Chapter 8: Screening for cervical cancer in developing ...

1 Vaccine 24S3 (2006) S3/71 S3/77 Chapter 8: Screening for cervical cancer in developing countriesLynette Dennya, , Michael Quinnb, R. SankaranarayanancaGroote Schuur Hospital, University of Cape Town, H45 Old Main Building, Observatory 7925, Cape Town, South AfricabUniversity Department of Obstetrics and Gynaecology and Oncology/Dysplasia Unit, Royal Women s Hospital, Melbourne, AustraliacScreening Group, International Agency for Research on cancer , Lyon, FranceReceived 14 March 2006; accepted 31 May 2006 AbstractOrganised and quality assured cytology-based Screening programmes have substantially reduced cervical cancer incidence in many devel-oped countries. However, there are considerable barriers to setting up cytology-based Screening programs, particularly in developing has stimulated the search for novel and alternative approaches to cytology for cervical cancer prevention.

2 These approaches generallyperform as well as cytology, and sometimes better, although many of them have a lower specificity, resulting in higher false-positive rates. Thepossibility of linking Screening to treatment in a one- or two-visit strategy appears to be safe, feasible and effective. Barriers to establishingscreening programs and the pitfalls encountered differ from one country to the next. Country-specific solutions need to be found, while beingcognisant of the criteria that have enabled successful Screening programmes. 2006 Elsevier Ltd. All rights : cervical cancer ; Screening ; developing countries1. IntroductionSuccessfully organised, population-based cervical cancerscreening programmes have not yet been implemented inmost developing countries, despite the greatest burden of cer-vical cancer in these countries[1], which is largely related topoverty, lack of resources and infrastructure and disenfran-chisement of Barriers to Screening in developing Competing health needsCompeting healthcare priorities posed by the impressiveburden of diseases other than cancers, coupled with a trendof shrinking public health budgets, is overwhelming in manydeveloping countries.

3 In sub-Saharan Africa in 1995, forexample, communicable diseases and maternal or perinatal Corresponding author. Tel.: +27 21 404 Denny).complications caused approximately 70% of all deaths inwomen; the equivalent figure in developed countries In 2000, the maternal mortality ratio in the least devel-oped countries was estimated to be 830 per 100,000 with251,000 of the 529,000 recorded maternal deaths (MaternalMortality in 2000: Estimates by WHO, UNICER, WNFPA( )).An additional significant health burden is the epidemicof human immunodeficiency virus (HIV) infection in manydeveloping countries, particularly in Africa. In 2005, itwas estimated that million people were living withHIV worldwide, of whom nearly 50% were women.

4 Whilesub-Saharan Africa has just over 10% of the world s pop-ulation, 60% of all people living with HIV live in theregion (UNAIDS/ WHO AIDS Epidemic Update: 2005( )). Limited human and financial resourcesMost countries in Eastern and Southern Africa have highincidences of cervical cancer coupled with extremely limited0264-410X/$ see front matter 2006 Elsevier Ltd. All rights Denny et al. / Vaccine 24S3 (2006) S3/71 S3/77facilities for Screening or treatment[2]. Malawi, for instance,which has a cervical cancer incidence rate of 47 per 10,000women, has one pathologist, one colposcope, no cytotech-nicians and no facilities for cervical cancer Screening ortreatment.

5 A similar or worse situation exists in many othersub-Saharan African countries such as Congo, Mozambique,Kenya, Tanzania and many Poorly developed healthcare servicesPrimary healthcare facilities, where preventative health-care such as cervical Screening should be located, are lim-ited, under-resourced and over-burdened in most develop-ing countries. Most low-resource countries have very lim-ited cancer diagnostic, treatment and palliative care ser-vices. A contributing factor to limited access to health-care in poor countries is the urban/rural bias, which isextreme in sub-Saharan Africa[3]. While 87% of the region surban population has access to health services, more than50% of the people in most sub-Saharan Africa countrieslive more than 10 km from the nearest primary care centre[3].

6 Women are uninformed and disempoweredThe World Development Report has cited education as anessential component to human health, stating that House-holds with more education enjoy better health, both for adultsand for children (a result that) is strikingly consistent in agreat number of studies, despite differences in research meth-ods, time periods and population samples [4]. Women indeveloping countries tend to be poorly educated, which hasprofound ramifications for the total quality of their lives, rang-ing from healthcare access, to health-seeking behaviour, tothe ability to generate income. In most societies they havea status subservient to men, with less control over familyresources, minimal access to money and, in general, inferiorsocial power[3].

7 War and civil strifeIn many developing countries, civil upheaval and generalviolence have been the status quo for decades. Some of theimportant consequences of war include displacement of peo-ple, the creation of refugees, disruption of healthcare services,with subsequent loss of infrastructure and personnel and thediversion of state money to defence, all of which make theestablishment of successful Screening programmes particu-larly Widespread povertyWidespread poverty characterises many developing coun-tries. In sub-Saharan African countries, for instance, only41% of the total population of the region has access to safewater and 26% to sanitation; these are the lowest percentagesof all the developing country regions[3].

8 The nature of the Screening testWhile the factors described above are probably the mostimportant reasons that cervical Screening programmes havenot been established in developing countries, the nature ofthe current Screening process is also a contributing many developing countries, establishing quality, national,cytology-based Screening programmes is beyond their capac-ity and first barrier to cytology-based Screening programmesis to develop the necessary infrastructure to obtain and trans-port the Pap smears to laboratories for processing and inter-pretation. Thereafter, the results need to be communicated tothe referring clinic and to the women who have been delay in itself is known to be a significant barrier toscreening, with large numbers of women not returning , high-quality cytology laboratories need to beestablished for cytology-based Screening programmes to beeffective.

9 Interpreting cervical smears is one of the most dif-ficult tasks and obtaining a high level of proficiency requiresseveral years of training. Maintaining skills requires ongoingeducation, close supervision and a built-in quality a woman with an abnormal smear has been iden-tified, she requires a referral for colposcopic , where available, tends to be located in tertiary,urban-based institutions and provided by specialists. Thisrequirement creates problems of access for poor women, bothurban and modern management of pre-invasive lesions has beenconsiderably simplified by the introduction of loop excisionelectrosurgical procedure (LEEP), also known as large loopexcision of the transformation zone (LLETZ).

10 This proce-dure can be performed in an outpatient setting, using localanaesthetic and relatively unsophisticated equipment. Thecomplication rate of LEEP is low and the reported cure rateranges from 80 to 95%[5]. For most countries with limitedor no Screening , there is a concomitant lack of colposcopicservices and outpatient methods of treating pre-invasive dis-ease. Hence, in those countries with limited Screening , mostwomen with abnormal smears are subjected to cone biopsy orhysterectomy, both of which are radical and expensive treat-ments that would be unsustainable for a Screening in low-resource settingsThe challenges and failure of cytology Screening pro-grammes to be developed and sustained in low-resourcecountries has stimulated the search for alternative methods ofscreening that would overcome the many barriers Denny et al.