There are no organized or opportunistic screening
programs for cervical cancer in any of the high- risk sub-Saharan African
countries. While data from
Currently, cytology smears are provided on demand in
antenatal, postnatal, gynecology, and family planning clinics in
A three-arm, prospective randomized intervention trial in South Africa is currently addressing the comparative safety, acceptability and efficacy of screening women with VIA and HPV DNA testing and immediately treating screen-positive women with cryotherapy performed by nurses in a primary health care setting. Outcome measures include reduction of high-grade cervical cancer precursors in treated versus untreated women, followed over a 12-month period.
Other countries: Cross-sectional/randomized screening intervention studies are currently ongoing in several African countries ¾ Burkina Faso, Congo (Brazzaville), Ghana, Guinea (Conakry), Kenya, Mali, Niger, and Nigeria ¾ to address the accuracy of various screening approaches such as cytology, HPV testing, VIA, and visual inspection with Lugol's iodine (VILI) as well as the detection rates associated with them.
Visual inspection-based approaches to cervical cancer
screening have been extensively investigated in
There are three large, ongoing cluster-randomized
intervention trials in
From the Ugandan experience, cervical cancer is the
commonest malignancy among women (13). Over 80% of patients diagnosed with cancer at
Mulago hospital present with advanced disease (63, 64). Cancer cervix patients
on palliative radiotherapy account for ~20 to 30% of the patients on the gynecological
wards at Mulago hospital. There are no organized screening programs in
Effective screening programs in developing countries:
To organize effective cervical cancer screening programs, developing countries will have to;
-find adequate financial resources, develop the infrastructure, train the needed manpower, and elaborate surveillance mechanisms for screening, investigating, treating, and follow-up of the targeted women.
- There is considerable discussion focused on which screening test to use ¾ cytology or alternatives to cytology, such as VIA or HPV testing ¾ or which combinations/sequence of screening tests should be used for screening in developing countries. Choosing a suitable screening test is only one aspect of a screening program.
- A more fundamental and challenging issue is the organization of the program in its totality. Whichever screening test is to be used, the challenges in organizing a screening program are more or less the same.
- However, screening tests (e.g. cytology, HPV testing) that require additional recalls and revisits for diagnostic evaluation and treatment may pose added logistic difficulties and these may emerge as another barrier for participation in low-resource settings.
-The choice of screening test in countries/ regions that plan to initiate new programs should be based on the comparative performance characteristics of cytology and its potential alternatives such as VIA, their relative costs, technical requirements, the level of development of laboratory infrastructure, and the feasibility in a given country/region.
-A highly sensitive test should be provided. If cytology is chosen, considerable attention should be given to obtaining good quality smears, staining, and reporting so that a moderately high sensitivity to detect lesions is ensured.
- If VIA is chosen for screening, considerable attention should be given to the proper monitoring and evaluation of the program inputs and outcomes before further expansion, since VIA is still an experimental option for cervical cancer screening and it remains to be demonstrated whether VIA-based screening programs are associated with a reduction in cervical cancer incidence and mortality.
- In developing countries, existing ineffective cytology- based programs should be urgently reorganized and monitored.
Quantitative studies have shown that after two or more negative cytology smears, even screening once every 10 years yields a 64% reduction in the incidence of invasive cervical cancer, assuming 100% compliance (15, 59). Further studies based on this model indicate that once-in-a-lifetime screening may yield around 25-30% reduction in the incidence of cervical cancer (60, 61,).
To have an impact on cervical cancer incidence and mortality, efforts must be focused on the following:
1) Increasing the awareness of women about cervical cancer and preventive
health-seeking behavior; screening all women aged 35¾50 years at least once, before expanding
the services and providing repeated screening (11). In
2) Providing a screening test with high sensitivity (since women have less frequent opportunities for repeated screening);
3) Treating women with high-grade dysplasia and cancer;
4) Monitoring program inputs and evaluating the outcomes should part of the package.
5) Strengthening training of service providers on how to perform cancer cervix screening is mandatory plus to training cytopathologists and cytotechnicians to ensure quality specimens and interpretation of results.
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1, Francis A Miiro 1, and Elisabete Weiderpass 2,3. Knowledge, attitudes and
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More information can be obtained from the following websites:
Release Date: January 2003 (Summary of Recommendations / Supporting Documents)
HPV Vaccine Studied For First Time In
3) Cancer screening web sit.htm. (bbc.co.uk) BBC Health Condition Screening Programmes.
4) Health Promotion Lifestyle. (http://www.patient.co.uk/showdoc/16/#can.
5)New scientist.com .Will the cancer Vaccine get to al lwomen? http://www.newscientist.com/channel/sex/mg18624954.500.
7)http://www.fpahealth.org.au/news/20021128_papvirus.html: Human Papilloma Virus(HPV) Vaccine.
8)The interested reader is referred to common text books about details of examination of a patient with cancer of the cervix and for details about staging of the cancer and management).
Cancer and Preinvasive Neoplasia (Hardcover)
by Stephen C., M.D. Rubin (Editor), William J. Hoskins (Editor)
Gynecologic Oncology (Hardcover)
by Philip J. Disaia, William T. Creasman
à Te Linde's
Operative Gynecology (Hardcover)
by Howard W. Jones (Editor), John A. Rock (Editor), Richard W. Te Linde (Editor)
NB To read about Programmes that have worked: Most of the section on Cervical Cancer Screening from developing countries is from a “WHO Bulletin” where I found good information regarding experience from developing countries”.