Cervical Cancer Screening and Treatment: Best Practices for LMICs
I have been following this discussion whole-heartedly. To let everyone know, I have moved it from the "Introductions" thread and made it it's own topic, given the depth of discussion. Also, to try and condense as much as possible, I have edited out some comments. Lastly, I've compiled all the resources here. Please just click on "Reply" to this thread, and lets continue!
You can still find the orginal conversation at:
Pathologist (in Boston). Recently started a program for women's cancer screening (cervical and breast); developing infrastructure - cytology laboratory etc., in South Indian towns and villages (Trichy, Manapparai, Thuraiyur) and a model for a self-sustainable cancer screening network.
Works nearby in Thanjavur (www.ictph.org.in); integrating Cervical Cancer Screening (and hopefully soon treatment) into a more broad based primary care practice. We do something similar with Diabetes and CVD as well.
Screening with VIA-VILI (vs cytology) within the context of a generalised Family-Nurse-Practitioner type clinic which attempts to offer the full range of PCMH services with just one provider. Currently we are referring up people for Cytology and for treatment if found positive but we understand that the approach of directly treating (in our primary care setting) on the basis of VIA-VILI would be much-much more effective -we see a number of drop-offs and no-shows otherwise. What do you think? Perhaps even the vaccine may turn out to be more cost-effective in DALY terms even though on an absolute cost basis it is much more expensive.
I agree VIA-VILI will be an ideal solution if it works. In fact, all the recent press around Shastri et al., presentations in ASCO seems to point that VIA is the best solution for LMIC cervical cancer. We implemented VIA-VILI got a colposcope in our center in 2011, and compared out results to HPV and cytology. We were dismayed at the predictive value of VIA in the Indian rural setting and have since moved to cytology based screening. I am very happy to share our numerical data with you and Maggie when we meet. On the other hand, in a populous country like India, we did an analysis on the cost to screen all the women in the age group of 30-55 in the district of Trichy. Assuming about 500,000 women, and with our modus operandi in 2011 it took 40$ / women resulting in 20 million dollars for just Trichy for just cervical cancer. Crazy... Now we are trying to get the costs down to 2$/woman. We have a camp in Perambalur next month to test this. VIA would reduce the costs, but it is not the solution. Infrastructure improvement to bring in a better screening test (cytology) is the solution. How? I am expecting to learn how in the GHDI program next month. 2$/woman and vaccine for the younger girls will be the solution. I am looking forwards to meeting you all.
But please do keep in mind a generalised primary care environment - camps rarely see the full complement of women and specialised efforts focussed on single conditions have been the bane of Indian healthcare systems. We need to embed a lot of care into a more general health systems environment. We are hoping for example to gradually incorporate mental health into our framework (which already includes Diabetes, common infectious diseases, ophthalmology, dermatology, dentistry, cardio-vascular diseases, and some pain work -
though a lot more needs to be done even here and in orthopaedics).
We are planning a VIA program which was recommended to us given the setting here so I would like to know if this kind program is really the solution because still cytology will still be required for confirmation of unequivocal VIA findings. I would like to know the acceptability of the VIA in other settings who have done it as women may not be attracted to this kind of testing due to cultural influences and how did you overcome this kind of
obstacles to have a successful program.
Our work has been guided by Dr. Krishnan of http://giahc.org/ -- her organisation is a strong believer in the VIA/VILI methodology. I understand from the recent exchanges of emails that
we have had on this forum that there are concerns about how accurate this approach is - I am not a medical doctor but before we started we looked at a number of large scale studies of this approach carried out by the IARC and have relied largely on their guidance
(http://screening.iarc.fr/doc/ACCP_recs_2007_factsheet_final.pdf) as well as the support of the Adyar Cancer Institute in Chennai, India (http://www.cancerinstitutewia.org/). The doctors on our staff have also been satisfied with this approach. You can read a little bit more about our work on our blog:
Nachiket and George: I think by the end of July, if I get trained enough (global health delivery intensive course) to decipher the truth about the VIA/VILI data out there, I will be happy. Dr. Sankar (IARC), Cancer Institute Adyar mean well in suggesting / implementing VIA for India. However, I think this stems from true frustrations and inabilities to develop laboratory infrastructure and quality training of cytotechnologists in India - two factors that helped in the western world in screening in 1970s and 80s. We implemented VIA/VILI in 2011 - we faced a 30% False positive rate (compared to HPV) and a similar (35%) False negative, with VIA. I decided to look into countries (mainly African) where it was touted as a success. In 2012 I spent time in South Africa and directly talked to some experts there - I am attaching a draft document of their experience. Subsequently, Anne Ruch (Guatemala), myself, and others have realized that improving infrastructure towards cytology is important than 'giving in' to the easy way (VIA - VILI). It is truly a shame that WHO/IARC is 'pushing' this 'abandoned' technique in LMICs. I am there to help in any ways I can for infrastructure improvement towards cytology.
Rajan: Thanks for sharing this perspective. I wonder if you could outline a little bit what is needed here - it is my understanding that making slides that can be sent off for more careful analysis is certainly possible in primary care settings even in India. Will that be enough? What about at the back-end - I understand that there are technologies that are able to substitute for a trained cytotechnologists at the back-end and do perhaps
even a more careful analysis of the slide and actually do the "counting" more carefully? Is that indeed the case? Would love to learn more about the alternatives you have in mind.
ANNA E. SCHMAUS
Up to now I always thought I am the only one who tries to explain why VIA is not a diagnostic method.
We, doctors, teachers, nurses from the NGO "One World Medical Network" (OWMN) are engaged in cervical cancer screening in LMICs and your experience is exactly the one we made. Doctors from OWMN say VIA is not a diagnostic method. The idea of using VIA instead of HPV or Pap test in LMICs is not because the quality is equal or even better, it is because of cost and time. No women in developed countries would accept to be treated because of an undefined VIA result because it is cheaper and no doctor would dare to do it. So why tries people to tell women in developing countries it is the best for them? It is not and doctors know it.
For many years doctors from OWMN practiced another method to diagnose cervical cancer. They developed a method to teach mid-level health workers to do a fast, easy and low cost Pap test. This method can be complemented with colposcopy. In order to receive reliably diagnoses we combine the method with telemedicine.
The order looks like that:
- face to face teaching in a rural hospital
- providing live teaching using CampusMedicus (telemedicine / teleteaching platform)
The teaching for mid-level health workers includes: Pap smear test, staining, cytology, histology. Having diagnosed HSIL or CIN2/3 they contact a cytologist (national / international) through the telemedicine platform. The cytologist will write a diagnosis within short time and the women will know whether she can stay in her home place or whether it will be better to see a gynecologist. This kind of method will avoid many false-positive treatments with all its consequences which are the case with VIA.
We are thinking now of using a cheap, ease to use and fast biomarker which will allow to do a triage. This would allow to find out women who do not show HSIL / CIN3 abnormalities and avoid doing any test at all.
I talked to Professor zur Hausen (nobel prize for finding out that HPV is the cause for cervical cancer). He told me that testing women only once in their live for HPV and then doing a pap test would already save many lives. A more regular testing would be better he admitted.
In Mongolia a cervical cancer screening projects was implemented by the Millennium Challenging Account. A consultant recommended VIA and cryotherapy for this project. However Mongolian doctors decided to go for Pap test and telemedicine. From beginning of the project in 2012 until now around 15,000 women were tested. The project will end by end of 2013, but as the Mongolian Ministry of Health is convinced by the positive result for women, they will continue this project. By exchanging cytology images with expert cytologists the mid-level health workers became so well trained, that now, that they can make decisions themselves more easily.
Dr. Rajan Dewar please let me know your statistic data, so that we can go together for better diagnoses for women.
Is any of this possible in primary care settings with non-specialist doctors and nurses? In a large country like India only very limited skills can be made available close to the patient. Can the GP / Nurse be trained to do the patient part of this work?
Yes it can be done! In Rwanda primary care is not massively specialized, but our GPs/ Nurses and community health workers at cell level have managed to team up for this kind of challenge. And trust me (i am not buttering anyone) our results are envious! Come and see!
ANNA E. SCHMAUS
yes, GP, nurses and midwives at primary care level where no cytologists or pathologists can be trained. Teleteaching supports the training process. Patient cases can be exchanged and diagnoses are available within short time. Doctors from OWMN did the training in African hospitals.
You can find more detailed information about the training of mid-level health worker and cytology here: http://med.cx/53. You can share this case with people by clicking on "send case". Insert one or more email addresses. You also can add comments which will be available to everybody who has access to the case.
The American Society of Clinical Oncology has posted a video of the presentation by Dr. Surendra Srinivas Shastri at the Plenary Session of the ASCO Annual Meeting in Chicago, reporting the results of his and his colleagues’ study of the effects of VIA screening by primary health workers on cervical cancer mortality in Mumbai. The video (along with a video of Dr. Paul Farmer from Partners in Health) can be viewed here: http://connection.asco.org/Magazine/Article/ID/3586/Exclusive-Video-of-Presen...
I work for Grounds for Health (www.groundsforhealth.org), an NGO, that collaborates with local coffee cooperatives, NGOs and Ministries of Health to establish sustainable cervical cancer prevention programs in coffee producing regions. We are currently working in Nicaragua, Peru and Tanzania. Our model focuses on training health care providers in screen and treat methods and on developing a network of community health workers who can help reduce barriers to access to cervical cancer prevention services.
We are committed to using VIA for screening and cryotherapy for treatment not only because it is feasible to implement in lower resource settings, but because it is an effective test. There is a great deal of research that demonstrates that VIA is more sensitive than Pap. While it does perhaps find more "false positives," with cryotherapy as a safe and inexpensive treatment with very low risk of complication, it is preferable to "over-treat" than it is to miss a true positive.
As noted in the Cervical Cancer Action Report 2012 issued by Cervical Cancer Action (http://www.cervicalcanceraction.org) an international coalition that advocates for the implementation of cervical cancer screening and treatment programs in all countries, "[the Pap] strategy has been effectively employed in high-income settings despite its sub-optimal performance in correctly identifying women with pre-cancerous lesions."
Obviously, the Pap test itself is not the only problem, but rather the extensive infrastructure required in order for it to perform at a high level (equipment, laboratory, pathologists, cytologists, response systems, etc.) is not within reach for most low resource settings. As we all know, screening without treatment is absolutely ineffective in reducing morbidity or mortality. Pap programs generally have more possibilities for loss to follow up than a program that follows the screen and treat method that is possible with visual inspection and cryotherapy. Even countries with adequate resources and good infrastructure struggle with loss to follow-up. We have found that in rural areas of LMICs, the loss to follow up rate is very high and thus morbidity and mortality rates do not change when the only program available is cytology based.
Our focus on VIA and cryotherapy is supported by The Alliance for Cervical Cancer Prevention (http://www.alliance-cxca.org/). As stated on their Web site: "New evidence continues to support the feasibility and accuracy of screening technologies that are alternatives to resource-intensive Pap smears. Comprehensive prevention programs that include human papillomavirus (HPV) vaccination of young adolescent girls before exposure to HPV, timely screening with HPV testing or visual inspection for mid-adult women, and appropriate treatment can dramatically reduce cervical cancer mortality."
Experience has demonstrated that VIA with cryotherapy is an simple, yet elegant solution that is possible to implement in even the most remote corners of the world.
For more information about Grounds for Health and our model, please visit our web site at www.groundsforhealth.org.
ANNA E. SCHMAUS
Please read the attachment of Dr. Rajan Dewar.
There you find the following information:
... In another trial conducted in India [Sanakaranararyanan R, Nene BM, Shastri SS et al. HPV screening for cervical cancer in rural India. N Engl J Med 2009;360:1385 – 1394], compared a single round of VIA, cytology, HPV DNA testing or no screening on cervical cancer mortality in a trial involving 132 000 women aged 30 – 59 years. No significant reduction in cervical cancer mortality was reported after VIA and treat in this study, whereas HPV DNA screening was followed by a significant 48% reduction in mortality from cervical cancer compared with the control group.
One World Medical Network will do a scientific project using mRNA as a triage. mRNA is also easy-to-use and cheap.
I appreciate Rebecca's opinion about the advantages of VIA; but we feel very insecure about treating those patients who were false positive. I am deeply convinced that developing quality infrastructure by training cyto-technologists is the right approach. It creates a local knowledge base, new value & skill at the site. Importantly - THIS IS THE ESTABLISHED TECHNIQUE THAT WORKED IN THE WESTERN WORLD and is the diagnostic standard even after a positive HPV test. I may be biased to this technique because I am a pathologist. I am happy to share my data and experience from the last 2-3 years, if any of you are currently at HSPH. We can arrange a group discussion specifically around this. I would love to learn from others.