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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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Related in: MedlinePlus

Images of VIA negative, VIA positive-cryotherapy eligible and VIA positive-cryotherapy ineligible lesions from women undergoing screening in the Cervical Cancer Prevention Program in Zambia (CCPPZ).Notes: Using the following criteria, CCPPZ nurses classify VIA tests results as VIA negative, VIA positive eligible for local ablation with cryotherapy, or VIA positive ineligible for cryotherapy requiring physician evaluation.VIA negative: Absence of an acetowhite lesion with at least one distinct border (Top Panel, Left)VIA positive, eligible for cryotherapy: Acetowhite lesion with at least one distinct border, located within or adjacent to the transformation zone, that: occupies <75% or <3 quadrants of the surface of the ectocervix, is completely visualized, can be completely covered by the largest available cryoprobe tip, has no evidence of abnormal vasculature (punctations, mosaicism, atypical blood vessels) and is not suspicious for ICC (Top panel, right)VIA positive, ineligible for cryotherapy: Acetowhite lesion with at least one distinct border, located within or adjacent to the transformation zone, that has any of the following characteristics:Occupies ≥3 quadrants or ≥75% of the surface of the ectocervix (Middle panel, left)Has evidence of abnormal vasculature (punctations, mosaicism, atypical blood vessels) (Middle panel, center)Cannot be completely covered by the largest available cryoprobe tip (Middle panel, right)Is suspicious for invasive cervical cancer (Bottom panel, left)Extends into the endocervical canal beyond complete visualization (Bottom panel, right)
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pone.0122169.g004: Images of VIA negative, VIA positive-cryotherapy eligible and VIA positive-cryotherapy ineligible lesions from women undergoing screening in the Cervical Cancer Prevention Program in Zambia (CCPPZ).Notes: Using the following criteria, CCPPZ nurses classify VIA tests results as VIA negative, VIA positive eligible for local ablation with cryotherapy, or VIA positive ineligible for cryotherapy requiring physician evaluation.VIA negative: Absence of an acetowhite lesion with at least one distinct border (Top Panel, Left)VIA positive, eligible for cryotherapy: Acetowhite lesion with at least one distinct border, located within or adjacent to the transformation zone, that: occupies <75% or <3 quadrants of the surface of the ectocervix, is completely visualized, can be completely covered by the largest available cryoprobe tip, has no evidence of abnormal vasculature (punctations, mosaicism, atypical blood vessels) and is not suspicious for ICC (Top panel, right)VIA positive, ineligible for cryotherapy: Acetowhite lesion with at least one distinct border, located within or adjacent to the transformation zone, that has any of the following characteristics:Occupies ≥3 quadrants or ≥75% of the surface of the ectocervix (Middle panel, left)Has evidence of abnormal vasculature (punctations, mosaicism, atypical blood vessels) (Middle panel, center)Cannot be completely covered by the largest available cryoprobe tip (Middle panel, right)Is suspicious for invasive cervical cancer (Bottom panel, left)Extends into the endocervical canal beyond complete visualization (Bottom panel, right)

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)

Images of VIA negative, VIA positive-cryotherapy eligible and VIA positive-cryotherapy ineligible lesions from women undergoing screening in the Cervical Cancer Prevention Program in Zambia (CCPPZ).Notes: Using the following criteria, CCPPZ nurses classify VIA tests results as VIA negative, VIA positive eligible for local ablation with cryotherapy, or VIA positive ineligible for cryotherapy requiring physician evaluation.VIA negative: Absence of an acetowhite lesion with at least one distinct border (Top Panel, Left)VIA positive, eligible for cryotherapy: Acetowhite lesion with at least one distinct border, located within or adjacent to the transformation zone, that: occupies <75% or <3 quadrants of the surface of the ectocervix, is completely visualized, can be completely covered by the largest available cryoprobe tip, has no evidence of abnormal vasculature (punctations, mosaicism, atypical blood vessels) and is not suspicious for ICC (Top panel, right)VIA positive, ineligible for cryotherapy: Acetowhite lesion with at least one distinct border, located within or adjacent to the transformation zone, that has any of the following characteristics:Occupies ≥3 quadrants or ≥75% of the surface of the ectocervix (Middle panel, left)Has evidence of abnormal vasculature (punctations, mosaicism, atypical blood vessels) (Middle panel, center)Cannot be completely covered by the largest available cryoprobe tip (Middle panel, right)Is suspicious for invasive cervical cancer (Bottom panel, left)Extends into the endocervical canal beyond complete visualization (Bottom panel, right)
© Copyright Policy
Related In: Results  -  Collection

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

pone.0122169.g004: Images of VIA negative, VIA positive-cryotherapy eligible and VIA positive-cryotherapy ineligible lesions from women undergoing screening in the Cervical Cancer Prevention Program in Zambia (CCPPZ).Notes: Using the following criteria, CCPPZ nurses classify VIA tests results as VIA negative, VIA positive eligible for local ablation with cryotherapy, or VIA positive ineligible for cryotherapy requiring physician evaluation.VIA negative: Absence of an acetowhite lesion with at least one distinct border (Top Panel, Left)VIA positive, eligible for cryotherapy: Acetowhite lesion with at least one distinct border, located within or adjacent to the transformation zone, that: occupies <75% or <3 quadrants of the surface of the ectocervix, is completely visualized, can be completely covered by the largest available cryoprobe tip, has no evidence of abnormal vasculature (punctations, mosaicism, atypical blood vessels) and is not suspicious for ICC (Top panel, right)VIA positive, ineligible for cryotherapy: Acetowhite lesion with at least one distinct border, located within or adjacent to the transformation zone, that has any of the following characteristics:Occupies ≥3 quadrants or ≥75% of the surface of the ectocervix (Middle panel, left)Has evidence of abnormal vasculature (punctations, mosaicism, atypical blood vessels) (Middle panel, center)Cannot be completely covered by the largest available cryoprobe tip (Middle panel, right)Is suspicious for invasive cervical cancer (Bottom panel, left)Extends into the endocervical canal beyond complete visualization (Bottom panel, right)
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