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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.

Parham GP, Mwanahamuntu MH, Kapambwe S, Muwonge R, Bateman AC, Blevins M, Chibwesha CJ, Pfaendler KS, Mudenda V, Shibemba AL, Chisele S, Mkumba G, Vwalika B, Hicks ML, Vermund SH, Chi BH, Stringer JS, Sankaranarayanan R, Sahasrabuddhe VV - PLoS ONE (2015)

Bottom Line: 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.We 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.

View Article: PubMed Central - PubMed

Affiliation: Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America; International Agency for Research on Cancer, Lyon, France.

ABSTRACT

Background: Very few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries.

Methods: In 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.

Findings: Between 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.

Interpretation: We 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.

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Performing VIA-based screening augmented by digital cervicography in the clinics of the Cervical Cancer Prevention Program in Zambia (CCPPZ).Notes: Nurses in CCPPZ clinics initially perform screening using VIA, after which they use a commercial brand (off-the-shelf) hand-held digital camera (Upper Panel) to take photographs of the cervix (cervigrams). Cervigrams are then displayed on a bedside television or camera monitor in real-time (Middle Panel), permitting magnification and detailed examination of lesion morphology, including size, margin sharpness, proximity to the transformation zone, degree of extension into the endocervical canal, abnormal vasculature (mosaicism, punctations, atypical blood vessels) and gross characteristics suspicious for ICC. Cervigrams are routinely shown to and discussed with patients during the screening procedure after which they are uploaded by nurses to a clinic computer where they can be (i) electronically transmitted using cellphone network lines to off-site experts (after deidentifcation) for rapid distance consultation (telecervicography), when necessary, (ii) batched and later routinely peer reviewed to form the basis of a rigorous ongoing continuing education and quality assurance program, and (iii) stored with the patient’s electronic medical record. Relevant cervigrams are transmitted by screening nurses to the referral clinic by email, after deidentification, where they are accessible by consultants at the time of patient visits. (Lower Panel).
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pone.0122169.g003: Performing VIA-based screening augmented by digital cervicography in the clinics of the Cervical Cancer Prevention Program in Zambia (CCPPZ).Notes: Nurses in CCPPZ clinics initially perform screening using VIA, after which they use a commercial brand (off-the-shelf) hand-held digital camera (Upper Panel) to take photographs of the cervix (cervigrams). Cervigrams are then displayed on a bedside television or camera monitor in real-time (Middle Panel), permitting magnification and detailed examination of lesion morphology, including size, margin sharpness, proximity to the transformation zone, degree of extension into the endocervical canal, abnormal vasculature (mosaicism, punctations, atypical blood vessels) and gross characteristics suspicious for ICC. Cervigrams are routinely shown to and discussed with patients during the screening procedure after which they are uploaded by nurses to a clinic computer where they can be (i) electronically transmitted using cellphone network lines to off-site experts (after deidentifcation) for rapid distance consultation (telecervicography), when necessary, (ii) batched and later routinely peer reviewed to form the basis of a rigorous ongoing continuing education and quality assurance program, and (iii) stored with the patient’s electronic medical record. Relevant cervigrams are transmitted by screening nurses to the referral clinic by email, after deidentification, where they are accessible by consultants at the time of patient visits. (Lower Panel).

Mentions: Given the concerns about suboptimal sensitivity and lack of an efficient quality assurance mechanism for VIA-based screening, we developed an innovative and locally adapted telecommunications matrix that provided single-visit point-of-care enhanced digital imaging of the cervix (digital cervicography), peer review, quality assurance, continuing medical education, objective record of screening test results, and access to expert opinion through immediate distance consultation, if needed [22]. (Fig 3) (Fig 4) Treatment decisions were made primarily on the basis of VIA, however, if there were disagreements between VIA and cervicography, the latter was used to make the final decision.


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.

Parham GP, Mwanahamuntu MH, Kapambwe S, Muwonge R, Bateman AC, Blevins M, Chibwesha CJ, Pfaendler KS, Mudenda V, Shibemba AL, Chisele S, Mkumba G, Vwalika B, Hicks ML, Vermund SH, Chi BH, Stringer JS, Sankaranarayanan R, Sahasrabuddhe VV - PLoS ONE (2015)

Performing VIA-based screening augmented by digital cervicography in the clinics of the Cervical Cancer Prevention Program in Zambia (CCPPZ).Notes: Nurses in CCPPZ clinics initially perform screening using VIA, after which they use a commercial brand (off-the-shelf) hand-held digital camera (Upper Panel) to take photographs of the cervix (cervigrams). Cervigrams are then displayed on a bedside television or camera monitor in real-time (Middle Panel), permitting magnification and detailed examination of lesion morphology, including size, margin sharpness, proximity to the transformation zone, degree of extension into the endocervical canal, abnormal vasculature (mosaicism, punctations, atypical blood vessels) and gross characteristics suspicious for ICC. Cervigrams are routinely shown to and discussed with patients during the screening procedure after which they are uploaded by nurses to a clinic computer where they can be (i) electronically transmitted using cellphone network lines to off-site experts (after deidentifcation) for rapid distance consultation (telecervicography), when necessary, (ii) batched and later routinely peer reviewed to form the basis of a rigorous ongoing continuing education and quality assurance program, and (iii) stored with the patient’s electronic medical record. Relevant cervigrams are transmitted by screening nurses to the referral clinic by email, after deidentification, where they are accessible by consultants at the time of patient visits. (Lower Panel).
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4401717&req=5

pone.0122169.g003: Performing VIA-based screening augmented by digital cervicography in the clinics of the Cervical Cancer Prevention Program in Zambia (CCPPZ).Notes: Nurses in CCPPZ clinics initially perform screening using VIA, after which they use a commercial brand (off-the-shelf) hand-held digital camera (Upper Panel) to take photographs of the cervix (cervigrams). Cervigrams are then displayed on a bedside television or camera monitor in real-time (Middle Panel), permitting magnification and detailed examination of lesion morphology, including size, margin sharpness, proximity to the transformation zone, degree of extension into the endocervical canal, abnormal vasculature (mosaicism, punctations, atypical blood vessels) and gross characteristics suspicious for ICC. Cervigrams are routinely shown to and discussed with patients during the screening procedure after which they are uploaded by nurses to a clinic computer where they can be (i) electronically transmitted using cellphone network lines to off-site experts (after deidentifcation) for rapid distance consultation (telecervicography), when necessary, (ii) batched and later routinely peer reviewed to form the basis of a rigorous ongoing continuing education and quality assurance program, and (iii) stored with the patient’s electronic medical record. Relevant cervigrams are transmitted by screening nurses to the referral clinic by email, after deidentification, where they are accessible by consultants at the time of patient visits. (Lower Panel).
Mentions: Given the concerns about suboptimal sensitivity and lack of an efficient quality assurance mechanism for VIA-based screening, we developed an innovative and locally adapted telecommunications matrix that provided single-visit point-of-care enhanced digital imaging of the cervix (digital cervicography), peer review, quality assurance, continuing medical education, objective record of screening test results, and access to expert opinion through immediate distance consultation, if needed [22]. (Fig 3) (Fig 4) Treatment decisions were made primarily on the basis of VIA, however, if there were disagreements between VIA and cervicography, the latter was used to make the final decision.

Bottom Line: 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.We 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.

View Article: PubMed Central - PubMed

Affiliation: Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America; International Agency for Research on Cancer, Lyon, France.

ABSTRACT

Background: Very few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries.

Methods: In 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.

Findings: Between 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.

Interpretation: We 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.

Show MeSH
Related in: MedlinePlus