How to improve cervical cancer screening in low- or middle-income countries?

Around 90% of cervical cancer deaths occur in low- or middle-income countries (LMICs) (Oncol Lett. 2020;20:2058–2074) and the excess death rate compared with higher income countries is largely the result of poor access to primary prevention, screening and effective treatment and palliative care. Two poster presentations at the ESMO Gynaecological Cancers Congress 2022 provide insights into improving screening from the perspective of two different countries.

Results from a study conducted in villages in rural India over a five-year period suggest that the use of specially trained paramedics may be an effective option to improve access to cervical cancer screening in women in remote areas who are unable to travel for screening at dedicated centres (Abstract 7P). Among 19 villages identified, 10 were willing to take part in the training of paramedics to conduct screening using visual inspection with acetic acid (VIA). Women testing positive using VIA were treated by thermal ablation or were referred to a major medical centre. Among 2,113 women screened by paramedics, 381 (18.0%) were reported to be VIA-positive. Of these, 34 transpired to be false-positive over the five-year period. The majority (337; 88.5%) of the women who tested positive using VIA underwent thermal ablation treatment. In the nine villages unwilling to take part in paramedic training, only 10 women underwent screening and all 10 received thermal ablation treatment.

“These data are certainly very encouraging and show that mid-level healthcare workers may be instrumental to increase screening access in hard-to-reach regions,” says Dr Peter Vuylsteke from the University of Botswana, Gaborone, Botswana. “However,” he cautions, “testing sensitivity is subject to inter-operator variability. Because of this, the type and standard of training are of paramount importance and, crucially, regular post-training follow-up is necessary to ensure that testing continues to be carried out correctly.”

A second poster provided an indication of the success of Brazil’s federal cervical cancer screening programme, which was implemented over 20 years ago (Abstract 8P). Between 2008 and 2015, among 873 cervical cancer hospitalisations analysed in the state of Sergipe, there was a yearly reduction in hospitalisations of around 10%, both for individuals in the capital city and those in the wider state. Analysed according to age group, there were statistically significant reductions in hospitalisations among patients 40–59 years and those aged 60 years and above. The authors suggest that the need for fewer hospitalisations is the result of better access to diagnostic methods and more effective interventions.

“These results provide good evidence that if you screen, you will improve the detection of cervical cancers – and cancers at an earlier stage – and this should result in fewer hospitalisations and deaths,” comments Vuylsteke. He does point out, however, that hospitalisations are not necessarily a sensitive indicator of disease severity. “In some countries, patients travelling long distances to treatment centres and/or those with restricted finances will be hospitalised even for relatively routine procedures, such as a colposcopy,” he says.

Vuylsteke thinks there are a number of key issues to be addressed to improve the success of cervical cancer screening in LMICs. “Screening must be conducted in a systematic way and individuals at risk need guidance from healthcare navigators" he says. "For example, HIV is closely associated with cervical cancer (Lancet Glob Health. 2021;9:e161–e169) and yet many of the patients with HIV we see at our centre have not been told by their local clinic that screening is available for them.” One way to increase uptake among populations would be to provide self-testing. “Self-testing has the dual advantage of offering patients a greater degree of privacy – an important factor for many women – and requiring fewer healthcare workers than traditional testing methods,” says Vuylsteke. “The drawback is that the test itself is more expensive.” Funding also encompasses wider issues. Some countries and regions currently receive external financial assistance for screening but the long-term security of such programmes is not guaranteed. And then there is the problem of how to deal with the results of screening programmes. “The first few years of an effective screening programme will see a huge increase in diagnoses of cervical cancer. There is little benefit in detecting cancers early if we are unable to treat the patients in a timely manner. Adequate provision of funds for resources – pathologists and healthcare staff, along with effective treatments – will be vital to the success of these programmes in LMICs,” Vuylsteke concludes.