Developing and Scaling Up Resource Appropriate

Approaches for Cervical Cancer Prevention in Low

Resource Settings: Essential Practices

Enriquito Lu, MD, MPH, Jhpiego

Paul D. Blumenthal MD, MPH,
Stanford University

XX FIGO Congress
Rome, Italy
11 October 2012
Global Situation - BURDEN

Source: Bray et al. , The Lancet Oncology 2012; 13:790-801 (DOI:10.1016/S1470-2045(12)70211-5)

~270,000 deaths annually; 88% in low-resource areas

2011 CCA REPORT CARD

 Comparing Cervical Cancer and HIV /AIDS in
Africa
HIV incidence in Africa Cervical cancer Incidence in
(UNAIDS 2010) Africa (Globocan 2008, IARC)
2o Prevention: Why a New Approach Is Needed
Client Journey Through Traditional Cervical Cancer Screening

1. Concern 2. Seek 3. Access 5. Smear to

4. Pap smear
over risk treatment service point laboratory

10.
9. Referral 8. Receive 7. Results to 6. Laboratory
Appointment
for treatment results service point test
for treatment

11. Return
12. Receive 13. Return
for
treatment for follow-up
appointment

Available and accepted screening methods are not practical or

accessible to the majority of women living in many countries
 WHY NOT HPV VACCINES ALONE?

• Large cohort of women who will not benefit from the

prophylactic HPV vaccines
• Access to affordable vaccines in developing countries
• Will take time
• Other competing health priorities
• Reaching target population is challenging:
• Young girls and women
• Early age of sexual debut and the uncertainty on
length of vaccine protection
• Potential for inadequate vaccination due to poor
compliance return visits for 3 doses
 Visual Inspection Methods

 VIA - visual inspection

with acetic acid &
naked eye
 VIAM - visual inspection
with acetic acid & low
magnification
 VILI - visual inspection
with Lugol’s Iodine
SROC Curve for Selected Cervical Cancer Tests

Colpo

Pap

VIA

HPV

Mitchell MF, et al Obstet Gynecol, 1998

Positive or Negative?

Negative Positive
 VIA Test Qualities
Study Country/St Number Detection of HGSIL and Cancer
udy of Cases
Sensitivity Specificity

Megevand et al (1996) South Africa 2,426 65% 98%

Sankaranarayanan et al India 2,935 90% 92%

(1998)
University of Zimbabwe 2,148 77% 64%
Zimbabwe/Jhpiego (1999)
Belinson (2001) China 1,997 71% 74%

Denny et al (2000) South Africa 2,944 67% 84%

Sankaranarayanan et al India 56,939 76.8% 85.5%
(2004)
Sauvaget et al. (2010) 26 Studies 132,186 80 % 92 %
(IARC/Trivandrum MC*)
 VIA: ACCEPTABLE SCREENING OPTION
WHO 6 African Country
WHO Demonstration Projects, 2012
COMPREHENSIVE “VIA is an attractive alternative to
CERVICAL CANCER cytology-based screening in low-resource
settings”
CONTROL ESSENTIAL UNFPA Cervical Cancer Prevention
PRACTICES Programme Guidance, 2011
GUIDELINES: 2006 “Screening for precancerous lesions can
be done in several ways including,
 VIA use under Research
cervical cytology (Pap tests), visual
Framework inspection with acetic acid [VIA] or
testing for HPV DNA”.
FIGO Global Guidance for Cervical
Cancer Prevention and Control,
2009
“At present, the most accessible and
effective modality for single visit approach
is visual inspection with acetic acid (VIA)
followed by cryotherapy of positive cases”
2011 CCA REPORT CARD
Cost Effectiveness of Cervical Cancer Screening
And other Health Interventions
EAST COAST MEETS WEST COAST
 What to do with VIA positives?

PRINCIPLE:
For a Screening Programs to be effective:
Need Linkage with Treatment Options for
VIA Positives
Characteristic Cryotherapy Diathermy Loop
Excision (LEEP)
Effectiveness 80–90% 90–95%
Side effects watery discharge; bleeding
infection risk
Anesthesia required no yes
CRYOTHERAPY Loop Electrosurgical Excision
Tissue sample no yes Procedure
LEEP
Power required no yes
Cost relatively low relatively high

Source: Gaffikin L, et al.(eds). 1997.

 Single Visit Approach (SVA) Steps

1 Counseling
2 VIA during Pelvic
Examination
3 Discuss results with the
woman and offer
cryotherapy if positive
4 Perform Cryotherapy
5 Post treatment
counseling and follow up

17
 SVA SERVICE DELIVERY OPTIONS
1. Full SVA on site
2. VIA at HCF/Same day
SPECIALTY CENTER
treatment at DH
Diagnostics
3. Fully Mobile SVA services Cancer Management
Palliative Care
4. Partially mobile SVA
services

1 3
PHC PHC
VIA No VIA
REFERRAL LEVEL
Cryotherapy No Cryotherapy
DISTRICT/PROVINCIAL
In SVA
HOSPITAL
Diagnostics
Cryo and LEEP
Others 4
PHC/Sub-PHC
2
PHC/Sub-PHC VIA Only
VIA and/or Cryo Service
VIA Only
Referral for addt’l care
SAFE Project: Thailand Selected Results

Lancet. 2003 Mar 8;361(9360):814-20.

 Thailand SAFE Project Women: 7 Years Later

VIA screening results (2000)

Followup Study VIA
Cohort A, VIA + in 2000 Cohort B, VIA – in 2000
screening results (n=565) (n=3,562)

SCJ not visible 28 (5.0%) 147 (4.1%)

Negative 464 (82.1%) 3,275 (91.9%)
Positive 54 (9.6%) 133 (3.7%)
Suspect cancer 1 (0.2%) --
Other 18 (3.2%) 7 (0.1%)
Followup Study Cohort A, VIA + in 2000 Cohort B, VIA – in 2000
Colpo/Histoloresults (n=565) (n=277)
CIN 3 2 3

Sanghvi et al., FIGO 2012

 Task Shifting – Compliance of SAFE study
Trained Nurses to VIA/Cryotherapy Standards

VIA STANDARDS % (n = 113)

Effective counseling 90
Preparation before VIA 88
Documentation 98 (n = 112)
Cryo STANDARDS % (n=76)
Detailing Tx Options 83
Cryounit Prep 92
Freezing Technique 88

Source: Sanghvi H et al., Reproductive Health Matters, 2008;10(32):1-10.

Cost Effectiveness of Screening every 5
Years in Thailand

Lancet. 2003 Mar 8;361(9360):814-20.

Reduction in Lifetime Risk

Lancet. 2003 Mar 8;361(9360):814-20.

 Cervical Cancer Prevention Challenges

• An appropriate test is not enough

• Effective service delivery system is
Essential
• Population Coverage
• Appropriate management of screen positives
• Limit loss to follow-up
• Reasonable treatment cost
Impact of Screening on Cervical Cancer Incidence

The results support the conclusion that ORGANIZED

SCREENING have had a major impact on cervical
cancer in Nordic countries – Laara et.al, Lancet, 1987
 TAKE HOME MESSAGE (1)

 LOOK BEFORE YOU LEAP-ASSESSMENT

 BUILD CAPABILITY
 DEVELOP SERVICE PROVISION CAPACITY
 MONITOR AND EVALUATE PROGRESS
 PREPARE AND BUDGET FOR
SCALE UP
 EXPAND PILOT SITES AND SCALE-
UP NATIONALLY
 DISSEMINATE SUCCESS
 TAKE HOME MESSAGES (2)

SCALING-UP SCREENING
 Implement Sustained Organized
Screening
1. Target All Eligible Women for Screening at
Regular Intervals
2. Design service delivery model to adapt to
organized screening
3. Offer free screening, treatment and automatic
referral
4. Sustain a strong link from community to
referral
 Thank You Grazie

It takes a minute to
prevent cervical cancer-
Go SVA!
Ricky Lu
rlu@jhpiego.net
Paul Blumenthal
pblumenthal@stanford.edu