Building local capacity for cervical cancer prevention in low resource settings: Changing strategy during the COVID-19 pandemic

From barriers to opportunities from COVID-19 pandemic: Stakeholder perspectives on cervical cancer screening programs in LMICs of the Asia-Pacific region

Cervical cancer is preventable, yet it remains the fourth most common cancer in women globally. The highest incidence and mortality occur in low- and middle-income countries (LMICs), where over 70% of women have never been screened, and 58% of the cases are in Asia. While the COVID-19 pandemic caused significant disruptions to cervical screening programs, particularly for LMICs, there were opportunities that emerged from the pandemic that were enablers of program recovery. Stakeholders played key roles in materialising strategy into implementation. Therefore, in this study, we examined the barriers and facilitators to implementing recovery strategies from the stakeholders' perspectives. We interviewed fifteen stakeholders from nine LMICs in the Asia-Pacific region directly involved in the implementation of the cervical screening program. A total of 23 barriers and 21 facilitators were identified, of which seven barriers and nine facilitators related directly to the pandemic. Pandemic-related barriers included movement restrictions, resource diversion, cancelled campaigns and training, deprioritisation of HPV prevention efforts, and a reduced health workforce. Stakeholders concurred that most barriers had predated the pandemic and remained as the pandemic eased. Conversely, the pandemic introduced facilitators such as means for targeted campaigns, improved understanding of viruses, accessible training with online platforms, better PCR testing capabilities, a shift in the government's position towards preventive health services, and openness to HPV testing and self-swabs. The emerging facilitators offered opportunities to address some of the persistent barriers, such as limited cervical cancer awareness and insufficient healthcare providers in screening programs. However, effective implementation of these emerging facilitators requires improved communication and collaboration between policymakers and implementers to accelerate the recovery of screening programs in LMICs. Further work is necessary to align emerging facilitators with the health system goals and resource settings of each country in turning these opportunities into actions.

Scaling cervical cancer screening in Mozambique: analysis of loop electrosurgical excision procedure (LEEP) specimens

OBJECTIVES

As cervical cancer screening programs are implemented and expanded, an increasing number of women require loop electrosurgical excision procedure (LEEP) for treatment of pre-invasive cervical disease. Our objective was to describe the pathological results of LEEP specimens performed as part of the MULHER study and identify factors associated with positive LEEP margins.

METHODS

The MULHER study enrolled 9014 women who underwent HPV testing followed by visual assessment for treatment (VAT) using visual inspection with acetic acid (VIA) and thermal ablation for those with positive results. Participants with lesions ineligible for ablation underwent LEEP. Pathology reports were reviewed for specimen size/volume, number of fragments, pathological diagnosis and margin status. Multivariable regression analysis was performed to identify variables associated with positive LEEP margins.

RESULTS

169 participants underwent LEEP. The median age was 38 years (range 30-49). 65.1% were women living with HIV. Pathological diagnosis was available for 154 patients and included cancer (n=6, 3.9%); cervical intraepithelial neoplasia (CIN) 2/3 (n=75, 48.7%); CIN 1 (n=67, 43.5%); and normal/benign findings (n=6,3.9%). 31.8% of LEEP specimens were removed in more than one fragment. The mean specimen volume was 2.9 cm3 (range 0.2-15.0). LEEP margin status was available for 130 patients. Positive margins (ectocervical/endocervical only, or both) were noted in 76 (58.5%) patients and associated with HIV+status (p=0.0499) and a diagnosis of CIN 2 or worse (p=0.0197). There were no associations between margin status and age, number of fragments or specimen volume.

CONCLUSION

Our results showed a high number of LEEP specimens with positive margins. Additional evaluation is needed to better understand the characteristics of precancerous cervical lesions in this high-risk population. As cervical cancer screening programs are scaled in Mozambique and other lower-resource countries, there is a need to train providers to perform high-quality LEEP and for accurate and timely pathological interpretation.

Challenges regarding the implementation of cervical cancer screening guidelines in Limpopo province, South Africa

BACKGROUND

 The World Health Organization's (WHO) call to eliminate cervical cancer is essential in improving structures and processes at primary healthcare facilities by galvanising change in providing cervical cancer screening services.

AIM

 The main objective of this study was to explore challenges affecting the implementation of cervical cancer screening guidelines in selected districts in Limpopo Province.

SETTING

 The study was carried out at primary health care services (PHCs) in Vhembe and Mopani districts, Limpopo province.

METHODS

 Qualitative non-experimental research design of an exploratory, descriptive and contextual nature of a qualitative paradigm to understand cervical cancer screening programme challenges from healthcare professionals' perspectives. The study population comprised two males and 16 female professional registered nurses working in Limpopo province's PHC services. The sample size was 18 professional nurses. A face-to-face interview guided by unstructured questionnaires was undertaken to elicit information regarding the implementation of cervical cancer screening services. Captured data were analysed using Tesch's open-coding method.

RESULTS

 The study revealed that the cervical cancer guidelines were not effectively implemented as there were contradictions and gaps when applying the guidelines about the management of HIV and AIDS, age restrictions and gestation. Furthermore, structural factors contributed to the inadequacy rate and failure to reach the set targets.

CONCLUSION

 Primary health care is an essential health care and human right; therefore, the government should ensure that guidelines and policies are supported financially and that professional nurses are capacitated for the efficient implementation of services.Contribution: Addressing the inequalities in the implementation of social policies for the prevention of cervical cancer prevention and improving the nurses' knowledge and practice behaviour regarding cervical cancer prevention are imperative.

The Mulher Study: cervical cancer screening with primary HPV testing in Mozambique

OBJECTIVE

To evaluate cervical cancer screening with primary human papillomavirus (HPV) testing in Mozambique, a country with one of the highest burdens of cervical cancer globally.

METHODS

Women aged 30-49 years were prospectively enrolled and offered primary HPV testing using either self-collected or provider-collected specimens. Patients who tested positive for HPV underwent visual assessment for treatment using visual inspection with acetic acid to determine eligibility for thermal ablation. If ineligible, they were referred for excision with a loop electrosurgical excision procedure, for cold knife conization, or for cervical biopsy if malignancy was suspected.

RESULTS

Between January 2020 and January 2023, 9014 patients underwent cervical cancer screening. Median age was 37 years (range 30-49) and 4122 women (45.7%) were patients living with HIV. Most (n=8792, 97.5%) chose self-collection. The HPV positivity rate was 31.1% overall and 39.5% among patients living with HIV. Of the 2805 HPV-positive patients, 2588 (92.3%) returned for all steps of their diagnostic work-up and treatment, including ablation (n=2383, 92.1%), loop electrosurgical excision procedure (n=169, 6.5%), and cold knife conization (n=5, 0.2%). Thirty-one patients (1.2%) were diagnosed with cancer and referred to gynecologic oncology.

CONCLUSION

It is feasible to perform cervical cancer screening with primary HPV testing and follow-up in low-resource settings. Participants preferred self-collection, and the majority of screen-positive patients completed all steps of their diagnostic work-up and treatment. Our findings provide important information for further implementation and scale-up of cervical cancer screening and treatment services as part of the WHO global strategy for the elimination of cervical cancer.

Addressing cervical cancer disparities in Texas: Expansion of a community-based prevention initiative for medically underserved populations

Although cervical cancer is preventable, significant disparities exist in access to screening and prevention services. In medically underserved areas (MUAs) of Texas, these rates are 55% higher compared to the remainder of the US. In 2019, we expanded a multicomponent, comprehensive program to improve cervical cancer prevention in partnership with 13 clinics and mobile vans in MUAs of Texas. Our multicomponent intervention program consists of community education and patient navigation coupled with a training/mentoring program for local medical providers to perform diagnostic procedures and treatment for patients with abnormal screening results. Hands-on training courses to learn these skills are coupled with biweekly telementoring conferences using Project ECHO® (Extension for Community Healthcare Outcomes). This program was implemented in 2015 and expanded to other MUAs in Texas in 2019. From March 2019 to August 2022, 75,842 individuals were educated about cervical cancer screening and HPV vaccination. A total of 44,781 women underwent screening for cervical cancer, and 2,216 underwent colposcopy and 264 underwent LEEP. High-grade cervical dysplasia was diagnosed in 658 individuals and invasive cervical cancer in 33 individuals. We trained 22 providers to perform colposcopy and/or LEEP. In addition, 78 Project ECHO telementoring sessions were held with an average of 42 attendees per session, with 72 individual patient cases discussed. Our comprehensive community-based prevention initiative for medically underserved populations has led to a significant number of individuals undergoing cervical cancer screening in MUAs, as well as improved access to colposcopy and LEEP services.

The impact of the COVID-19 pandemic on cancer care including innovations implemented in Sub-Saharan Africa: A systematic review

Background

The coronavirus 2019 (COVID-19) pandemic has caused disruptions in the delivery and utilisation of cancer services. The impact of these interruptions is disproportionately borne by low- and middle-income countries in Sub-Saharan Africa (SSA). There are speculations of increased late-stage presentation and mortality as services are returning to the pre-pandemic state. This review aims to explore the extent to which the COVID-19 pandemic impacted cancer services across SSA and to identify innovations implemented across SSA to mitigate the impacts.

Methods

Using database-specific search strategies, a systematic literature search was conducted in PubMed, Ovid (MedLine), Web of Science, and African Index Medicus. Eligible studies included original research, reports, perspectives and summaries of national or regional outcomes published in the English language. The primary outcome was changes in the delivery and utilisation of cancer prevention and screening, diagnosis, treatment and follow-up services. The secondary outcome was to identify implemented innovations to mitigate the impact of the pandemic on service delivery.

Results

Out of the 167 articles identified in the literature search, 46 were included in the synthesis. A majority (95.7%) of the included articles described suspension and/or delay of screening, diagnosis, and treatment services, although two studies (4.3%) described the continuation of services despite the lockdown. Care was additionally impacted by transportation limitations, shortages of staff and personal protective equipment, disruption of the medication supply chain and patients' fears and stigma associated with contracting COVID-19. A major innovation was the use of telemedicine and virtual platforms for patient consultation and follow-up during the pandemic in SSA. Furthermore, drones and mobile applications were used for sample collection, medication delivery and scheduling of treatment. In some instances, medication routes and treatment protocols were changed.

Conclusions

The delivery and utilisation of cancer services decreased substantially during the pandemic. Cancer centres initiated innovative methods of care delivery, including telehealth and drone use, with long-term potential to mitigate the impact of the pandemic on service delivery. Cancer centres in SSA must explore sustainable, facility or country-specific innovations as services return to the pre-pandemic state.

Registration

The review was registered in PROSPERO with registration number CRD42022351455.

The recovery strategies to support cervical cancer elimination in lower-and middle-income countries (LMICs) following COVID-19 disruptions

The COVID-19 pandemic has exacerbated the existing challenges to achieving the WHO target of eliminating cervical cancer as a public health problem by working towards the target of fewer than four cases per 100 000 women. We reviewed the literature to identify potential recovery strategies to support cervical cancer prevention programs in lower-and middle-income countries (LMICs) following COVID-19 disruptions and the extent to which strategies have been implemented. Utilising the WHO health systems framework, we mapped these recovery strategies against the six building blocks to examine their reach across the health system. Most recovery strategies were focused on service delivery, while leadership and governance played a pivotal role in the continuity of cervical cancer prevention programs during the pandemic. Leadership and governance were the drivers for outcomes in the building blocks of health information systems, financing and critical support in operationalising service delivery strategies. In the aftermath of the COVID-19 pandemic with strained health resources and economies, stakeholders would significantly influence the coverage and sustainability of cervical cancer prevention programs. The support from multisectoral stakeholders would accelerate the recovery of cervical cancer prevention programs. To achieve the WHO target by 2030, we call for future studies to understand the barriers and facilitators from the perspectives of stakeholders in order to support the decision-making processes and information required to implement recovery strategies in LMICs.

Mobilizing stakeholders to drive the cervical cancer elimination agenda in Kenya: The national cervical cancer stakeholders' forum 2022

Background

Kenya is among the nineteen countries in Sub-Saharan Africa with the highest burden of cervical cancer globally. The high burden of cervical cancer in developing countries reflects the absence of effective cervical cancer prevention programs with limited resources invested to provide comprehensive services.

Objective

We aimed to engage stakeholders in a structured consultative forum, to gain insights and forge effective partnerships to drive the cervical cancer elimination agenda in Kenya.

Methods

The National Cervical Cancer Stakeholders Consultative Forum was organized as a part of activities to commemorate the National Cervical Cancer Awareness Month on 19th January 2022 in Nairobi, Kenya. The overall goal of the meeting was to provide a forum to sensitize stakeholders on the National Cervical Cancer Prevention and Control Program (NCCP) with a view to strengthen partnerships, increase coordination for improved service delivery and to provide a forum for resource mobilisation and alignment of key stakeholders towards elimination of cervical cancer in Kenya. Nominal group technique was adopted for structured discussions, and the findings analysed to derive key themes.

Findings

Key challenges to primary and secondary prevention of cervical cancer were identified as low awareness, stigma and misinformation, high unmet need for treatment of early lesions, few health care providers with capacity to screen and treat, inadequate supplies, inefficient health information systems and poor referral pathways. Championing integration of cervical cancer screening and treatment services into routine health programs, strengthening policy implementation and robust monitoring and evaluation were identified as critical interventions.

Conclusion

The National Cervical Cancer Stakeholders Forum 2022 provided insights for enabling Kenya to progress on the 2030 elimination targets. Such forums can be useful in bringing all actors together to evaluate achievements and identify opportunities for more effective national cervical cancer prevention and control programs.

Hands-On Training Courses for Cervical Cancer Screening, Diagnosis, and Treatment Procedures in Low- and Middle-Income Countries

In 2018, there were approximately 570,000 new cases of cervical cancer worldwide. More than 85% of cases occurred in low- and middle-income countries (LMICs), primarily because of poor access to screening and a limited number of medical providers trained to diagnose and treat cervical precancerous lesions. Our objective was to provide locally arranged, hands-on training courses for medical providers in LMICs to learn to perform cervical cancer screening, diagnosis, and treatment procedures. The courses included didactic lectures and hands-on training stations using low-cost simulation models developed by bioengineers and students at Rice University in Houston, TX, United States, and the Malawi Polytechnic in Blantyre, Malawi. The hands-on training stations included visual inspection with acetic acid (VIA), colposcopy, cervical biopsy, endocervical curettage, loop electrosurgical excision procedure (LEEP), and thermal ablation. Provider pre- and postcourse confidence levels in performing the procedures were evaluated. From February 2017 to January 2020, we arranged 15 hands-on training courses in seven cities across six countries (El Salvador, Mozambique, Trinidad and Tobago, Lesotho, Malawi, and Nepal). Overall, there were 506 participants. The average number of participants per course was 38 (range 19-92). The participants included doctors, nurses, and midwives. The course duration varied from 1 to 3 days. Increased confidence in performing VIA, colposcopy and cervical biopsy, ablation, and LEEP was reported by 69%, 71%, 61%, and 76% of participants, respectively. Our findings suggest that locally arranged, hands-on cervical cancer prevention training courses in LMICs can improve provider confidence in performing cervical cancer screening, diagnosis, and treatment procedures. These courses are part of a larger strategy to build local capacity for delivering and improving cervical cancer prevention services in LMICs.

Hands-on training courses improved provider confidence in cervical cancer screening, diagnostic and treatment in LMICs.