Expanding Cervical Cancer Screening in Mozambique: Challenges Associated With Diagnosing and Treating Cervical Cancer

PURPOSE

Mozambique has one of the highest burdens of cervical cancer globally. Treatment options are few as most women present with advanced disease, and there are limited trained health professionals and health care resources. The objective of this study was to describe the outcomes of women diagnosed with invasive cancer as part of the Mozambican women undergoing cervical cancer screening with human papillomavirus (HPV) testing in conjunction with family planning services (MULHER) study.

MATERIALS AND METHODS

Women age 30-49 years were prospectively enrolled in the MULHER study and offered screening with primary HPV testing followed by treatment of screen-positive women with thermal ablation or excision as appropriate. Women with cervical examination findings suspicious for cancer were referred to one of the three gynecologic oncologists in the country.

RESULTS

Between January 2020 and January 2023, 9,014 women underwent cervical cancer screening and 30 women were diagnosed with cervical cancer. In this cohort, four patients (13.3%) had early-stage disease, 18 (60.0%) had locally advanced disease, one (3.3%) had distant metastatic disease, and seven (23.3%) did not have staging information available. Five patients (16.6%) died without receiving oncologic treatment, and seven patients (23.3%) are still awaiting treatment. Of the remaining 18 patients, three (17.6%) underwent surgery and four (23.5%) received radiotherapy. Eleven (36.7%) patients received only chemotherapy.

CONCLUSION

As cervical screening programs are implemented in low-resource settings, there will likely be an increase in the number of women diagnosed with invasive cervical cancer. Our results in Mozambique demonstrate the need to increase access to advanced surgery, radiation, and palliative care services.

Measuring Knowledge Change and Skills Improvement in Participants of a Comprehensive Cervical Cancer Prevention Training Program in Low-Resource Areas in Texas and Mozambique

Abstract 5

Purpose

There are more than 530,000 new cases of cervical cancer and 275,000 related deaths annually worldwide. More than 85% of cases and deaths occur in low- and middle-income countries and some areas of the United States. There is a shortage of medical specialists to provide prevention, screening, and treatment services in these regions. Needed are programs that are focused on increasing the clinical capacity to improve cancer prevention services via innovative, locally held, hands-on training courses in conjunction with regular telementoring. Locally held, hands-on training courses for colposcopy, cervical biopsy, and loop electrosurgical excisional procedures using innovative training models and theoretical practical lectures were held in conjunction with telementoring using Project ECHO (Extension for Community Health Outcomes).

Methods

We initiated a cervical cancer prevention education program with two complementary components: locally held, hands-on training courses using innovative teaching aids that were developed by Rice University, and Project ECHO telementoring using regularly held videoconferences to ensure regular mentoring. These innovative training models are low cost (< $80 USD) and allow course participants to simulate different cervical cancer screening and early treatment techniques, including VIA, colposcopy, cervical biopsies, cryotherapy, and loop electrosurgical excisional procedures.

Results

To date, four hands-on training programs have been held in Mozambique (n = 2) and underserved areas of Texas, including the Rio Grande Valley (n = 1) and Laredo (n = 1). In addition, since 2014, 99 ECHO telementoring sessions have been held with providers in the Rio Grande Valley and Laredo (average, n = 23 providers) as well as Mozambique (average, n = 11 providers).

Conclusion

Through this cervical cancer prevention education program, we have found that locally held, hands-on training courses using innovative models, complemented with Project ECHO telementoring, is an innovative way to improve cervical cancer screening and prevention efforts in low-resource settings. Evaluation is ongoing to determine the efficacy of these programs compared with traditional training methods. Funding: The Cancer Prevention Research Institute of Texas, The University of Texas MD Anderson Sister Institution Network Fund, The University of Texas MD Anderson Cancer Center Moon Shots program, and The Prevent Cancer Foundation.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

No COIs from the authors.

Cervical cancer prevention and treatment in Latin America

Cervical cancer is a preventable disease with a known etiology (human papillomavirus), effective preventive vaccines, excellent screening methods, and a treatable pre-invasive phase. Surgery is the primary treatment for pre-invasive and early-stage disease and can safely be performed in many low-resource settings. However, cervical cancer rates remain high in many areas of Latin America. This article presents a number of evidence-based strategies being implemented to improve cervical cancer outcomes in Latin America.

Project ECHO: A Telementoring Program for Cervical Cancer Prevention and Treatment in Low-Resource Settings

Cervical cancer incidence and mortality rates are significantly higher in low- and middle-income countries compared with the United States and other developed countries. This disparity is caused by decreased access to screening, often coupled with low numbers of trained providers offering cancer prevention and treatment services. However, similar disparities are also found in underserved areas of the United States, such as the Texas-Mexico border, where cervical cancer mortality rates are 30% higher than in the rest of Texas. To address these issues, we have adopted the Project ECHO (Extension for Community Healthcare Outcomes) program, a low-cost telementoring model previously proven to be successful in increasing local capacity, improving patient management skills, and ultimately improving patient outcomes in rural and underserved areas. We use the Project ECHO model to educate local providers in the management of cervical dysplasia in a low-resource region of Texas and have adapted it to inform strategies for the management of advanced cervical and breast cancer in Latin America and sub-Saharan Africa. This innovative approach, using ECHO, is part of a larger strategy to enhance clinical skills and develop collaborative projects between academic centers and partners in low-resource regions.