Cervical Cancer Screening (CCS) in the Gwassi Division A Briefing Note on Current Practices in the Region

Why is Cervical Cancer Screening Important?

¤  Cervical cancer is the second most common type of cancer among women, and was responsible for over 250,000 deaths in 2005, approximately 80% of which occurred in developing countries.

¤  Without urgent action, deaths due to cervical cancer are projected to rise by almost 25% over the next 10 years in developing countries.

WHO. Comprehensive cervical cancer control: a guide to essential practice. www.who.int. http://whqlibdoc.who.int/publications/2006/9241547006_eng.pdf. Published 2006

Why is Cervical Cancer Screening Important?

¤  Cervical cancer and HIV infection represent synergistic threats to women’s reproductive health and mortality.

¤  HIV infection increases the women’s risk of HPV infection, cervical neoplasia and invasive cervical cancer.

¤  In Kenya, cervical cancer is the most common cancer diagnosed among women and the most common cause of cancer-related death

Palefsky J. Human papillomavirus-related disease in people with HIV. Curr Opin HIV AIDS. 2009;4(1):52–56.

Why is Cervical Cancer Screening Important?

¤  From the time that cancer precursors (mild dysplasia) are identified, it usually takes 10 to 20 years for invasive cancer to develop.

¤  Cervical cancer control is possible through screening and treatment.

Impact for the Community

¤  The Nyanza province is the region hardest hit by HIV within Kenya, with infection rates ranging from 14% to 40% in different districts. Estimates in Gwassi are around 22%.

¤  Additionally, women were more likely to be HIV infected than men. In particular, young women aged 15-24 years were four times more likely to be infected than young men in the same age group, according to the 2007 Kenya AIDS Indicator Survey.

¤  The wide availability of HIV care centers and ARV therapy in the division is expected to increase the lifespan of women living with HIV, but also to increase the lifetime risk of developing cervical cancer.

WHO Guidelines for Developing Countries

From the WHO Publication: Comprehensive Cervical Cancer Control: a guide to essential practice

Recommended target ages of CCS

¤ New programmes should start screening women aged 30 years or more, and include younger women only when the highest-risk group has been covered.

¤  Existing organized programmes should not include women less than 25 years of age in their target populations.

¤  If a woman can be screened only once in her lifetime, the best age is between 35 and 45 years.

Factors for Screening Success

¤  High coverage (80%) of the population at risk

¤  Appropriate follow-up and management for those who are positive on screening.

¤  Effective links between program components (e.g. from screening to diagnosis and treatment)

¤  High quality of coverage, screening tests, diagnosis, treatment, and follow-up

¤  Adequate resources

Screening Methods for Low Resource Settings

¤  Cytology based programs can be difficult to implement in low-resource setting, due to inherent requirements: ¤  highly trained personnel

¤  well equipped laboratories

¤  transport of specimens

¤  an effective system for collecting information and following up patients

¤  Visual inspection methods show promise for replicating the success of cytology-based programs but have not been demonstrated in large scale studies.

Visual Screening Methods for Low Resource Settings

¤  Two visual methods are available: ¤  visual inspection with acetic acid (VIA)

¤  visual inspection with Lugol’s iodine (VILI)

¤  Abnormalities are identified by inspection of the cervix without magnification, after application of dilute acetic acid (vinegar) (in VIA) or Lugol’s iodine (in VILI).

¤  Results are immediate and there is no reliance of laboratory testing.

Evidence for the use of Visual Screening Methods

¤  VIA and VILI are recommended by WHO only for use in pilot settings, because the impact on cervical cancer incidence and mortality is still unproven.

¤  In research settings, VIA has been shown to have an average sensitivity for detection of precancer and cancer of almost 77%, and a range of 56% to 94%. The specificity ranges from 74% to 94% with an average of 86%.

¤  One study has shown that VILI can detect 92% of women with precancer or cancer, a sensitivity considerably higher than that of either VIA or cytology. Its ability to identify women without disease is similar to that of VIA (85%), and lower than that of Pap smears.

¤  One study showed that VILI had a higher reproducibility than VIA.

Advantages and Disadvantages of Visual Screening Methods

Advantages

¤  Relatively simple and can be taught to nurses, nurse-midwives and other health workers.

¤  Assessment is immediate. No transport, laboratory equipment or personnel, is needed.

¤  Likely to be less costly than other approaches in routine use.

¤  Results are available immediately, reducing loss to follow-up.

Disadvantages

¤  Low positive predictive value of the test increases the number of women who test positive do not have disease.

¤  Cannot be relied on in postmenopausal women.

¤  No permanent record of the test that can be reviewed later

¤  VIA has mostly been evaluated as a once-in-a-lifetime screening test, its performance in periodic screening has not been assessed

Standard practice for diagnosis: colposcopy and biopsy

¤  Biopsy performed with the aid of a colposcope is the standard method for diagnosis of cervical precancer and preclinical invasive cancer.

¤  Barriers to colposcopy and biopsy services ¤  Colposcopes are sophisticated, relatively expensive

instruments.

¤  Specialized training and experience are required to maintain proficiency.

¤  Biopsy samples need to be transported to a histopathology service, which may be difficult in low-resource settings.

Treatment Options for Precancer

¤  Precancer should be treated on an outpatient basis whenever possible.

¤  Both cryotherapy and LEEP (loop electrosurgical excision procedure) may be suitable for this purpose, depending on eligibility criteria and available resources.

Advantages and Disadvantages of Cryotherapy

Advantages

¤  High cure rate for small lesions

¤  Equipment simple and relatively inexpensive, training takes a few days

¤  Can be performed as an outpatient procedure

¤  Fast

¤  Anesthesia not required

¤  Electricity not required

Disadvantages

¤  Less effective for larger lesions (cure rates < 80% at one year)

¤  No tissue sample available for histological examination

¤  Needs continuous supply of carbon dioxide or nitrous oxide

¤  Causes prolonged and profuse watery discharge

Advantages and Disadvantages of LEEP

Advantages

¤  High cure rate

¤  Reliable histology specimen obtained,

¤  Few complications

¤  Can be performed on an outpatient basis at a secondary level facility

¤  Fast and technically simple to perform

Disadvantages

¤  Requires intensive training

¤  Postoperative bleeding in less than 2% of treated women

¤  More sophisticated equipment needed

¤  Requires electricity

¤  Requires local anesthesia

A Case Study of a Pilot Cervical Cancer Screening Program (initiated by FACES in the Nyanza province) Huchko, M., Bukusi, E. and Cohen C., Building capacity for cervical cancer screening in outpatient HIV clinics in the Nyanza province of western Kenya. Int J Gynaecol Obstet . 2011 August ; 114(2): 106–110.

Introduction

¤  Family AIDS Care and Education Services (FACES) is an NGO providing HIV care and treatment in the Nyanza province of Kenya.

¤  FACES developed a pilot program in Lumumba Hospital in Kisumu, where they had a long established HIV care program.

¤  The pilot study was conducted over three years, and 3,642 women underwent screening.

¤  Screening was offered as part of comprehensive HIV care to all non-pregnant women aged over 25 years.

Screening Protocol

¤  The clinical protocol was developed on the basis of recommendations from the WHO’s Comprehensive Guide to Cervical Cancer Control for resource-limited settings, coupled with relevant evidence from recent clinical trials.

¤  The protocol uses visual inspection with 3–5% acetic acid (VIA) as a screening test, followed by colposcopy and biopsy to confirm cervical intraepithelial neoplasia.

¤  Women with biopsy-proven CIN2/3 are offered treatment via loop electrosurgical excision procedure (LEEP), performed by clinical officers on-site.

¤  LEEP was chosen for treatment because it has has significantly better outcomes in HIV-infected women than cryotherapy

FAC

ES Pilot Pro

gra

m Flo

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Training

¤  Clinical officers were provided specific training for competency in VIA and colposcopy. For both techniques, training includes a week of daily, 90-minute didactic sessions at the start or end of the clinical day. A short test assesses their retention and understanding.

¤  The didactic training is followed by a predetermined number of observed VIA and colposcopic examinations.

¤  The screening protocol relies on a confirmatory biopsy for treatment decisions. ¤  To facilitate histology interpretation and tracking of results, a local

pathologist trained the laboratory staff in specimen processing. ¤  Pathology specimens are sent weekly to Nairobi, and the results are sent

back via email

Results from the Pilot Program

¤  During the 3-year pilot (2007-2010): ¤  3642 women were screened for cervical neoplasia with VIA

(87% of the 4186 women offered screening).

¤  531 (15%) underwent colposcopy for either positive or unsatisfactory VIA.

¤  CIN2/3 was diagnosed and confirmed histologically in 259 women (7.1%)

¤  243 LEEPs were performed, with no serious adverse events requiring treatment or referral.

¤  Eight women (0.1%) were diagnosed with invasive cancer.

Future of the Pilot Program

¤  This program was funded through a seed grant, and therefore depends heavily on the existing infrastructure of the HIV clinic.

¤  Universal access to cervical cancer screening will require programs that can be scaled up to more remote areas that have even fewer resources and lower levels of staffing.

¤  Sustainability will depend on the validation of low-cost screening tests among HIV-infected women to determine whether the time, expense, and infrastructure requirements of colposcopy can be removed, and screening can be paired with same-day treatment to reach more remote sites.

Current Practices in Gwassi Division

As of July|August 2013

Facilities offering CCS

¤  There are currently three facilities offering CCS in the Gwassi division: ¤  Nyandiwa Dispensary ¤  Magunga Health Center ¤  Kisegi Sub-District Hospital

¤  All programs are supported by FACES

¤  Only VIA screening is offered. Colposcopy is referred to the district hospital in Sindo.

¤  In most cases, CCS is the only time a woman will have undergone a gynecological examination, as a result, health workers report some discomfort among older women (40 and above), but see immediate uptake among younger women (20-30)

Nyandiwa Dispensary

¤  Nyandiwa initiated their screening program in July 2012

¤  In 2012 (July –December), 131 women were screened

¤  In 2013 (January -July), 42 women were screened

¤  During the life of the program, 9 women had positive results and were referred to the district hospital in Sindo for colposcopy.

¤  Nyandiwa does not screen on a fixed schedule, but offers screening on demand. They do not push the service due to heavy workload, but perform when requested.

Magunga Health Centre

¤  Magunga initiated their screening program in June 2012

¤  In 2012 (June – December), 95 women were screened

¤  In 2013 (January -July), 25 women were screened

¤  Screening is offered two days per week

¤  Since initiation, no positive findings have been reported

¤  Due to the heavy workload, the staff report difficulty accommodating screening on demand.

Kisegi Sub-District Hospital

¤  Kisegi initiated their screening program in July 2012

¤  In 2012 (July – December), 71 women were screened

¤  In 2013 (January -July), 47 women were screened

¤  Screening is recommended on Fridays, but also performed on demand

¤  Since initiation, one positive finding has been reported

¤  There is only one female staff trained in CCS which increase demand on days she is in the facility. Women state a strong preference for a female health worker.

Responses from Community Health Survey regarding CCS

¤  A community health survey was conducted over two days in Nyandiwa.

¤  Participants were asked questions about their health, their health seeking behavior and attitudes and thoughts on the status of health in the community.

¤  The questionnaire was response guided, women were asked questions to gauge awareness of CCS programs, their purpose, and their participation.

¤  The survey was conducted in English which biases the literacy and educational levels of the sample.

¤  The following data reflects the responses of 28 women.

Demographic Information Age and Marital Status

0

2

4

6

8

10

12

15-19 20-24 25-29 30-34 35-39 Over 40 Num

be

r of R

esp

ond

ent

s

Age Bracket

Single Married (monogamous) Married (Polygamous)

Demographic Information HIV Status

82%

14%

4%

HIV Status

HIV -

HIV +

Prefer Not to State

Demographic Information Childbearing and Level of Education

50% 50%

Have Children

Yes No

25% 29%

46%

0% 10% 20% 30% 40% 50%

Level of Education

General CCS Awareness

57%

43%

Have you heard about Cervical Cancer Screening?

Yes

No

Perceptions of Cervical Cancer

¤  Selected responses from the question: “What do you know about Cervical Cancer?” ¤  “it is brought about by the males”

¤  “it is a dangerous disease” (3 respondents)

¤  “it leads to barrenness”

¤  “there is no cure, it leads to death”

¤  “it can be treated/cured” (3 respondents)

¤  “nothing” (3 respondents)

Screening Prevalence

21%

79%

Have You Ever Been Screened?

Yes

No

Frequency and Recency of CCS

0

1

2

3

4

5

Within the last 6 months

Within the last year

How long ago were you screened?

0

1

2

3

4

5

One Time More than One Time

How many times have you been screened?

No women who had been screened reported any positive findings.

Stated Reasons for Not Having Been Screened

¤  For women who had heard about cervical cancer screening, but had not been screened, they were then asked “Why have you not been screened?”

¤  Selected responses: ¤  “never had any problems” (2 responses)

¤  “never been to the clinic/where the screening takes place” (2 responses)

¤  “because screening is done by a male health worker”

¤  “have never been offered” (2 responses)

¤  “lack of money”

Level of Interest Among Unscreened

82%

14%

4%

If screening was offered, would you be interested?

Yes

No

Maybe

¤  Reasons given for negative responses:

¤  “I might die”

¤  “No reason”

¤  “If you thought there were no problems, then you wouldn’t be screened”

¤  “I don’t like to be screened”