A participatory assessment to identify strategies for improved cervical cancer prevention and treatment in Bolivia

Abstract

Cervical cancer remains a leading cause of death for women in many countries of the world. In Latin America and the Caribbean, cervical cancer has become the primary cause of cancer-related deaths among women despite the introduction of screening programs more than 30 years ago. Each year in Latin America and the Caribbean 52 000 new cases are diagnosed, and 25 000 women die of the disease (1). Bolivia has one of the highest cervical cancer incidence rates in the Americas (58.1/100 000 women) (2). An estimated 661 deaths per year in Bolivia are attributed to cervical cancer, equivalent to an agestandardized mortality rate of 22.2/100 000. This compares with 7.6/100 000 in Argentina and 12/ 100 000 for all of South America. These statistics are particularly noteworthy given that cervical cancer can be prevented by the timely identification and treatment of precancerous lesions (3, 4). Bolivia is one of the poorest countries in South America. Some 70% of Bolivians live in poverty, with limited access to adequate housing, sanitation, education, and health care. Surveys indicate that the public sector in Bolivia provides health care for 40%-60% of the population, and performs 70% of all the Pap smears done in the country for cervical cancer screening (5, 6). Various efforts related to cervical cancer prevention in Bolivia have yet to result in an appreciable decrease in morbidity and mortality from the disease. These efforts have included Pap smear screening, creating the Component for the Detection and Control of Women's Cancer (Componente de Detección y Control del Cáncer de la Mujer) (the "Women's Cancer Component") as a unit within the Ministry of Health and Social Welfare (MHSW) (Ministerio de Salud y Previsión Social), and developing national clinical norms for the prevention of cervical cancer. To identify the obstacles that have impeded the effectiveness of cervical cancer prevention, three organizations joined together in 2001 to coordinate an assessment of the existing cervical cancer prevention and treatment services and the development of appropriate intervention strategies. The three groups were the Women's Cancer Component, EngenderHealth (an international reproductive health organization based in New York City), and the Pan American Health Organization. These groups adapted the World Health Organization (WHO) three-stage "Strategic Approach" for strategic planning and reproductive health policy and program development (7, 8

Bolivian Health Providers' Attitudes Toward Alternative Technologies for Cervical Cancer Prevention: A Focus on Visual Inspection with Acetic Acid and Cryotherapy

“…30 A recent qualitative assessment found that in many parts of the country, men are the ones deciding whether or not women should get screened or receive treatment and that many women do not seek care because of the stigma attached to the Pap test. 28 This is consistent with our findings showing that most physicians believe that taboos about Pap testing represent the major specific barrier for early detection of cervical cancer in Bolivia.…”

“…27 Adequate follow-up of women with positive Pap test results has been the main challenge to the successful implementation of cytology-based programs in LAC, including Bolivia, where < 20% of eligible women receive treatment for precancerous lesions. 28 As most cytologybased services are available in urban areas, women need to make costly trips to health facilities to get screened and receive diagnostic and treatment services if needed. At facilities offering these services, women experience long delays to receive care or Pap test results.…”

“…28 Education efforts may prove an effective strategy to increase cervical cancer screening coverage, as 44% of women in Sucre who reported having been screened at least once in their lifetime cited receiving information on cervical cancer as the main reason for seeking care. 30 Because men participate in the health decisions of women, it is important that health education and promotion strategies for the Bolivian public are tailored toward both men and women.…”

Evidence-based Screening, Early Diagnosis and Treatment Strategy of Cervical Cancer for National Policy in Low-resource countries: Example of India

“…The screening process, along with the delays between screening, test results and ultimate treatment are major obstacles to the success of cytology-based programs in low-resource settings. Although cytology screening has been introduced in LMIC over the past 30 years, it has not resulted in the expected decreases in cervical cancer incidence and mortality similar to those observed in the HIC, primarily because of the above mentioned hurdles associated with low coverage of the target population (Dzuba et al, 2005 the CIN2 and CIN 3 (53% in HIC, and 26-65% in LMIC) (Almonte et al, 2007;Cuzick et al, 2006;Sankaranarayanan et al, 2004b;Sarian et al, 2005), repeated screening at regular intervals is necessary for the programmes to be effective. This low sensitivity in developed countries is overcome by organized periodic screening, which is not feasible with the opportunistic screening carried in low-resource setting.…”

Cervical Smears at Public Health Centres in Eastern Trinidad: Coverage and Follow-up, 2009–2010

“…Billette-de Villemeur et al reported that out of 1154 women in France referred for follow-up care for ASCUS, more than 75% did not meet the guidelines (7). Dzuba et al also reported from Bolivia that 50% to 80% of women with abnormal cervical smears were lost to follow-up (16). A similar study by Singhal et al in the United States of America (USA) found that a significant proportion of women were not receiving the care as recommended (6).…”