Regional and country-level trends in cervical cancer screening coverage in sub-Saharan Africa: A systematic analysis of population-based surveys (2000-2020)

Human papilloma virus vaccination in the resource-limited settings of sub-Saharan Africa: Challenges and recommendations

Human papillomaviruses (HPV) cause 99% of all cervical cancer cases globally, with the high-risk genotypes 16 and 18 causing at least 70% of these cases. An estimated 90% of the global cervical cancer burden occurs in low-to-middle-income countries (LMICs), particularly in sub-Saharan Africa (SSA). Primary prevention through the administration of efficacious HPV vaccines is key to the World Health Organization's global strategy for accelerating the elimination of cervical cancer as a disease of public health concern. The rollout of HPV vaccination in SSA is faced with several challenges, such as the high cost of vaccine procurement, a lack of funding and political will from the central governments of countries, and inadequate infrastructure for vaccine cold chain storage and transport. Stigma, misinformation, lack of education and awareness, and vaccine hesitancy constitute the social factors that affect the successful rollout or implementation of vaccination programs in SSA. Based on the challenges SSA faces in rolling out HPV vaccination, we recommend using strategies that address both the demand-side and supply-side obstacles to HPV vaccination uptake. These include costs and availability, fighting vaccine hesitancy, and increasing vaccine confidence.

Early evaluation of a screen-and-treat strategy using high-risk HPV testing for Uganda: Implications for screening coverage and treatment

Background

Uganda has a high burden of cervical cancer and its current coverage of screening based on visual inspection with acetic acid (VIA) is low. High-risk HPV (hrHPV) testing is recommended by the World Health Organization as part of the global elimination strategy for cervical cancer. In this context, country-specific health economic evaluations can inform national-level decisions regarding implementation. We evaluated the recommended hrHPV screen-and-treat strategy to determine the minimum required levels of coverage and treatment adherence, as well as the maximum price level per test, for the strategy to be cost-effective in Uganda.

Methods

We conducted a headroom analysis to estimate potential room for spending on implementing the hrHPV screen-and-treat strategy at different levels of coverage and treatment adherence (from 10% to 100%) at each screening round, and at different price levels of the hrHPV test. We compared the strategy with the existing VIA-based screen-and-treat policy in Uganda. We calculated headroom as the product of number of life years gained by the strategy and the willingness-to-pay threshold, minus the incremental costs incurred by the strategy. Positive headroom was interpreted as an indication of cost-effectiveness.

Results

Compared with VIA-based screening with low 5% coverage, the hrHPV screen-and-treat strategy required at least 30% coverage and adherence for positive mean headroom, and compared with 30% VIA-based screening coverage, the minimum levels were 60%. At 60% coverage and adherence, the maximum acceptable price per hrHPV test was found to be between 15 and 30 international dollars.

Conclusions

The hrHPV-based screen-and-treat strategy could be cost-effective in Uganda if the screening coverage and treatment adherence are at least 30% in each screening round, and if the price per test is set below 30 international dollars. The minimum required levels of screening coverage and adherence to treatment provide potential starting points for decision-makers in planning the rollout of hrHPV testing. The headroom estimates can guide the planning costs of screening infrastructure and campaigns to achieve the required coverage and treatment adherence in Uganda.

Bridging the Gap: Immune Checkpoint Inhibitor as an Option in the Management of Advanced and Recurrent Cervical Cancer in Sub-Saharan Africa

Cervical cancer remains a leading cause of cancer-related mortality in women in low and middle-income countries despite efforts to improve prevention and standard-of-care interventions. Sub-Saharan Africa (SSA) leads the numbers for global cervical cancer incidence and mortality, with the majority of the incidence diagnosed in the late stage of the malignancy. Although the global cervical cancer death rate has been on the decline for the last two decades owing to advancements in screening and treatment options, the mortality rate in SSA has not declined very much. Chemotherapy has been the treatment of choice for cervical cancer in SSA without meeting the expected survival outcomes in these patients, with the majority having advanced diseases at diagnosis. Immune checkpoint inhibitors have recently shown clinical promise in improving the survival of patients with advanced cervical cancer and have been integrated into the treatment guidelines in most high-income countries, which have helped further reduce the mortality rate of cervical cancer. However, many SSA countries are yet to fully benefit from using immune checkpoint inhibitors in cervical cancer. In this review, we discuss the challenges hindering the effective use of immune checkpoint inhibitors for advanced cervical cancer in Africa and possible solutions.

Drivers of breast cancer and cervical cancer screening among women of reproductive age: insights from the Ghana Demographic and Health Survey

BACKGROUND

The two major causes of cancer-related deaths among women in Ghana are breast cancer (BC) and cervical cancer (CC). These types of cancers typically do not show any symptoms until they have progressed. Therefore, it is important to screen for early detection. This research aimed to investigate the rate of breast cancer and cervical cancer screening, as well as the factors associated with it, among women of reproductive age in Ghana.

METHODS

This study analysed data from the 2022 Ghana Demographic and Health Survey. A total of 15,014 women aged 15 to 49 years were included in the analysis. Descriptive statistics and binary logistic regression were employed to analyse the data with the aid of STATA/SE, version 17.

RESULTS

It was found that 18.4% and 5.0% of the women had screened for BC and CC, respectively. Women aged 45-49 years were about three times more likely (aOR = 2.83, 95% CI: 1.88-4.24) to screen for BC compared to those aged 15-19 years. Women who had tested for HIV had increased odds (aOR = 1.88, 95% CI: 1.56-2.25) of screening for BC compared to their counterparts. Women within the richest wealth index (aOR = 1.95, 95% CI: 1.40-2.72) had increased odds of screening for BC compared to those in the poorest wealth index. Regarding CC screening, women with higher education (aOR = 2.56, 95% CI: 1.53-4.29) were two times more likely to screen for CC compared to those with no formal education. Women who did not use tobacco (aOR = 0.45, 95% CI: 0.21-0.96) had decreased odds of CC screening compared to their counterparts.

CONCLUSIONS

This study showed that the uptake of BC and CC screening services among women in Ghana was very low. The drivers of BC and CC screening included enabling, predisposing, and need factors. Stakeholders can leverage the mass media to raise awareness and educate women in reproductive age about the importance of BC and CC screening. This study provides relevant information that can inform BC and CC policies and programmes in Ghana.

Inferring the natural history of HPV from global cancer registries: insights from a multi-country calibration

Human papillomavirus (HPV) is the cause of almost all cases of cervical cancer, a disease that kills some 340,000 women per year. The timeline from initial infection with HPV to the onset of invasive cervical cancer spans decades, and observational studies of this process are limited to settings in which treatment of precancerous lesions was withheld or inadequate. Such studies have been critical for understanding the natural history of HPV. Modeling can shed additional insight on the natural history of HPV, especially across geographical settings with varying prevalence of factors known to affect the host-side immune response to HPV, such as HIV and tobacco use. In this study, we create models for the 30 most populous countries in Sub-Saharan Africa, each with country-specific demographic, and behavioral inputs. We found that it was not possible to fit the data if we assumed that the natural history parameters were exactly identical for all countries, even after accounting for demographic and behavioral differences, but that we could achieve a good fit with the addition of a single immunocompetence parameter for each country. Our results indicate that variation in host immune responses may play a role in explaining the differences in the burden of cervical cancer between countries, which in turn implies a greater need for more geographically diverse data collection to understand the natural history of HPV.

Cost-effectiveness of approaches to cervical cancer screening in Malawi: comparison of frequencies, lesion treatment techniques, and risk-stratified approaches

BACKGROUND

Recently-updated global guidelines for cervical cancer screening incorporated new technologies-most significantly, the inclusion of HPV DNA detection as a primary screening test-but leave many implementation decisions at countries' discretion. We sought to develop recommendations for Malawi as a test case since it has the second-highest cervical cancer burden globally and high HIV prevalence. We incorporated updated epidemiologic data, the full range of ablation methods recommended, and a more nuanced representation of how HIV status intersects with cervical cancer risk and exposure to screening to model outcomes of different approaches to screening.

METHODS

Using a Markov model, we estimate the relative health outcomes and costs of different approaches to cervical cancer screening among Malawian women. The model was parameterized using published data, and focused on comparing "triage" approaches-i.e., lesion treatment (cryotherapy or thermocoagulation) at differing frequencies and varying by HIV status. Health outcomes were quality-adjusted life years (QALYs) and deaths averted. The model was built using TreeAge Pro software.

RESULTS

Thermocoagulation was more cost-effective than cryotherapy at all screening frequencies. Screening women once per decade would avert substantially more deaths than screening only once per lifetime, at relatively little additional cost. Moreover, at this frequency, it would be advisable to ensure that all women who screen positive receive treatment (rather than investing in further increases in screening frequency): for a similar gain in QALYs, it would cost more than four times as much to implement once-per-5 years screening with only 50% of women treated versus once-per-decade screening with 100% of women treated. Stratified screening schedules by HIV status was found to be an optimal approach.

CONCLUSIONS

These results add new evidence about cost-effective approaches to cervical cancer screening in low-income countries. At relatively infrequent screening intervals, if resources are limited, it would be more cost-effective to invest in scaling up thermocoagulation for treatment before increasing the recommended screening frequency. In Malawi or countries in a similar stage of the HIV epidemic, a stratified approach that prioritizes more frequent screening for women living with HIV may be more cost-effective than population-wide recommendations that are HIV status neutral.

Human Caring Perspectives of Care Meanings and Expressions in a Nigerian Cancer Care Setting

BACKGROUND

Caring in Africa is often viewed from sociopolitical and humanity perspectives.

OBJECTIVE

The aim of this study was to investigate the meanings and expressions of caring from the narratives of persons living with cancer and their nurses.

METHODS

This study adopted a qualitative ethnonursing methodology. A purposive sampling technique was used to select the key participants, who were grouped into 7 nurses and 6 patients. General participants included 4 physicians, 3 ward assistants, and 6 patients' relatives. Interviews of participants were digitally audio-taped and then transcribed verbatim. Data analysis in this study followed the phases of ethnonursing data analysis enabler and was conducted using NVivo 14 software. Data categories were reviewed and sorted to discover recurrent patterns within the data.

RESULTS

Caring was seen as a social practice that is both transactional and transformational. Six thematic patterns emerged: restoring hope, reaching out to the inner lifeworlds of the patients, mutual empathy, going the extra mile, compassionate presence, and being human/having a sense of human connection. The study revealed that there are discernible patterns in care needs and expectations, even though each cancer patient is unique in his or her specific care needs and expectations.

CONCLUSION

Caring in this study constituted a variety of meanings, and human caring was demonstrated and practiced interpersonally. Hence, there is evidence of living caring in everyday life, in observable ways.

IMPLICATIONS FOR PRACTICE

Nurses should enhance both their own and the patient's sense of personal meaning in the caring partnership to enable them to be present in concrete unique nursing situations with the suffering human being.

The Role of Health Information Sources on Cervical Cancer Literacy, Knowledge, Attitudes and Screening Practices in Sub-Saharan African Women: A Systematic Review

Cervical cancer is the leading cause of cancer deaths among Sub-Saharan African women. This systematic review aimed to identify information sources and their relation to cervical cancer knowledge, literacy, screening, and attitudes. Peer-reviewed literature was searched on 2 March 2022, and updated on 24 January 2023, in four databases-CINAHL Plus, Embase, PubMed, and Web of Science. Eligible studies included those that were empirical, published after 2002, included rural women, and reported on information sources and preferences. The quality of the selected articles was assessed using the Mixed Methods Appraisal Tool. Data extraction was conducted on an Excel spreadsheet, and a narrative synthesis was used to summarize findings from 33 studies. Healthcare workers were the most cited information sources, followed by mass media, social networks, print media, churches, community leaders, the Internet, and teachers. Community leaders were preferred, while healthcare workers were the most credible sources among rural women. There was generally low cervical cancer knowledge, literacy, and screening uptake, yet high prevalence of negative attitudes toward cervical cancer and its screening; these outcomes were worse in rural areas. A content analysis revealed a positive association of health information sources with cervical cancer literacy, knowledge, screening, and positive screening attitudes. Disparities in cervical cancer prevention exist between rural and urban Sub-Saharan African women.

The association between HIV infection, disability and lifestyle activity among middle-aged and older adults: an analytical cross-sectional study in Ivory Coast (the VIRAGE study)

INTRODUCTION

People living with HIV (PLWH) live longer and face new health challenges resulting from the confluence of chronic HIV infection and the natural effect of aging and comorbidities. However, there is a dearth of information on the long-term impact of HIV infection on the health and wellbeing of PLWH in sub-Saharan Africa. This research aimed to fill this gap by reporting on physical, functional and social outcomes among PLWH treated at a referral center in Abidjan, Ivory Coast, and comparing them with those of a control group.

METHODS

Body composition, functional capacity, sarcopenia, limitations in daily activities and social participation were assessed among 300 PLWH (aged ≥ 30 years) and 200 uninfected adults of similar age and sex. The associations between these outcomes and participants' socioeconomic characteristics, HIV history and physical activity level were assessed using generalized additive models adjusted for age and sex.

RESULTS

The median age was 51 years, and the median antiretroviral therapy duration was 15 years. Compared to controls, PLWH reported higher levels of physical activity (p < 0.0001). They had a lower muscle index (adjusted p < 0.0001) and grip strength (adjusted p < 0.0001) but achieved similar performance on the 6-min walk test (6MWT, p = 0.2). Among PLWH, physical activity level was positively associated with better performance in the 6MWT (p = 0.006) and greater hand grip strength (p = 0.04). The difference in physical performance according to the level of physical activity appeared mainly after the age of 60. PLWH reported similar rates of activity limitations (p = 0.8), lower depression levels and greater scores for social functioning (p = 0.02).

CONCLUSION

In this study, PLWH achieved high levels of physical activity, which may explain why they maintained good physical performance and social functioning despite having a higher risk of sarcopenia. These results have important implications for resource-limited health systems and show avenues for chronic care models.

TRIAL REGISTRATION

This study was registered on the ClinicalTrials.gov website (NCT05199831, first registration the 20/01/2022).

Knowledge and attitude toward cervical cancer screening among women aged 30-49 years attending selected health facilities in Ethiopia: Using structural equation model

Background

According to estimates, there were 570,000 new cases of cervical cancer in 2018, making it the fourth most common malignancy among women worldwide. Almost all 342,000 deaths from cervical cancer take place in low- and middle-income countries, accounting for 90 % of deaths. Few studies use structural equation modeling to comprehensively analyze the predictors of cervical cancer screening.

Objective

The purpose of this study was to assess knowledge and attitude towards cervical cancer screening and its associated factors among women aged 30-49 years in Ethiopia.

Methods

A facility-based cross-sectional study was conducted among eligible women attending health centers in Oromia and the southern nationality People regions. A systematic random sampling method was used to select 916 respondents. The data was collected using a structured interviewer-administered questionnaire. Structural equation modelling was employed to assess the direct and indirect relationship between knowledge and attitude toward cervical cancer screening.

Results

The overall proportion of knowledge and attitude towards cervical cancer detection among women 30-49 years of age were 28 % and 57 %, respectively., income (adjusted β = 0.075, 95 % CI: 0.042, 0.091), being urban (adjusted β = 0.088, 95 % CI: 0.062, 0.093), being employee (adjusted β = 0.119, 95 % CI: 0.113, 0.342), the number of parity (adjusted β = 0.014, 95 % CI: 0.012, 0.021), usage of contraceptive (adjusted β = 0.719, 95 % CI: 0.057, 0.082) and family history of cervical cancer (adjusted β = 0.211, 95 % CI: 0.18, 0.302) were statistically significant associated factors with knowledge and Being smoker (adjusted β = -0.157, 95 % CI: 0.265, -0.141). Having multiple sexual partnership (adjusted β = 0.169, 95 % CI: 0.148, 0.349), having formal education (adjusted β = 0.118, 95 % CI: 0.052, 0.294), live in urban area (adjusted β = 0.116, 95 % CI: 0.023, 0.347), knowledge (adjusted β = 0.42, 95 % CI: 0.301, 0.567) were statistically significant associated factors with the attitude of women toward cervical cancer screening.

Conclusions

and recommendation: The study highlights a lack of awareness of cervical cancer screening, highlighting the need for improved routine practices, education campaigns, and treatment provision.

A systematic review of ethnic minority participation in randomised controlled trials of systemic therapies for gynecological cancers

OBJECTIVE

Randomised controlled trials (RCTs) must include ethnic minority patients to produce generalisable findings and ensure health equity as cancer incidence rises globally. This systematic review examines participation of ethnic minorities in RCTs of licensed systemic anti-cancer therapies (SACT) for gynecological cancers, defining the research population and distribution of research sites to identify disparities in participation on the global scale.

METHODS

A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Phase II and III RCTs of licensed therapies for gynecological cancers published 01/11/2012-01/11/2022 that reported patient race/ethnicity were included. Extracted data included race/ethnicity and research site location. RCT populations were aggregated and participation of groups compared. Global distribution of research sites was described.

RESULTS

26 RCTs met inclusion criteria of 351 publications included in full-text screening, representing 17,041 patients. 79.8% were "Caucasian", 9.1% "East Asian", 3.7% "Black/African American" and 6.1% "Other, Unknown, Not Reported". "Caucasian" patients participated at higher rates than all other groups. Of 5,478 research sites, 80.1% were located in North America, 13.0% in Europe, 3.4% in East Asia, 1.3% in the Middle East, 1.3% in South America and 0.8% in Australasia.

CONCLUSIONS

Ethnic minorities formed smaller proportions of RCT cohorts compared to the general population. The majority of sites were located in North America and Europe, with few in other regions, limiting enrollment of South Asian, South-East Asian and African patients in particular. Efforts to recruit more ethnic minority patients should be made in North America and Europe. More sites in underserved regions would promote equitable access to RCTs and ensure findings are generalisable to diverse groups. This review assessed the global population enrolled in contemporary RCTs for novel therapies now routinely given for gynecological cancers, adding novel understanding of the global distribution of research sites.

Cervical precancer and cancer incidence among insured women with and without HIV in South Africa

HIV infection increases the risk of developing cervical cancer; however, longitudinal studies in sub-Saharan Africa comparing cervical cancer rates between women living with HIV (WLWH) and women without HIV are scarce. To address this gap, we compared cervical precancer and cancer incidence rates between WLWH and women without HIV in South Africa using reimbursement claims data from a medical insurance scheme from January 2011 to June 2020. We used Royston-Parmar flexible parametric survival models to estimate cervical precancer and cancer incidence rates as a continuous function of age, stratified by HIV status. Our study population consisted of 518 048 women, with exclusions based on the endpoint of interest. To analyse cervical cancer incidence, we included 517 312 women, of whom 564 developed cervical cancer. WLWH had an ~3-fold higher risk of developing cervical precancer and cancer than women without HIV (adjusted hazard ratio for cervical cancer: 2.99; 95% confidence interval [CI]: 2.40-3.73). For all endpoints of interest, the estimated incidence rates were higher in WLWH than women without HIV. Cervical cancer rates among WLWH increased at early ages and peaked at 49 years (122/100 000 person-years; 95% CI: 100-147), whereas, in women without HIV, incidence rates peaked at 56 years (40/100 000 person-years; 95% CI: 36-45). Cervical precancer rates peaked in women in their 30s. Analyses of age-specific cervical cancer rates by HIV status are essential to inform the design of targeted cervical cancer prevention policies in Southern Africa and other regions with a double burden of HIV and cervical cancer.

The lived experiences and caring needs of women diagnosed with cervical cancer: A qualitative study in Dar es Salaam, Tanzania

BACKGROUND

Cervical cancer continues to be a major global public health concern affecting the lives of many women and resulting in financial burdens. In 2020, cervical cancer was the seventh most commonly diagnosed cancer among all cancers worldwide and Tanzania was ranked fourth among the countries with the highest incidence rates (59.1 new cases per 100,000 women) of cervical cancer. The lived experience and caring needs of patients and their families provide insights into the psychosocial aspects of healthcare among the affected population. However, there is inadequate information concerning the lived experiences of cervical cancer patients in Tanzania and Sub-Saharan Africa in general. This study aimed to explore the lived experiences and caring needs of cervical cancer patients at Ocean Road Cancer Institute (ORCI) in Dar es Salaam, Tanzania.

METHODS

A qualitative descriptive study was carried out among cervical cancer patients at ORCI in Dar es Salaam, Tanzania. Using a purposeful sampling technique, 12 cervical cancer patients were interviewed with the principles of saturation guiding sample size determination. A semi-structured face-to-face interview guide was employed to collect the information. A conventional content analysis approach was used to analyze data after translation with the aid of NVivo 12.0 computer software.

RESULTS

Five themes emerged after data analysis: knowledge and attitude about cervical cancer, sufferings from a disease process, socio-economic disruptions, psychological problems, and sexual and reproductive concerns.

CONCLUSION

The findings of this study provide insights into the life experiences and caring needs of cervical cancer patients and call for response from healthcare stakeholders to develop and implement comprehensive and culturally consonant approaches in providing care to the affected population. More qualitative studies are required to ascertain the lived experiences of advanced cervical cancer patients and those of long-term cervical cancer survivors.

Cancer Care During the COVID-19 Pandemic: The African Narrative and Prospects

The COVID-19 pandemic has had a significant impact on healthcare services globally. Whilst it has been particularly disruptive for cancer care in low-resource settings, a few African countries have been able to adapt strategies to enable continued delivery of medical care to persons with cancer. This study seeks to highlight how much effect the coronavirus pandemic has had on oncological care in Africa and to indicate the way forward. For this narrative review, PubMed and Google Scholar were used to search for literature addressing the effect of the coronavirus pandemic on the care of patients with cancer in Africa with ensuing coping strategies. Selection criteria were manuscripts published since the onset of the pandemic in 2019 and written in the English language with Africa being the focus. In total, 52 research papers involving up to 21 African nations were found and reviewed. Across the board, the COVID-19 pandemic resulted in the deferral of oncological screening programs and a halt in immunization activities routinely scheduled for preventable cancers. It caused a colossal shortage in the availability of appropriately trained medical personnel, reduced frequency and duration of outpatient consultations, and a delay in cancer investigations and diagnosis. It also stirred up the substandard modification of chemotherapy regimens and radiotherapy due to the scarcity of anticancer medications and radioisotopes and engendered the cancellation of cancer surgical procedures. Palliative care for patients with locally advanced and metastatic disease was in many cases interrupted and cancer research activities were abruptly deferred. Ultimately, these led to poor patient outcomes and increased cancer-related fatalities. However, a few African countries - Rwanda, Ghana, and Tunisia - have continued to adapt telemedicine, small unmanned aircraft systems (sUAS), and home therapy to facilitate cancer care. To date, there is a paucity of data concerning the successes and cost-effectiveness of these relatively new methods recently adapted to cater to the medical needs of cancer patients in Africa. The pandemic has presented the African community an opportunity to advance her healthcare systems, especially as it pertains to the delivery of medical care to persons with cancer. The need of the hour is to study further the alternative cancer care delivery systems initiated during the pandemic in order to determine their sustainability in Africa at large.

Prevalence of Human Papillomavirus in Different Mucous Membranes in HIV Concordant Couples in Rwanda

BACKGROUND

The prevalence of human papillomavirus (HPV) infections in other anatomical sites besides the uterine cervix is unknown in East Africa. Here, we assessed the prevalence and concordance of HPVs in different anatomical sites in HIV concordant couples in Rwanda.

METHODS

Fifty HIV-positive concordant male-female couples at the HIV clinic at the University Teaching Hospital of Kigali in Rwanda were interviewed, swabbed from the oral cavity (OC), oropharynx (OP), anal canal (AC), vagina (V), uterine cervix (UC) and penis. A pap smear test and a self-collected vaginal swab (Vself) were taken. Twelve high-risk (HR)-HPVs were analyzed.

RESULTS

HR-HPVs occurred in 10%/12% in OC, 10%/0% in OP and 2%/24% in AC (p = 0.002) in men and women, respectively. HR-HPVs occurred in 24% of UC, 32% of Vself, 30% of V and 24% of P samples. Only 22.2% of all HR-HPV infections were shared by both partners (κ -0.34 ± 0.11; p = 0.004). The type-specific HR-HPV concordance was significant between male to female OC-OC (κ 0.56 ± 0.17), V-VSelf (κ 0.70 ± 0.10), UC-V (κ 0.54 ± 0.13), UC-Vself (κ 0.51 ± 0.13) and UC-female AC (κ 0.42 ± 0.15).

CONCLUSIONS

HPV infections are prevalent in HIV-positive couples in Rwanda but concordance within couples is low. Vaginal self-sampling for HPV is representative of cervical HPV status.