA, representing 88% of eligible women), positive experiences during screening, and good communication between study staff and participants. This communication enabled us to quickly address misperceptions about the study intent and procedures and to better understand some of the barriers to care. Challenges included insufficient medication for diagnosed sexually transmitted infections, finding ways to engage interested women who were ineligible due to young age, and not screening interested women because they needed male partner approval.

Conclusion

Community-based screen-and-treat programs with thermal ablation for ICC can be an effective way to engage hard-to-reach women in ICC preventive care. Our findings support existing literature which suggests that involvement of local leadership, women from the community, and their male partners, as well as ongoing peer education, may facilitate greater participation in ICC screening and treatment. In addition, we found ongoing communication between study staff and participants to be mutually beneficial. Finally, we suggest that future interventions consider bundling sexually transmitted infection treatment into ICC preventive care when engaging hard-to-reach populations.

Cancer of the cervix uteri: 2021 update

Since the publication of the 2018 FIGO Cancer Report, giant strides have been made in the global effort to reduce the burden of cervical cancer, with the World Health Organization (WHO) rolling out a global strategy for cervical cancer elimination, aiming for implementation by 2030. In over 130 countries, including low- and middle-income countries, HPV vaccination is now included in the national program. Screening has seen major advances with wider implementation of HPV testing. These interventions will take a few years to show their impact. Meanwhile, over half a million new cases are added each year. FIGO's revised staging of cervical cancer (2018) has been widely implemented and retrospective analyses of data based on the new staging have been published. Minimally invasive surgery has been shown to be disadvantageous in women with cervical cancer. This chapter discusses the management of cervical cancer based on the stage of disease, including attention to palliation and quality of life issues.

Barriers to follow-up after an abnormal cervical cancer screening result and the role of male partners: a qualitative study

INTRODUCTION

Cervical cancer is the leading cause of cancer deaths among women in Malawi, but preventable through screening. Malawi primarily uses visual inspection with acetic acid (VIA) for screening, however, a follow-up for positive screening results remains a major barrier, in rural areas. We interviewed women who underwent a community-based screen-and-treat campaign that offered same-day treatment with thermocoagulation, a heat-based ablative procedure for VIA-positive lesions, to understand the barriers in accessing post-treatment follow-up and the role of male partners in contributing to, or overcoming these barriers.

METHODS

We conducted in-depths interviews with 17 women recruited in a pilot study that evaluated the safety and acceptability of community-based screen-and-treat programme using VIA and thermocoagulation for cervical cancer prevention in rural Lilongwe, Malawi. Ten of the women interviewed presented for post-treatment follow-up at the healthcare facility and seven did not. The interviews were analysed for thematic content surrounding barriers for attending for follow-up and role of male partners in screening.

RESULTS

Transportation was identified as a major barrier to post-thermocoagulation follow-up appointment, given long distances to the healthcare facility. Male partners were perceived as both a barrier for some, that is, not supportive of 6-week post-thermocoagulation abstinence recommendation, and as an important source of support for others, that is, encouraging follow-up attendance, providing emotional support to maintaining post-treatment abstinence and as a resource in overcoming transportation barriers. Regardless, the majority of women desired more male partner involvement in cervical cancer screening.

CONCLUSION

Despite access to same-day treatment, long travel distances to health facilities for post-treatment follow-up visits remained a major barrier for women in rural Lilongwe. Male partners were identified both as a barrier to, and an important source of support for accessing and completing the screen-and-treat programme. To successfully eliminate cervical cancer in Malawi, it is imperative to understand the day-to-day barriers women face in accessing preventative care.

Barriers and facilitators in cervical cancer screening uptake in Abidjan, Côte d'Ivoire in 2018: a cross-sectional study

Backgrounds

Cervical cancer (CC) incidence remains unacceptably high in Côte d’Ivoire. In an effort to prevent this malignant condition, a national CC screening program has been scaled up in the country. This study aimed at assessing CC screening uptake and its associated factors in Abidjan in 2018.

Methods

A cross-sectional survey was conducted from July to September 2018 in the main healthcare facilities of three randomly selected out of the eight health districts of Abidjan. During the study period, a standardized questionnaire was administrated by research assistants to all women aged 25 to 55 years old, attending the three participating facilities. Demographics, knowledge on CC, personal history of CC screening and reasons for not attending CC screening were collected. A logistic regression model was computed to document factors associated with reported CC screening uptake.

Results

A total of 1158 women with a median age of 32 years (IQR [27–36]), including 364 (31.4%) with no formal education were included. Of those participants, 786 (67.9%) had ever heard about CC. CC screening uptake at least once was reported by 7.5% [95% CI: 6.0–9.0] participants. In multivariable analysis, being ≥45 years (aOR: 6.2 [2.3–17.2]), having a university level (aOR: 2.8 [1.2–6.6]) (versus non formal education) and access to mass campaign information (aOR: 18.2 [8.5–39.1]) were associated with a reported CC screening uptake. The main reported barriers to CC screening were unawareness towards CC screening (75.5%), negligence (20.5%), fear of CC detection (3.9%) and fear of additional costs (3.3%).

Conclusion

CC screening uptake remains low despite current initiatives to support awareness and prevention in Abidjan. Awareness campaigns need to be massively increased with the adjunction of tailored messages based on the level of women’s education to enhance the CC screening coverage and reach the WHO goal of CC elimination by 2030.

Safety and Acceptability of Thermal Ablation for Treatment of Human Papillomavirus Among Women Living With HIV in Western Kenya

PURPOSE

The WHO now recommends thermal ablation as an alternative to cryotherapy within “screen-and-treat” cervical cancer programs in low- and middle-income countries (LMICs). We conducted a safety and acceptability clinical trial of thermal ablation in a Kenyan Ministry of Health hospital among women living with HIV (WLWH; ClinicalTrials.gov identifier: NCT04191967).

METHODS

Between August 2019 and February 2020, WLWH age 25-65 years underwent human papillomavirus (HPV) self-collection in western Kenya. HPV-positive women underwent visual inspection with acetic acid, biopsy, and treatment with thermal ablation performed by a nonphysician clinician, if eligible by standard guidelines. A questionnaire was administered after treatment to assess for pain and treatment acceptability. Adverse events (AEs) were evaluated 4-6 weeks after treatment with a standardized grading tool.

RESULTS

A total of 293 HPV-positive WLWH underwent thermal ablation in the study period. The mean age was 40.4 years (standard deviation, 8.7 years). After treatment, 15 (5.1%), 231 (78.8%), 42 (14.3%), and 5 (1.8%) reported none, mild, moderate, and severe pain with treatment, respectively. At follow-up, spotting, vaginal discharge, and pelvic pain were reported by 99 (37.8%), 258 (98.5%), and 46 (17.6%), respectively, for a median of 3.3 (interquartile range [IQR], 2-3), 14 (IQR, 7-21), and 7 (IQR, 3-7) days, respectively. Most participants graded their AEs as mild (grade 1): 94 (95.0%) for bleeding, 125 (48.5%) for vaginal discharge, and 37 (80.4%) for pelvic pain. No grade 3 or 4 AEs were reported. The vast majority (99.2%) were satisfied with the treatment and would recommend it to a friend.

CONCLUSION

Thermal ablation performed by nonphysicians in the public health sector in Kenya proved safe and highly acceptable in treating HPV-positive WLWH.

Increasing cervical cancer screening at a non-government medical center in Lilongwe, Malawi

Malawi has the highest incidence of and mortality rate due to cervical cancer in the world. This is largely because of inadequate screening and high rates of human immunodeficiency virus (HIV) infection, which greatly increases cervical cancer risk. We describe the implementation of a quality improvement program to increase use of cervical cancer screening at a non-government medical center in Lilongwe, Malawi. The intervention, developed and launched from March to August 2017, aimed to promote education among patients and clinicians about the importance of cervical cancer screening and improve accessibility of screening information within medical records. Visual inspection with acetic acid (VIA) was used to screen for cervical cancer. Women with a positive VIA were offered treatment using thermocoagulation. The number of VIA screenings conducted in 2016 (pre-intervention), 2017 (intervention), and 2018 (post-intervention) was 125, 234 and 456, respectively. Of the 815 women screened during this period, 36 (4.4%) had a VIA-positive result and 12 (1.5%) had suspect cancer. Of the VIA-positive women, 13 (36.1%) received same-day treatment with thermocoagulation. An interrupted time series regression revealed that there was a sustained increase in monthly screenings between the pre- and post-intervention period (β = 30.84; p = 0.006; 95% CI 9.72-51.97), suggesting that the intervention likely was effective in increasing cervical cancer screening. Our results demonstrate that focusing on developing sustainable solutions and improving system processes, without additional equipment or funding, significantly increased the number of women screened and should be considered in other settings to enhance cervical cancer prevention services.

Women's experiences in a community-based screen-and-treat cervical cancer prevention program in rural Malawi: a qualitative study

BACKGROUND

Malawi has the world's highest cervical cancer incidence and mortality due to high rate of HIV coupled with inadequate screening and treatment services. The country's cervical cancer control program uses visual inspection with acetic acid (VIA) and cryotherapy, but screening is largely limited by poor access to facilities, high cost of cryotherapy gas, and high loss-to-follow-up. To overcome these limitations, we implemented a community-based screen-and-treat pilot program with VIA and thermocoagulation. Through a qualitative study, we explore the experiences of women who underwent this community-based pilot screening program.

METHODS

We implemented our pilot program in rural Malawi and conducted an exploratory qualitative sub-study. We conducted in-depth interviews with women who were treated with thermocoagulation during the program. We used semi-structured interviews to explore screen-and-treat experience, acceptability of the program and attitudes towards self-sampling for HPV testing as an alternative screening method. Content analysis was conducted using NVIVO v12.

RESULTS

Between July - August 2017, 408 participants eligible for screening underwent VIA screening. Thirty participants had VIA positive results, of whom 28 underwent same day thermocoagulation. We interviewed 17 of the 28 women who received thermocoagulation. Thematic saturation was reached at 17 interviews. All participants reported an overall positive experience with the community-based screen-and-treat program. Common themes were appreciation for bringing screening directly to their villages, surprise at the lack of discomfort, and the benefits of access to same day treatment immediately following abnormal screening. Negative experiences were rare and included discomfort during speculum exam, long duration of screening and challenges with complying with postprocedural abstinence. Most participants felt that utilizing self-collected HPV testing could be acceptable for screening in their community.

CONCLUSIONS

Our exploratory qualitative sub-study demonstrated that the community-based screen-and-treat with VIA and thermocoagulation was widely accepted. Participants valued the accessible, timely, and painless thermocoagulation treatment and reported minimal side effects. Future considerations for reaching rural women can include community-based follow-up, cervical cancer education for male partners and self-sampling for HPV testing.

Prevention of cervical cancer through two HPV-based screen-and-treat implementation models in Malawi: protocol for a cluster randomized feasibility trial

Background

Cervical cancer is the leading cause of cancer incidence and mortality among Malawian women, despite being a largely preventable disease. Implementing a cervical cancer screening and preventive treatment (CCSPT) program that utilizes rapid human papillomavirus (HPV) testing on self-collected cervicovaginal samples for screening and thermal ablation for treatment may achieve greater coverage than current programs that use visual inspection with acetic acid (VIA) for screening and cryotherapy for treatment. Furthermore, self-sampling creates the opportunity for community-based screening to increase uptake in populations with low screening rates. Malawi’s public health system utilizes regularly scheduled outreach and village-based clinics to provide routine health services like family planning. Cancer screening is not yet included in these community services. Incorporating self-sampled HPV testing into national policy could address cervical cancer screening barriers in Malawi, though at present the effectiveness, acceptability, appropriateness, feasibility, and cost-effectiveness still need to be demonstrated.

Methods

We designed a cluster randomized feasibility trial to determine the effectiveness, acceptability, appropriateness, feasibility, and budget impact of two models for integrating a HPV-based CCSPT program into family planning (FP) services in Malawi: model 1 involves only clinic-based self-sampled HPV testing, whereas model 2 includes both clinic-based and community-based self-sampled HPV testing. Our algorithm involves self-collection of samples for HPV GeneXpert® testing, visual inspection with acetic acid for HPV-positive women to determine ablative treatment eligibility, and same-day thermal ablation for treatment-eligible women. Interventions will be implemented at 14 selected facilities. Our primary outcome will be the uptake of cervical cancer screening and family planning services during the 18 months of implementation, which will be measured through an Endline Household Survey. We will also conduct mixed methods assessments to understand the acceptability, appropriateness, and feasibility of the interventions, and a cost analysis to assess budget impact.

Discussion

Our trial will provide in-depth information on the implementation of clinic-only and clinic-and-community models for integrating self-sampled HPV testing CCSPT with FP services in Malawi. Findings will provide valuable insight for policymakers and implementers in Malawi and other resource-limited settings with high cervical cancer burden.

Trial registration

ClinicalTrials.gov identifier: NCT04286243. Registered on February 26, 2020.

Uptake and safety of community-based "screen-and-treat" with thermal ablation preventive therapy for cervical cancer prevention in rural Lilongwe, Malawi

Malawi has the highest invasive cervical cancer (ICC) mortality rate worldwide, and ICC is the leading cause of cancer death among women. In 2004, Malawi adopted visual inspection with acetic acid (VIA) and ablative treatment with cryotherapy. However, screening coverage has remained low (<30%) and few women (<50%) who require ablative treatment receive it. Additional barriers include long distances to health facilities and challenges with maintaining gas supplies. Thermal ablation is a safe and effective alternative to cryotherapy. We assessed the safety and uptake of community-based ICC screening with VIA and same-day treatment using a handheld thermocoagulator (HTU) in rural Malawi. We held educational talks alongside community leaders and conducted VIA screening in nonclinic community settings to nonpregnant women aged 25 to 49 years without history of hysterectomy or genital cancer/precancer. Eligible women received same-day thermal ablation and HIV testing/counseling. We collected cervical biopsies before treatment and followed up women at Weeks 6 and 12, with repeat biopsy at Week 12. Between July and August 2017, 408 (88%) of 463 eligible women underwent VIA. Overall, 7% (n = 30) of women had a positive VIA, of whom 93% (n = 28) underwent same-day thermal ablation. Among the 30 VIA-positive women, 5 had cervical intraepithelial neoplasia (CIN) 1, 4 had CIN 2/3 and 21 had benign histologic findings. Abnormal vaginal discharge (60%) and light vaginal bleeding (52%) were the most reported adverse events. There was high uptake of the community-based ICC screening in the study population and treatment was safe in this setting. Similar strategies that minimize false-positive results are urgently needed in Malawi.

Improving uptake of cervical cancer screening services for women living with HIV and attending chronic care services in rural Malawi

Malawi has the second highest age-standardised incidence rate and the highest mortality rate of cervical cancer in the world. Though the prevalence of HIV is currently 11.7% for Malawian women of reproductive age, cervical cancer screening rates remain low. To address this issue, we integrated cervical cancer screening into a dual HIV and non-communicable disease clinic at a rural district hospital in Neno, Malawi. The project was implemented between January 2017 and March 2018 using the Plan-Do-Study-Act model of quality improvement (QI). At baseline (January to December 2016), only 13 women living with HIV were screened for cervical cancer. One year after implementation of the QI project, 73% (n=547) of women aged 25 to 49 years living with HIV enrolled in HIV care were screened for cervical cancer, with 85.3% of these receiving the screening test for the first time. The number of women living with HIV accessing cervical cancer services increased almost 10 times (from four per month to 39 per month, p<0.001). Key enablers in our QI process included: strong mentorship, regular provision of cervical cancer health talks throughout the hospital, nationally accredited cervical cancer prevention training for all providers, consistent community engagement, continuous monitoring and evaluation, and direct provision of resources to strengthen gaps in the public system. This practical experience integrating cervical cancer screening into routine HIV care may provide valuable lessons for scale-up in rural Malawi.

Health care workers' experiences with implementation of "screen and treat" for cervical cancer prevention in Malawi: A qualitative study

BACKGROUND

Cervical cancer remains a major cause of mortality and morbidity in low- and middle-income countries, despite the availability of effective prevention approaches. "Screen and treat" (a single-visit strategy to identify and remove abnormal cervical cells) is the recommended secondary prevention approach in low-resource settings, but there has been relatively scarce robust implementation science evidence on barriers and facilitators to providing "screen and treat" from the provider perspective, or about thermocoagulation as a lesion removal technique.

METHODS

Informed by the Consolidated Framework for Implementation Research (CFIR), we conducted interviews with ten experienced "screen and treat" providers in Malawi. We asked questions based on the CFIR Guide, used the CFIR Guide codebook for a descriptive analysis in NVivo, and added recommended modifications for studies in low-income settings.

RESULTS

Seven CFIR constructs were identified as positively influencing implementation, and six as negatively influencing implementation. The two strong positive influences were the relative advantage of thermocoagulation versus cryotherapy (Innovation Characteristics) and respondents' knowledge and beliefs about providing "screen and treat" (Individual Characteristics). The two strong negative influences were the availability of ongoing refresher trainings to stay up-to-date on skills (Inner Setting, Implementation Climate) and insufficient resources (staffing, infrastructure, supplies) to provide "screen and treat" to all women who need it (Inner Setting, Readiness for Implementation). Weak positive factors included perceived scalability and access to knowledge/information, as well as compatibility, leadership engagement, and team characteristics, but these latter three were mixed in valence. Weak negative influences were structural characteristics and donor priorities; and mixed but weakly negative influences were relative priority and engaging clients. Cross-cutting themes included the importance of broad buy-in (including different cadres of health workers and leadership at the facility and in the government) and the opportunities and challenges of offering integrated care (screening plus other services).

CONCLUSIONS

Although "screen and treat" is viewed as effective and important, many implementation barriers remain. Our findings suggest that implementation strategies will need to be multi-level, include a diverse set of stakeholders, and explicitly address both screening and treatment.

MiR-139-5p-ZEB1 is a Molecular Regulator of Growth, Invasion, and Epithelial-to-Mesenchymal Transition of Cervical Cancer

Objective

To verify that miR-139-5p-zinc finger E-box-binding homeobox 1 (ZEB1) is a molecular regulator of the biological function and epithelial–mesenchymal transition (EMT) of cervical cancer (CC) cells.

Methods

Cancerous tissues, corresponding paracancerous tissues, and serum were sampled from patients with CC. MiR-139-5p and ZEB1 in tissue specimens, serum specimens, and purchased CC cell lines were quantified, and Pearson correlation coefficient was adopted for correlation analysis of miR-139-5p in clinical specimens. Receiver operating characteristic (ROC) curves were adopted to analyze the diagnostic value of miR-139-5p and ZEB1 for CC. The expression of genes in CC cells was changed by transfection. The proliferation, colony formation, invasion, and apoptosis of cells were determined, and the protein level of EMT markers (N-cadherin, vimentin, and E-cadherin) was also quantified. Moreover, the targeting relationship between miR-139-5p and ZEB1 was determined.

Results

Our data showed that the expression of miR-139-5p decreased greatly in CC tissues, and it also significantly decreased in the serum, while the expression of serum ZEB1 was opposite. In addition, the miR-139-5p expression in CC tissues was positively correlated with that in serum, while serum miR-139-5p was negatively correlated with serum ZEB1. The areas under the curves (AUCs) of the two for identifying CC were 0.923 and 0.890, respectively. Both up-regulation of miR-139-5p and down-regulation of ZEB1 suppressed the colony formation, proliferation, invasion, and EMT of CC cells, and intensified their apoptosis. Moreover, miR-139-5p negatively regulated the transcription of ZEB1, and down-regulation of the former could reverse the molecular regulatory effects of down-regulating ZEB1 on the above biological behaviors of CC cells.

Conclusion

The above data imply that miR-139-5p-ZEB1 axis may be the key to curbing the progression of CC.

Cervical human papillomavirus prevalence, risk factors and outcomes in a cohort of HIV-infected women in Harare, Zimbabwe

Background

Human papillomavirus (HPV) associated invasive cervical cancer (ICC) is common in Zimbabwe, disproportionately affecting women living with HIV (WLHIV). Understanding high-risk HPV (hrHPV) infection in relation to cervical disease is important for ICC prevention amongst WLHIV.

Objectives

To describe the prevalence of cervical hrHPV, type distribution, associated risk factors and ICC screening outcomes in an urban cohort of Zimbabwean women.

Methods

In this cohort study, WLHIV were tested for hrHPV infection using the Cepheid Xpert® HPV assay and followed up for incident cervical disease. Follow-up assessments were done by visual inspection with acetic acid (VIA). Descriptive statistics and logistic regression were used to describe hrHPV burden and association between hrHPV and potential risk factors. Incidence rates (IR) and rate ratios of cervical disease by hrHPV infection status were also calculated.

Results

Amongst 321 WLHIV recruited, hrHPV prevalence was 24.9% (n = 80). Fifty-two of these women (65%) were positive for hrHPV types other than 16 or 18/45. Younger age (22–29 years), early sexual debut (13–16 years) and antiretroviral therapy (ART) regimen (second-line ART) were independently associated with hrHPV positivity. Positive VIA IR ratio between hrHPV-positive and -negative women was 12.57 (95% confidence interval [CI]: 4.14–38.19). Only women with hrHPV infection had incident cervical disease (IR: 6.41/100 person-years, (95% CI: 3.33–12.32). There were no ICC cases by the end of the 2-year follow-up.

Conclusion

There was a high prevalence of hrHPV infection other than 16 and 18/45 in this cohort. Integrating HPV testing in cervical cancer screening programmes may increase screening intervals in hrHPV-negative women, reducing costs for programmes. We recommend further research into cross protectivity of the bivalent and quadrivalent HPV vaccines against these other hrHPV types.

Breast and cervical cancer screening services in Malawi: a systematic review

Background

To identify and to assess factors enhancing or hindering the delivery of breast and cervical cancer screening services in Malawi with regard to accessibility, uptake, acceptability and effectiveness.

Methods

Systematic review of published scientific evidence. A search of six bibliographic databases and grey literature was executed to identify relevant studies conducted in Malawi in the English language, with no time or study design restrictions. Data extraction was conducted in Excel and evidence synthesis followed a thematic analysis approach to identify and compare emerging themes.

Results

One hundred and one unique records were retrieved and 6 studies were selected for final inclusion in the review. Multiple factors affect breast and cervical cancer service delivery in Malawi, operating at three interlinked levels. At the patient level, lack of knowledge and awareness of the disease, location, poor screening environment and perceived quality of care may act as deterrent to participation in screening; at the health facility level, services are affected by the availability of resources and delivery modalities; and at the healthcare system level, inadequate funding and staffing (distribution, supervision, retention), and lack of appropriate monitoring and guidelines may have a negative impact on services. Convenience of screening, in terms of accessibility (location, opening times) and integration with other health services (e.g. reproductive or HIV services), was found to have a positive effect on service uptake. Building awareness of cancer and related services, and offering quality screening (dedicated room, privacy, staff professionalism etc.) are significant determinants of patient satisfaction.

Conclusions

Capitalising on these lessons is essential to strengthen breast and cervical cancer service delivery in Malawi, to increase early detection and to improve survival of women affected by the disease.

Cervical Cancer Screening Guidelines in the Postvaccination Era: Review of the Literature

Cervical cancer is relatively rare in high-income countries, where organized screening programs are in place, as well as opportunistic ones. As the human papillomavirus (HPV) vaccination rates increase, the prevalence of cervical precancers and cancers is going to decrease rapidly very soon, even if, in the most optimistic scenario, it is unlikely that optimal vaccination coverage will be achieved. Then, the optimal screening paradigm for cervical cancer prevention in the postvaccination era is still debated. Screening guidelines are being developed with the aim of reducing the number of tests a woman needs during her lifetime, in order to receive the maximum benefit from screening, while decreasing potential harms that may result with the use of a screening strategy (overdiagnosis, overtreatment, anxiety, and costs). With this purpose in mind, new management guidelines for cervical cancer screening abnormalities are recommendations based on risks, not on results. This review aims to summarize the process that led to the introduction of the HPV DNA test in screening programs and the different screening strategies. Moreover, it aims to introduce the new risk-based guidelines for the future, where full HPV genotyping can resize the risk on the basis of specific high-risk genotypes. In the same way, the data regarding HPV vaccination could be introduced as soon as women vaccinated with the nonavalent vaccine reach the screening age, with the recommendation of a prolonged screening interval.

Evaluating smartphone strategies for reliability, reproducibility, and quality of VIA for cervical cancer screening in the Shiselweni region of Eswatini: A cohort study

BACKGROUND

Cervical cancer is among the most common preventable cancers with the highest morbidity and mortality. The World Health Organization (WHO) recommends visual inspection of the cervix with acetic acid (VIA) as cervical cancer screening strategy in resource-poor settings. However, there are barriers to the sustainability of VIA programs including declining providers' VIA competence without mentorship and quality assurances and challenges of integration into primary healthcare. This study seeks to evaluate the impact of smartphone-based strategies in improving reliability, reproducibility, and quality of VIA in humanitarian settings.

METHODS AND FINDINGS

We implemented smartphone-based VIA that included standard VIA training, adapted refresher, and 6-month mHealth mentorship, sequentially, in the rural Shiselweni region of Eswatini. A remote expert reviewer provided diagnostic and management feedback on patients' cervical images, which were reviewed weekly by nurses. Program's outcomes, VIA image agreement rates, and Kappa statistic were compared before, during, and after training. From September 1, 2016 to December 31, 2018, 4,247 patients underwent screening; 247 were reviewed weekly by a VIA diagnostic expert. Of the 247, 128 (49%) were HIV-positive; mean age was 30.80 years (standard deviation [SD]: 7.74 years). Initial VIA positivity of 16% (436/2,637) after standard training gradually increased to 25.1% (293/1,168), dropped to an average of 9.7% (143/1,469) with a lowest of 7% (20/284) after refresher in 2017 (p = 0.001), increased again to an average of 9.6% (240/2,488) with a highest of 17% (17/100) before the start of mentorship, and dropped to an average of 8.3% (134/1,610) in 2018 with an average of 6.3% (37/591) after the start of mentorship (p = 0.019). Overall, 88% were eligible for and 68% received cryotherapy the same day: 10 cases were clinically suspicious for cancer; however, only 5 of those cases were confirmed using punch biopsy. Agreement rates with the expert reviewer for positive and negative cases were 100% (95% confidence interval [CI]: 79.4% to 100%) and 95.7% (95% CI: 92.2% to 97.9%), respectively, with negative predictive value (NPV) (100%), positive predictive value (PPV) (63.5%), and area under the curve of receiver operating characteristics (AUC ROC) (0.978). Kappa statistic was 0.74 (95% CI; 0.58 to 0.89); 0.64 and 0.79 at 3 and 6 months, respectively. In logistic regression, HIV and age were associated with VIA positivity (adjusted Odds Ratio [aOR]: 3.53, 95% CI: 1.10 to 11.29; p = 0.033 and aOR: 1.06, 95% CI: 1.0004 to 1.13; p = 0.048, respectively). We were unable to incorporate a control arm due to logistical constraints in routine humanitarian settings.

CONCLUSIONS

Our findings suggest that smartphone mentorship provided experiential learning to improve nurses' competencies and VIA reliability and reproducibility, reduced false positive, and introduced peer-to-peer education and quality control services. Local collaboration; extending services to remote populations; decreasing unnecessary burden to screened women, providers, and tertiary centers; and capacity building through low-tech high-yield screening are promising strategies for scale-up of VIA programs.

Circular RNA circ_PVT1 induces epithelial-mesenchymal transition to promote metastasis of cervical cancer

Cervical cancer is one of the most common gynecological malignant tumors. At present, it has been confirmed that the occurrence and development of cervical cancer is related to human papillomavirus infection. As a new regulatory molecule and research hotspot, circRNA is abnormally expressed in tumors and other diseases, and is expected to become a new biomarker for diagnosis and prediction of tumor occurrence and development. In this research, bioinformatics analysis and RT-PCR analysis showed that hsa_circ_0009143 (circRNA_PVT1) was up-regulated in cervical cancer. Knockdown of circRNA_PVT1 inhibits the migration and invasion of cervical cancer cells and would prevent pulmonary metastasis. Overexpression of circRNA_PVT1 induced migration and invasion of cervical cancer cells, which would result in the promotion of pulmonary metastasis. Finally, we found that circRNA_PVT1 can induce EMT of cervical cancer cells via targeting miR-1286 by exosome pathway, which can be a novel mechanism of cervical cancer progression.

"A loving man has a very huge responsibility": A mixed methods study of Malawian men's knowledge and beliefs about cervical cancer

BACKGROUND

In Malawi, numerous barriers may prevent women from accessing cervical cancer screening services - including social factors such as male partner involvement. We conducted surveys that included open- and closed-ended questions with married Malawian men to evaluate their knowledge and beliefs about cervical cancer.

METHODS

HIV-positive adult (≥18 years) men (married or in a stable relationship) were recruited from an antiretroviral therapy clinic in Lilongwe, Malawi. Men were asked a series of survey questions to assess their knowledge about cervical cancer, experience with cervical cancer, their female partner's screening history, and their beliefs about gender norms and household decision-making. Following the survey, participants responded to a set of open-ended interview questions about cervical cancer screening, and men's role in prevention.

RESULTS

One hundred-twenty men were enrolled with average age 44 years and 55% having completed secondary school or higher education. Despite only moderate knowledge about cervical cancer and screening (average assessment score of 62% correct), all men expressed support of cervical cancer screening, and most (86%) believed they should be involved in their female partner's decision to be screened. Over half (61%) of men said their female partner had previously been screened for cervical cancer, and this was positively correlated with the male respondent having more progressive gender norms around sexual practices. Some men expressed concerns about the screening process, namely the propriety of vaginal exams when performed by male clinicians, and whether the procedure was painful.

CONCLUSIONS

Male partners in Malawi want to be involved in decisions about cervical cancer screening, but have limited knowledge about screening, and hold rigid beliefs about gender norms that may affect their support for screening. Messaging campaigns addressing men's concerns may be instrumental in improving women's adoption of cervical cancer screening services in Malawi and similar settings.

Cervical cancer screening - The challenges of complete pathways of care in low-income countries: Focus on Malawi

Cervical cancer is the fourth most common cancer among women globally, with approximately 580,000 new diagnoses in 2018. Approximately, 90% of deaths from this disease occur in low- and middle-income countries, especially in areas of high HIV prevalence, and largely due to limited prevention and screening opportunities and scarce treatment options. In this overview, we describe the opportunities and challenges faced in many low- and middle-income countries in delivery of cervical cancer detection, treatment and complete pathways of care. In particular, drawing on our experience and that of colleagues, we describe cervical screening and pathways of care provision in Malawi, as a case study of a low-resource country with high incidence and mortality rates of cervical cancer. Screening methods such as cytology – although widely used in high-income countries – have limited relevance in many low-resource settings. The World Health Organization recommends screening using human papillomavirus testing wherever possible; however, although human papillomavirus primary testing is more sensitive and detects precancers and cancers earlier than cytology, there are currently costs, infrastructure considerations and specificity issues that limit its use in low- and middle-income countries. The World Health Organization accepts the alternative screening approach of visual inspection with acetic acid as part of ‘screen and treat’ programmes as a simple and inexpensive test that can be undertaken by trained health workers and hence give wider screening coverage; however, subjectivity and variability in interpretation of findings between providers raise issues of false positives and overtreatment. Cryotherapy using either nitrous oxide or carbon dioxide is an established treatment for precancerous lesions within ‘screen and treat’ programmes; more recently, thermal ablation has been recognized as suitable to low-resource settings due to lightweight equipment, short treatment times, and hand-held battery-operated and solar-powered models. For larger lesions and cancers, complete clinical pathways (including loop excision, surgery, radiotherapy, chemotherapy and palliative care) are required for optimal care of women. However, provision of each of these components of cancer control is often limited due to limited infrastructure and lack of trained personnel. Hence, global initiatives to reduce cervical mortality need to adopt a holistic approach to health systems strengthening.

Cervical cancer screening uptake in women aged between 15 and 64 years in Mozambique

Cervical cancer is the most common cancer in Mozambique, reflecting the high prevalence of both human papillomavirus and HIV infections. A national screening program for cervical cancer was started in 2009, using the visual inspection with acetic acid and cryotherapy, targeting women aged 30-55 years. We aimed to estimate the self-reported prevalence and determinants of cervical cancer screening uptake in Mozambique. A cross-sectional study of a representative sample of the women aged 15-64 years (n=1888) was carried out in 2014/2015 following the WHO-Stepwise Approach to Chronic Disease Risk Factor Surveillance. The prevalence of screening uptake using visual inspection with acetic acid or cervical cytology, at least once in a lifetime, was 3.0% [95% confidence interval (CI): 2.2-4.1]; the prevalence was the lowest in the center region (1.4%) and the highest in the capital city of Maputo (11.1%). Among women aged 30-55 years, the prevalence was 3.4% (95% CI: 2.3-5.2) and the factors independently associated with a greater frequency of screening uptake were education (≥8 schooling years vs. none: prevalence ratio=5.57, 95% CI: 1.34-23.16) and use of oral contraceptives (prevalence ratio=2.33, 95% CI: 1.05-5.15). This was the first national Mozambican survey on cervical cancer screening uptake ever carried out and it showed a very low prevalence of screening, even in the more urban and affluent areas. There is an urgent need to raise public awareness of cervical cancer screening and to increase the number of screening units and trained personnel throughout the country.