The economic burden of cervical cancer in Eswatini: Societal perspective

Exploring the complexity of the implementation determinants of human papillomavirus vaccination in Africa through a systems thinking lens: A rapid review

A rapid review was conducted to explore the implementation determinants of human papillomavirus (HPV) vaccination in the World Health Organization African Region and describe their dynamic relationship. PubMed and Google Scholar were searched in October 2023 to find relevant literature. A total of 64 published studies that reported factors affecting HPV vaccination were identified. Analysis of identified factors yielded 74 implementation determinants of HPV vaccination across the five domains of the Consolidated Framework for Implementation Research (CFIR): two (2.70%) were in the innovation domain, seven (9.46%) were in the outer setting domain, 14 (18.92%) were in the inner setting domain, 37 (50%) were in the individual domain and 14 (18.92%) were in the implementation process domain. A causal loop diagram of these implementation determinants revealed four balancing and seven reinforcing loops. Applying systems lens promoted a more holistic understanding of the implementation determinants of HPV vaccination, exposing leverage points for interventions.

Toward a Framework to Assess the Financial and Economic Burden of Cervical Cancer in Low- and Middle-Income Countries: A Systematic Review

PURPOSE

To review the economic burden assessment of cervical cancer in low- and middle-income countries (LMICs) and use the findings to develop a pragmatic, standardized framework for such assessment.

METHODS

We first systematically reviewed articles indexed in scientific databases reporting the methodology for collecting and calculating costs related to the cervical cancer burden in LMICs. Data on study design, costing approach, cost perspective, costing period, and cost type (direct medical costs [DMC], direct nonmedical costs [DNMC], and indirect costs [IC]) were extracted. Finally, we summarized the reported limitations in the methodology and used the solutions to inform our framework.

RESULTS

Cervical cancer treatment costs across LMICs vary greatly and can be extremely expensive, up to 70,968 International US dollars. Economic and financial assessment methods also vary greatly across countries. Of the 28 reviewed articles, 25 studies reported DMC for cervical cancer treatment by extracting cost information from billing or insurance databases (eight studies), conducting surveys (five), and estimating the costs (12). Only 11 studies-mainly through surveys-reported DNMC and IC. The economic burden assessment framework includes health care/payer and societal perspectives (DMC, DNMC, IC, and human capital loss) across the cervical cancer screening and treatment continuum. To assess health care/payer costs, we recommend combining the predefined treatment standards with actual local treatment practices, multiplied by unit costs. To assess societal costs, we recommend conducting a cost survey in line with a standardized yet adaptable protocol.

CONCLUSION

Our standardized, pragmatic framework allows assessment of economic and financial burden of cervical cancer in LMICs despite the different levels of available resources across countries. This framework will facilitate global comparisons and monitoring and may also be applied to other cancers.

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.

The economic burden of cervical cancer on women in Uganda: Findings from a cross-sectional study conducted at two public cervical cancer clinics

There is limited research on how a cervical cancer diagnosis financially impacts women and their families in Uganda. This analysis aimed to describe the economic impact of cervical cancer treatment, including how it differs by socio-economic status (SES) in Uganda. We conducted a cross-sectional study from September 19, 2022 to January 17, 2023. Women were recruited from the Uganda Cancer Institute and Jinja Regional Referral Hospital, and were eligible if they were ≥ of 18 years and being treated for cervical cancer. Participants completed a survey that included questions about their out-of-pocket costs, unpaid labor, and family's economic situation. A wealth index was constructed to determine their SES. Descriptive statistics were reported. Of the 338 participants, 183 were from the lower SES. Women from the lower SES were significantly more likely to be older, have ≤ primary school education, and have a more advanced stage of cervical cancer. Over 90% of participants in both groups reported paying out-of-pocket for cervical cancer. Only 15 participants stopped treatment because they could not afford it. Women of a lower SES were significantly more likely to report borrowing money (higher SES n = 47, 30.5%; lower SES n = 84, 46.4%; p-value = 0.004) and selling possessions (higher SES n = 47, 30.5%; lower SES n = 90, 49.7%; p-value = 0.006) to pay for care. Both SES groups reported a decrease in the amount of time that they spent caring for their children since their cervical cancer diagnosis (higher SES n = 34, 31.2%; lower SES n = 36, 29.8%). Regardless of their SES, women in Uganda incur out-of-pocket costs related to their cervical cancer treatment. However, there are inequities as women from the lower SES groups were more likely to borrow funds to afford treatment. Alternative payment models and further economic support could help alleviate the financial burden of cervical cancer care in Uganda.

What rate of Iranian women perform Pap smear test? Results from a meta-analysis

In this study, an attempt was made to estimate the aggregated proportion of Pap smear test uptake among women in Iran from 2012 to 2022 using meta-analysis. The data collection process involved reviewing records registered in databases between January 1, 2012, and September 11, 2022. The final data was analyzed using random effects models, and potential heterogeneity was assessed using the I2 index. To examine publication bias, Egger's test and Funnel Plot were employed. Sensitivity analysis, specifically single study exclusion Meta-analysis, was conducted to assess the influence of each individual study on the aggregated percentage of Pap smear test uptake. A total of 28,754 women were included across the 33 articles analyzed. The pooled percentage of Pap smear test uptake for both one-time and regular screenings was found to be 46.52% (95% CI: 40.91 to 52.14) and 17.80% (95% CI: 12.42 to 23.18), respectively. No significant evidence of publication bias was detected, although the influence of smaller studies was confirmed. Sensitivity analysis indicated that the overall rate of Pap smear test uptake was not highly sensitive to the results of individual studies. The findings emphasize the low rate of regular Pap smear testing among Iranian women and suggest that tailored interventions considering cultural and geographical factors specific to different provinces in Iran could help increase the utilization of this screening service.

Body mass index and cervical cancer screening among women aged 15-69 years in Eswatini: evidence from a population-based survey

BACKGROUND

Cervical cancer stands as one of the most prevalent cancer types among women, despite its preventable nature through early screening and vaccination strategies. The link between being overweight or obese and various adverse health outcomes, including an elevated cancer risk, is well established. Within this study, our central objective was to explore the correlation between body mass index (BMI) and cervical cancer screening (CCS) rates. Moreover, we sought to investigate whether socioeconomic status potentially modulates this relationship.

METHODS

Our analysis encompassed 1791 respondents who participated in the World Health Organization's STEPwise approach to noncommunicable disease risk factor surveillance carried out in Eswatini in 2014. We assessed the connection between BMI, along with other determinants, and CCS through both unadjusted and adjusted logistic regression models.

RESULTS

The uptake of CCS was 14.4% and the prevalence of overweight and obesity was estimated at 28.1 and 34.9% respectively. After accounting for other pertinent variables, the likelihood of obtaining CCS was amplified for individuals classified as obese (adjusted odds ratio [aOR] = 1.99, 95% confidence interval [CI] = 1.26-3.12) or overweight (aOR = 1.98, 95% CI = 1.05-3.74). Furthermore, factors such as being separated or divorced (aOR = 2.03, 95% CI = 1.11-3.72) and engaging in regular physical exercise (aOR = 3.02, 95% CI = 1.21-6.02) were associated with increased odds of undergoing CCS.

CONCLUSIONS

This study underscores the noteworthy role played by both overweight and obesity, in conjunction with various socioeconomic factors, in shaping CCS patterns among the surveyed women. For Eswatini, targeted interventions aimed at enhancing CCS participation should take into account the multifaceted factors highlighted within this investigation.

Impact and Cost-Effectiveness of Alternative Human Papillomavirus Vaccines for Preadolescent Girls in Mozambique: A Modelling Study

Mozambique has one of the highest rates of cervical cancer in the world. Human papillomavirus (HPV) vaccination was introduced in 2021. This study evaluated the health and economic impact of the current HPV vaccine (GARDASIL^® hereafter referred to as GARDASIL-4) and two other vaccines (CECOLIN^® and CERVARIX^®) that could be used in the future. A static cohort model was used to estimate the costs and benefits of vaccinating girls in Mozambique over the period 2022-2031. The primary outcome measure was the incremental cost per disability-adjusted life-year averted from a government perspective. We conducted deterministic and probabilistic sensitivity analyses. Without cross-protection, all three vaccines averted approximately 54% cervical cancer cases and deaths. With cross-protection, CERVARIX averted 70% of cases and deaths. Without Gavi support, the discounted vaccine program costs ranged from 60 million to 81 million USD. Vaccine program costs were approximately 37 million USD for all vaccines with Gavi support. Without cross-protection, CECOLIN was dominant, being cost-effective with or without Gavi support. With cross-protection and Gavi support, CERVARIX was dominant and cost-saving. With cross-protection and no Gavi support, CECOLIN had the most favorable cost-effectiveness ratio. Conclusions: At a willingness-to-pay (WTP) threshold set at 35% of Gross Domestic Product (GDP) per capita, HPV vaccination is cost-effective in Mozambique. The optimal vaccine choice depends on cross-protection assumptions.

Barriers and facilitators to effective cervical cancer screening in Belize: a qualitative analysis

PURPOSE

Belize has among the highest cervical cancer incidence and mortality rates of Latin American and Caribbean countries. This study evaluates the perspectives of key stakeholders for cervical cancer screening in Belize and identifies the barriers and facilitators for providing equitable access to prevention services.

METHODS

Semi-structured interviews discussing cervical cancer screening were conducted with key stakeholders across the six districts of Belize in 2018. Interviews were transcribed, coded, and analyzed thematically; themes were organized by levels of the social-ecological model.

RESULTS

We conducted 47 interviews with health care providers (45%), administrators (17%), government officials (25%), and other stakeholders (13%). Majority (78%) of interviews were from the public sector. Perceived barriers to cervical cancer screening were identified across multiple levels: (1) Individual Patient: potential delays in Pap smear results and fear of a cancer diagnosis; (2) Provider: competing clinician responsibilities; (3) Organizational: insufficient space and training; (4) Community: reduced accessibility in rural areas; and (5) Policy: equipment and staffing budget limitations. The main facilitators we identified included the following: (1) at the Community level: resource-sharing between public and private sectors and dedicated rural outreach personnel; (2) at the Policy level: free public screening services and the establishment of population-based screening.

CONCLUSION

Despite free, publicly available cervical cancer screening in Belize, complex barriers affect access and completion of management when abnormal screening tests are identified. Provider workload, education outreach, and additional funding for training and facilities are potential areas for strengthening this program and increasing detection and management for cervical cancer control.

Economic burden of cervical cancer and premalignant lesions associated with human papilloma virus: a societal perspective

BACKGROUND

Cervical cancer is one of the most common cancers in women, the cause of which is mostly human papilloma virus (HPV). The aim of this study was to determine the economic burden of cervical cancer and premalignant lesions associated with HPV infection from a societal perspective.

METHODS

The study is a partial economic evaluation (cost of illness), which was conducted cross-sectionally in the referral university clinic in Fars province in 2021. The prevalence-based and bottom-up approaches used to calculate the costs, the indirect costs were calculated by human capital approach.

RESULTS

The mean cost of premalignant lesions associated with HPV infection was USD 2,853 per patient, which 68.57% was direct medical costs. In addition, the mean cost of cervical cancer was USD 39,327 per patient, the largest share of which (57.9%) was related to indirect costs. The mean annual cost of cervical cancer patients in the country was estimated at USD 40,884,609 as well.

CONCLUSION

Cervical cancer and premalignant lesions associated with HPV infection imposed a significant economic burden on the health system and patients. The results of the present study can help health policymakers with efficient and equitable prioritization and allocation of resources.

Economic Burden of Cervical Cancer in Bulgaria

Bulgaria is among the European Union (EU) countries with the highest burden of cervical cancers and life expectancy below the EU average. The majority of cervical cancer cases (more than 95%) are caused by the human papillomavirus (HPV). The aim of this retrospective, cost of illness study is to identify direct healthcare costs of cervical cancer in Bulgaria from the payer perspective and to calculate indirect costs and the associated years of life lost. Costs data were sourced from the National Health Insurance Fund from January 2018 to December 2020. Years of life lost were calculated based on the country and gender-specific life expectancy. Indirect costs due to productivity loss were calculated using the human capital approach. The total treatment costs for 3540 patients with cervical cancer are EUR 5,743,657 (2018), EUR 6,377,508 (2019), and EUR 6,751,182 (2020). The costs associated with drug acquisition and administration accounted for the majority (63%) of total healthcare costs followed by hospital management costs (14%). An estimated total of 20,446 years of life were lost due to cervical cancer for the period 2018-2020. The costs of productivity losses are estimated at EUR 7,578,014. Our study showed that the economic burden of cervical cancer in Bulgaria is substantial. Focus on cervical cancer prevention via vaccination against the human papillomavirus, timely screening, early diagnosis, and higher vaccine coverage rates could reduce its economic burden in Bulgaria.

Epidemiological/Disease and Economic Burdens of Cervical Cancer in 2010-2014: Are Younger Women at Risk?

OBJECTIVE

Cervical cancer is an important factor threatening women's health in China. This study examined the epidemiological and economic burden of cervical cancer among the medically insured population, which could provide data support for government departments to formulate policies.

METHODS

All new cases of cervical cancer under the Urban Employee Basic Medical Insurance (UEBMI) plan in a provincial capital city in eastern China from 2010 to 2014 were collected. The Cox proportional hazard model was used to analyze the factors affecting the survival rates for cervical cancer. Outpatient and hospitalization expenses were used to assess the direct economic burden, and the Potential Years of Life Loss (PYLL) and potential economic loss were calculated by the direct method to assess indirect burden.

RESULTS

During the observation period, there were 1115 new cases and 137 deaths. The incidence rate was 14.85/100,000 person years, the mortality was 1.82/100,000 person years, and the five-year survival rate was 75.3%. The age of onset was mainly concentrated in the 30-59 age group (82.9%) and the tendency was towards younger populations. The age of onset (HR = 1.037, 95% CI = 1.024-1.051), the frequency of hospitalization services (HR = 1.085, 95% CI = 1.061-1.109), and the average length of stay (ALOS) (HR = 1.020, 95% CI = 1.005-1.051) were the related factors affecting overall survival. Among the direct economic burden, the average outpatient cost was $4314, and the average hospitalization cost was $12,007. The average outpatient and hospitalization costs within 12 months after onset were $2871 and $8963, respectively. As for indirect burden, the average Potential Years of Life Loss (PYLL) was 27.95 years, and the average potential economic loss was $95,200.

CONCLUSIONS

The epidemiological and economic burden reported in the study was at a high level, and the onset age of cervical patients gradually became younger. The age of onset, the frequency of hospitalization services and the ALOS of cervical cancer patients should be given greater attention. Policymakers and researchers should focus on the trend of younger onset age of cervical cancer and the survival situation within 12 months after onset. Early intervention for cervical cancer patients, particularly younger women, may help reduce the burden of cervical cancer.

Association of interleukin-10 rs1800896, rs1800872, and interleukin-6 rs1800795 polymorphisms with squamous cell carcinoma risk: A meta-analysis

The relationship between interleukin (IL)-10 and IL-6 gene polymorphisms and squamous cell carcinoma (SCC) has been demonstrated but with inconsistent conclusions. The aim of this study was to evaluate the potential associations of IL gene polymorphisms and the SCC risk. PubMed, Cochrane Library, Web of Science, China National Knowledge Infrastructure, China Biomedical Database, WanFang, and China Science and Technology Journal Database databases were searched for articles reporting the correlations of IL-10 and IL-6 gene polymorphisms with the SCC risk. Odds ratio and 95% confidence interval were calculated using Stata Version 11.2. Meta-regression, sensitivity, and publication bias were analyzed. False-positive reporting probability and Bayesian measure of the false-discovery probability were used to explore the credibility of the calculation. Twenty-three articles were included. The IL-10 rs1800872 polymorphism showed a significant correlation with the SCC risk in the overall analysis. Studies pooled by ethnicity revealed that the IL-10 rs1800872 polymorphism reduced the SCC risk in the Caucasian population. The results of this study suggest that the IL-10 rs1800872 polymorphism may confer a genetic susceptibility to SCC, particularly oral SCC, in Caucasians. However, the IL-10 rs1800896 or IL-6 rs1800795 polymorphism was not significantly associated with the SCC risk.

Targeting elimination of cervical cancer by 2030: a baseline assessment in six African countries-part II

Background

Africa is home to many countries with the highest incidence of cervical cancer in the world. It is encouraging to see that the efforts to prevent and manage this disease are intensifying across the continent. The World Health Organization (WHO) has, in the last years, led a world-wide initiative to eliminate cervical cancer as a public health problem, starting by setting clear targets for 2030.

Aim

To assist those African countries with the largest burden of cervical cancer, to reach the set targets, as a first step, WHO initiated a baseline capacity assessment in African high burden countries. We present and discuss the results thereof in this paper.

Method

The countries selected for the baseline evaluation were Eswatini, Guinea, Malawi, Rwanda, Uganda and Zambia. The data were collected by a mailed questionnaire in English, with 129 questions, most of them with preset answer options. It was answered by national coordinators of non-communicable diseases, cancer control or reproductive health programmes in the ministries of health and by the WHO country representatives. Based on the answers, suggestions were made towards optimising the efforts for cancer control.

Results

Except for Eswatini and Guinea, vaccination against the human papilloma virus (HPV) has reached between 74% and 98% of girls in the age bracket. The main method for cervical screening is still inspection with acid acetic. HPV testing, recommended by WHO, is being introduced slowly. The numbers of women screened are not yet nearing the required levels. Between 30% and 70% of the cervical cancers diagnosed are being treated with palliative intent. A deficit of personnel was reported for all professions involved in cervical cancer care.

Conclusions

Guinea will need assistance to implement HPV immunisations and expand screening. In all six countries surveyed, steps should be taken to introduce or scale up the more precise HPV screening instead of acid acetic inspection of the cervix, to replace the current cryoablation of the preinvasive lesions of the cervix with thermal ablation and to increase the capacity for screening. Solutions need to be found for covering the dearth in gynaecological oncologists and radiotherapy installations and personnel.

The Socioeconomic Impact of Cervical Cancer on Patients in Ethiopia: Evidence from Tikur Anbessa Specialized Hospital

Background

Cervical cancer is very common among women living in low-resource environments, according to the literature. About 85% of the cases and 88% of the deaths due to cervical cancer occurred in developing countries. Women in low- and middle-income countries have a 35% higher average life risk of cervical cancer than women in high-income countries. However, research on the socioeconomic impact of cervical cancer on patients is virtually absent in the country.

Objective

To assess the socioeconomic impact of cervical cancer on patients at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia in 2021.

Methods

Institutional based cross-sectional study design was employed. A structured and semi-structured questionnaire was used. The participants were selected using a simple random sampling technique. The collected data was entered and analyzed using the SPSS version 24 statistical software package.

Results

Out of 423 sampled respondents, 416 agreed to participate in the study and the response rate was 98%. The study revealed that cervical cancer has a social impact on patients in terms of social discrimination 61.8%, loss of body image 63%, loss of sexual functioning 78%, and loss of femininity 89%. It has also an economic impact in terms of loss of income of 45.7%, financial distress due to medical and nonmedical expenditures 71%, work and employment challenges 66.8%.

Conclusion and Recommendation

Cervical cancer has an enormous socioeconomic impact on patients in terms of social discrimination, loss of body image, loss of sexual functioning, loss of femininity, loss of income, financial distress, work and employment challenges. Hence, efforts on reduction of social discrimination, psychotherapy support, and financial support are needed to limit the socioeconomic impact of cervical cancer on patients.

Incidence, Treatment and Outcomes of Cervical Cancer in Low- and Middle-income Countries

Cervical cancer is one of the most common cancers in developing nations. It has had a tremendous impact on the lifetime of millions of women over the last century and continues to do so. In this collaborative clinicians' review, we highlight the incidence, treatment and clinical outcomes of cervical cancer in low-income (LICs) and low- and middle-income countries (LMICs) across Asia, South America, South Africa and Eastern Europe. With the cervical cancer burden and locally advanced cancers being high, the majority of LICs/LMICs have been striving to adhere to optimal evaluation and treatment guidelines. However, the huge gap in resource availability, rural versus urban disparity and access to resources have led to poor compliance to evaluation, treatment and post-treatment rehabilitation. To mitigate the overwhelming numbers, various treatment strategies like neoadjuvant chemotherapy, hypofractionation radiation schedules (both external and brachytherapy) have been attempted with no major success. Also, the compliance to concurrent chemoradiation in various regions is a major challenge. With the burden of advanced cancers, the lack of palliative care services and their integration in cancer care is still a reality.