Population-Level Scale-Up of Cervical Cancer Prevention Services in a Low-Resource Setting: Development, Implementation, and Evaluation of the Cervical Cancer Prevention Program in Zambia

Abstract

BackgroundVery few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries.MethodsIn a public sector cervical cancer prevention program in Zambia, nurses provided visual-inspection with acetic acid (VIA) and cryotherapy in clinics co-housed with HIV/AIDS programs, and referred women with complex lesions for histopathologic evaluation. Low-cost technological adaptations were deployed for improving VIA detection, facilitating expert physician opinion, and ensuring quality assurance. Key process and outcome indicators were derived by analyzing electronic medical records to evaluate program expansion efforts.FindingsBetween 2006-2013, screening services were expanded from 2 to 12 clinics in Lusaka, the most-populous province in Zambia, through which 102,942 women were screened. The majority (71.7%) were in the target age-range of 25–49 years; 28% were HIV-positive. Out of 101,867 with evaluable data, 20,419 (20%) were VIA positive, of whom 11,508 (56.4%) were treated with cryotherapy, and 8,911 (43.6%) were referred for histopathologic evaluation. Most women (87%, 86,301 of 98,961 evaluable) received same-day services (including 5% undergoing same-visit cryotherapy and 82% screening VIA-negative). The proportion of women with cervical intraepithelial neoplasia grade 2 and worse (CIN2+) among those referred for histopathologic evaluation was 44.1% (1,735/3,938 with histopathology results). Detection rates for CIN2+ and invasive cervical cancer were 17 and 7 per 1,000 women screened, respectively. Women with HIV were more likely to screen positive, to be referred for histopathologic evaluation, and to have cervical precancer and cancer than HIV-negative women.InterpretationWe creatively disrupted the 'no screening' status quo prevailing in Zambia and addressed the heavy burden of cervical disease among previously unscreened women by establishing and scaling-up public-sector screening and treatment services at a population level. Key determinants for successful expansion included leveraging HIV/AIDS program investments, and context-specific information technology applications for quality assurance and filling human resource gaps.

Policies and Programs for Cervical Cancer Prevention and Control in Public Health Services

“…Six studies were carried out in Brazil [13,14,15,16,17,18] and four in the United States [19,20,21,22] . There was only one article from each of the following countries: Argentina [23] , Australia [24] , Canada [25] , England [26] , Italy [27] , Malawi [28] , Zambia [29] and United Kingdom [30] . Thus, the final sample comprised 18 articles.…”

“…With regard to the treatment and diagnostic of precursor lesions identified in the target population, data from three Brazilian [16,18,17] , one Zambian [29] and one British studies [26] were identified.…”

“…They found extremely satisfactory results due to the agility of the processes. They also identified a larger number of histological exams in HIV-positive women than in HIV-negative ones, who were part of the population in their research [29] .…”

Efficacy, Safety, and Acceptability of Thermal Coagulation to Treat Cervical Intraepithelial Neoplasia: Pooled Data From Bangladesh, Brazil and India

“…2017;6(3-4):58-64 services, particularly in many sub-Saharan African countries. This approach has been shown to be acceptable, safe, efficacious and feasible in demonstration projects and large-scale national or regional programs are on-going in countries such as Thailand and Zambia [4,6,7,[17][18][19][20]. Recently a screen-andtreat approach using thermal coagulation has been evaluated in a large screen-and-treat field program in Malawi, in which thermal coagulation for treatment of VIA-positive lesions was introduced as an alternative to cryotherapy [21].…”

Population-level scale-up of surgery platforms for women’s cancer care in low- and middle-income countries

“…Simultaneously implementing contextually-appropriate screening and early detection programs for such priority cancers, alongside the scale-up of cancer surgery service platforms, and tightly linking positive screening results to diagnostic and treatment interventions, is a necessity. Examples of such interventions in the women's cancers domain include "screen and treat" using VIA (visual inspection of the cervix using acetic acid) and cryotherapy/cold coagulation/loop electrosurgical excision procedure for cervical cancer prevention [22]; and clinical breast examination and ultrasound-guided biopsy of palpable breast masses for breast cancer early detection. Initially choosing only a few sites (and aiming for those with the best infrastructure, adequate levels of human resources and highest burden of disease) for testing the scale-up model would facilitate success.…”