Communitybased Cervical Cancer Screening

1
Community-based Cervical Cancer Screening

• By
• C. O. Amotsuka, M.BB.S, (Ib.) MPH (Tulane)
• On April 16, 2007 At
• Center for Bioethics, Ashi, Ibadan
• West African Framework Program for Global Health

2
Outline

• Why Cervical Cancer Screening?
• Cervical Cancer Worldwide
• West African Women at High Risk
• Cervical Cancer in Nigeria
• Need for Screening Economic Loss due to Cancer
• Community-Based Cervical Screening
• Role of Hospitals
• Conclusion

3
Why Cervical Screening?
4
Cervical Cancer Worldwide - 1

• Globally, there are nearly 1.4million cases of
  clinically recognized cervical cancer 1
• It is estimated that as many as 7 million women
  will have high-grade changes in the cervix almost
  becoming cancer globally
• 80 of these are in developing countries like
  Nigeria

5
Cervical Cancer Worldwide -2

• Second commonest cancer of women worldwide,
  trailing behind breast cancer.1
• Most (about 80) occur in developing countries,
  like Nigeria.1
• Industrialized countries have reduced its
  incidence by gt 70 in the last 50 years

6
West African Women at High Risk

• Most important risk factor is infrequent cervical
  screening or lack of accessible cervical
  screening services
• Early age at sexual contact
• Human Papilloma Virus infection
• Early marriage below age 20 years
• Multiple partners and polygamy
• Multiparity, having many children

7
Cervical Cancer in Nigeria - 1

• Second commonest female cancer since 1995
• Remains the commonest genital tract cancer- for
  63 of cancers at the U. C. H. (Babarinsa et al.,
  2000)4
• About 12 of women in Southwest Nigeria had
  pre-cancerous cervical lesions (Ayinde et al)6
• Level of awareness low, only about 15 of women
  aged 20-65yrs in the same region had heard about
  the disease

8
Cervical Cancer in Nigeria - 2

• Affects women 30 years and above
• Commonest cancer of women in Calabar, Zaria and
  Eruwa (lecture delivered by Dr. A.A.F. Banjo,
  Consultant Pathologist, University of Lagos at a
  Workshop on Breast and Cervical Cancer Prevention
  organized by Medical Women Association of
  Nigeria, Lagos Branch, and University of Michigan
  in 2004)
• Majority (60) of population in rural areas with
  no access to cervical screening

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Situation in Nigeria

• Currently in Nigeria, less than 10 of women are
  screened Babarinsa Adewole, 1996,7 Ajayi
  Adewole, 1998.) About 40 to 50 of women are
  screened in developed countries9
• No national policy and no widespread cervical
  screening for women
• Women come to hospital with invasive cancer of
  the cervix at advanced stages when radiotherapy
  is of little or no benefit and even radical
  hysterectomy is of no benefit5

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Need for Cervical Screening Services

• Gro Harlem Brundtland, the World Health
  Organization (WHO) Secretary General agrees that
  all nations should prevent cervical cancer as an
  investment in humankind, global and national
  economy
• It is an investment into the nations and
  families fortunes and future

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Economic Loss to Cancer in Nigeria

• The Independent Policy programme at The National
  Institute of Social and Economic Research
  concluded that Nigeria losses 56.5-78.5 billion
  Naira each year to all cancers. (Extrapolation
  from the 1993 World Bank report investing in
  health at lecture delivered by Akinwumi Fajola
  UCH, Ibadan, 2004).

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Cervical Cancer Prevention

• Cancer of the cervix can be prevented by
  providing widespread and regular cervical
  screening services for all women who have been
  sexually active!
• How do we achieve this?

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Cervical Screening Tests

• The Pap Smear test
• The Visual Inspection of the Acetic Acid painted
  cervix (VIA) affordable and more sensitive
• The One-Visit Approach screening with VIA by
  trained personnel and provision of cryotherapy
  for obvious mildly moderate cervical dysplasia

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Community-based Screening

• When we talk of health care, we think of
  hospitals and drugs, but
• When we talk of preventive health- we should
  consider the issue of
• ACCESS
• Screening services must be near enough to those
  at high risk, with little or no transportation
  cost to them. Remember at least 70 of Nigerians
  earn less than US1 per day!

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Qualities of a Screening Center

• Accessibility of screening center, Affordable
  cost, approachable health workers
• Counseling an essential part, both pre- and post-
  screening
• Courtesy to clients, clean center with
  confidentiality
• Environment must ensure privacy, window curtains,
  screens, cover sheets
• Simple enough and set within the community, so
  women can relate with it and feel at ease init.
  Not a five-star hotel standard
• Services for cervical dysplasia must be present
  at site of screening

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Role of Hospitals in Cervical Screening -1

• All health workers (doctors, nurses, medical
  students, nursing students) in hospitals should
  have screening skills (VIA and Pap Smear)
• All family practice and O G residents should
  have colposcopy, cryotherapy and LEEP (Loop
  Electrosurgical excision procedure) skills to
  treat cervical intraepithelial neoplasia
• Experience at the community screening centers
  could be part of their rotations

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Role of Hospitals in Cervical Screening -2

• Hospitals to serve as cytology centers for Pap
  Smears and biopsies as well as referral centers
  for advanced cervical cancer management
• All hospitals should have well equipped centers
  for cervical screening and management of cervical
  intraepithelial neoplasia

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• FOR EFFECTIVE CERVICAL SCREENING, WE MUST GO TO
  WHERE THE PEOPLE ARE!
• SCREENING CENTERS IN HOSPITAL SETTINGS WILL
  CONTINUE TO SEE THE TIP OF THE ICEBERG!
• COMMUNITY CERVICAL SCREENING IS THE ANSWER!

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Save Our Future Foundation Experience Since 2002
- 1

• Awareness with market women and men, churches and
  mosques, radio and television
• Capacity building- over 50 doctors and nurses
  trained
• Collaboration with University College Hospital,
  College of Medicine, University Health Service,
  Catholic Hospital, Oluyoro, FMCA, etc and Family
  Medicine Dept. Univ. of Mississippi Med. Center,
  Jackson are international partners

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Save Our Future Foundation Experience Since 2002
- 2

• Extended assistance to residents doing research
  at Family Medicine, UCH, and MPH, UI
• Screening Services done at markets and churches
  as well as hospital based
• Services continue for screening and colposcopy,
  cryotherapy after community programs

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Way Forward - 1

• Awareness raising in community and radio
• Capacity Building organized systematically to
  cover all regions
• Community screening centers set up

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Way Forward - 2

• Equip the centers with simple furniture, basic
  comfort, water, essential tools for screening
• Staff trained to be user friendly even to dirty
  smelling clients. No abuses, no sarcasm, no
  expression of surprise or fear
• Standard Services with protocol to guide
  providers, supervised and monitored

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Conclusion

• Cervical Screening Services must be coordinated.
  There should be a synergy between community
  centers, both private and government with
  screening centers in the larger hospitals
• The Coordinating mechanism should be an
  independent entity that is not political
• All must work together for a common goal To
  reduce cervical cancer by early detection and
  effective treatment of cervical intraepithelial
  neoplasia.

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• THANK YOU

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References

• Parkin D. M. Personal Communication, IARC (July
  2000).
• Planning Appropriate Cervical Cancer Programs.
  2nd Edition 2000 Program for Appropriate
  Technology in Health (PATH).
• Babarinsa, I. A. Akang, E. E. U. Adewole I. F.
  (1998) Pattern of Gynaecological Malignancies at
  Ibadan Cancer Registry (1976-1996). Nig. Qt. J.
  Med.8103-106.
• Ayinde, A. E., Adewole, I. F. Babarinsa I. A.
  (1998) Trends in Cervical Cancer Screening in
  Ibadan Nigeria. A four-year review. W. Afr. J.
  Med. Vol. 17 No.125-30.
• Babarinsa, I. A. and Adewole, I. F. (1998).
  Knowledge and attitude to utilization of cervical
  cytology screening by female workers in a
  Nigerian Teaching Hospital. Nig. Med. Pract. Vol.
  35No. ¾48-52.
• Ajayi I. O. and Adewole I. F. (1998). Knowledge
  and attitude of general outpatient attendants in
  Nigeria to cervical cancer screening. Cent. Afr.
  J. Med. Vol.44, No.241-43.
• World Health Organization (WHO). Primary
  Prevention of Cervical Cancer. WHO, Geneva,
  October 3-November 2, CAN/85.1 (1985).
•