Implementation of Cervical Cancer Screening in Developing Countries

Ann Marie Beddoe, MD

In low- and middle-income countries, cervical cancer is one of the leading causes of death among women due to the limited access to preventive screenings and the high rate of HIV. Pap smears, although routinely done, have a lack of follow-up that delays treatments for abnormal results.

“In most developing countries cervical cancer is the most common cancer among women. Actually, for some of the countries, it is the prime cause of mortality for reproductive age women,” said Ann Marie Beddoe, MD.

A “see and treat” cervical-cancer screening program was implemented at a local HIV clinic in Limpopo, South Africa, which increased the awareness of cervical cancer among health workers and participants. Nurses were trained as to how to screen patients, which led to more efficient results and treatments.

OncLive: Please provide an overview of your study.

In an interview with OncLive at the 2017 Society of Gynecologic Oncology Annual Meeting, Beddoe, assistant professor of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Hospital, discussed a study implementing cervical cancer screening and highlights HPV predictors in developing countries.Beddoe: Approximately 2 years ago, we started doing some cervical cancer screening in Limpopo, which is in the northern part of South Africa. That area is rich in agriculture, there are many migrant farm workers who come from neighboring farm countries. The HIV prevalence among these migrant farm workers and local sex workers is extremely high—higher than the 16% that is normally seen in South Africa. There was a farm-based HIV clinic where these farm workers could come and get tested for HIV and get medicine.

We approached them about integrating cervical cancer screening into the program because they had this high influx of women, who were transient but who were also at high-risk for cervical cancer by virtue of being HIV positive. They agreed to have us do this screening, but what we did was try to teach the nurses who did the counseling for HIV how to do visual inspection with acetic acid (VIA), and then how to do the prior therapy to teach them. What we found was that they were doing Pap smears annually on these patients but there was absolutely no follow-up on the Pap smears, or if there was an abnormal Pap smear taken to the local hospital, it would sometimes take up to a year before any action was implemented.

Are there any next steps following this research?

What are the main takeaways you would like community oncologists to understand about this study?

You are also involved in a similar study looking at predictors of HPV in Liberia, can you discuss this further?

By teaching the nurses how to do the VIA, recognize abnormalities, and then treat them, we actually cut down on the waiting time and so we felt that it had a big impact on that community. I think we're going to stay focused on these farm workers because they are a very high-risk group but our next step is to try to introduce HPV screening, which is going to be a little complicated but we're trying to use the careHPV so that on the same day we can get results and then we can have them do training. It does slow down their evaluation of patients, counseling and giving medications, so we're trying to find ways that will be more efficient for the nurses. Integration of services is probably the best model that one can follow. Instead of having these isolated silos of only cervical cancer screening or only HIV screening, if we can integrate the 2, we save money, we’re more efficient, and we reach a lot more people that way. We did something very similar in Liberia, except we did open calls for all women in Liberia because Liberia is a country where there is no cervical cancer screening at all. We introduced cervical cancer screening and as a part of that project, we did demographics and had questionnaires that were done 1-on-1 between the nurses and the participants.

What we found was that there was a lot of "missingness," meaning that there were some questions that patients did not answer. For example, age of first sex and number of sexual partners.

What are the main takeaways from this study?

When we pulled all of our data together, we looked at what effect this missingness had on the exact correlation between these factors and their risk for HPV. That paper looked specifically at age of first sexual contact, which a large number of our patients refused to answer, and so we wanted to do a correlation with the impact that that particular variable had on HPV prevalence in that community.I think that when we do these screening programs and we try to get some demographic data, it's very difficult to get all of your questions answered but that shouldn’t deter you from moving forward with your project and trying to get as much information as possible. Then, taking into account that there are some questions that won't be answered, try to extrapolate the strength of that particular question on the prevalence of the disease.

Are there any ongoing trials in cervical cancer that you are particularly excited to see the results of?

What advice would you give researchers who are interested in bringing more clinical trials to these developing countries?

I think for researchers, in general, just because you're not getting the answers you want, it should not hold up your projects and that you should take those into account because the prevalence rates that you get may be way off based on not answering some simple questions. Keeping that in mind is a good lesson to have as you do these projects. You may be overshooting or undershooting. I am interested in the immune trials that are ongoing now, including a couple of vaccine trials with cervical cancer, which I think will be terrific for the places that I work in. I work in New York, but a lot of my work is done in Liberia and in developing countries and in most developing countries, cervical cancer is the most common cancer among women. Actually, for some of the countries it is the prime cause of mortality for reproductive age women. Having these trials available would make a big difference in countries and the technology in these countries is not on par with what we have but eventually trying to get those kinds of trials into developing countries would be what I have a lot of interest in.I think even more than in developing countries, within the United States, we have large immigrant populations and women come from these countries where they have not had formal or effective screening programs. We see a microcosm of these other countries within the United States and if you are in a community where you see a lot of immigrant populations, the lesson from this is to be aggressive about your treatment, be aggressive about recommending HPV vaccines, because they may or may not be with you for a long time in terms of their migratory status. When you see these patients, be aggressive about treatment.