Cervical Cancer Screening in rural Uganda Part 2

Naima Thavory Joseph, MD, MPH

Brigham & Women’s Global Women’s Health Fellow, 2^nd year

Attending Physician, Obstetrics and Gynecology, MGH

Cervical Cancer Screening in rural Uganda Part 2

It was the rainy season. Torrential downpour of rain drops the size of bullets thundered against our tent, a never-ending backdrop to our hard work. Every so often the tent edge would give way, and a destructive avalanche of water would make its way along the sides of the tent.  The exam tables centered towards the middle and covered in protective plastic. The grass was soft and mushy, with puddles that would seep through our boots. The healthcare workers and volunteers in protective rain gear, encouraging each other, despite the conditions.  In spite of the weather, long lines of women stretched the field.  Women huddled, awaiting an opportunity to receive cervical cancer screening. After an hour, the rain passed, and the screening resumed. And so it went on, every day, predictably from 1pm to 3pm, the rain stymieing, but never obstructing our goal to provide cervical cancer screening to the rural women of Nyakabare parish.

Huge cyclinder

Every morning we would wake up at 5:30 a.m.  We would eat a light breakfast, and drive to an open field, to set up camp. We set up 5 exam stations, each set up with a heavy exam table, light source, dilute acetic acid solution, cotton swabs, speculums, gloves, and menstrual pads.  Women would start off receiving education about the female reproductive tract and specifically the location of the cervix. They learned about the Human Papillomavirus, the virus that is responsible for over 99% of cervical cancer cases worldwide. They learned about screening using visual inspection of the cervix, after first highlighting abnormal lesions with acetic acid.  They also learned about treatment options. Eligible women, meaning those with lesions that were appropriate for treatment in our tent, would undergo cryotherapy, a minimally invasive procedure in which the cervix is ablated and diseased tissue destroyed with extreme cold.  The cryotherapy cylinder was at least 30 lbs, and every morning, we carried it to the designated treatment station, our muscles vellicating long after from the effort.  

Exam bed

This screening method is called Visual Inspection with Acetic Acid (VIA), and has been endorsed by several organization, including the World Health Organization, as a method to overcome barriers to traditional cytology based screening used in high income countries. What I always considered, “just a pap smear,” is a labor and resource intensive screening method, which has contributed to 50% reduced cervical cancer mortality, since its introduction by George Papanicolaou in the 50s. Interestingly, the first patient he screened using this method, was his wife.  Dr. Papanicolaou was a pathologist. Fittingly, because a gynecologist is the least important person in this supply chain. It requires a trained provider capable of performing the screen, but also a cytotechnologist, a pathologist, a lab capable of processing the specimens, and an infrastructure to relay the results to the patient and appropriately refer her for further examination and testing. In countries like the United States, or in the United Kingdom, highly developed healthcare infrastructure make the Pap smear, one of the cytology based screens, a highly effective screening modality.  But in Uganda, availability of Pap smears is limited.

Supplies

Nurse Alexcer Ramuli is the lead nurse in charge of programming at the Cervical Cancer Prevention Clinic at Mbarara Regional Referral Hospital, her thoughts on the state of cervical cancer screening in Uganda. She was trained by the WHO on VIA, and now is responsible for training throughout the country.  The pap is offered at CCP for free, but follow up includes waiting at least 1 month for the results, at which point the patient has either moved, changed phone numbers, or cannot afford the transportation costs of a second trip into the city.  With VIA, patients can know their results on the same day. If cryotherapy is available, the patient will also receive treatment on the same day, obviating the infrastructure requirements and potential loss to follow up.  Dr. Ronald Mayanga is the medical director of the CCP and expert on cervical cancer screening in Uganda, and travels to perform cervical cancer screening camps, as well as trainings. Both note that despite training, many providers are performing VIA incorrectly, or that women are declining due to privacy issues or fear of pain from pelvic examination. Studies estimate that only 30% of Ugandan women receive appropriate cervical cancer screening and that VIA is the most commonly used screening modality.  The experiences of Dr. Mayanga and Alexer’s suggested that alternative screening method that had improved detection reliability and patient acceptability was called for.

High-risk human papillomavirus (hrHPV) testing has been recommended by the World Health Organization as a preferred screening strategy when feasible. HrHPV testing is more sensitive than cytology, has a higher negative predictive value for precancerous lesions than cytology and VIA, has less inter-observer variability than VIA, and has a favorable cost-effectiveness profile versus cytology or VIA. Finally, hrHPV testing remains efficient in settings with high HPV vaccine penetration, and to date there have been no randomized trials comparing HPV testing to cytology screening in a population with substantial uptake of HPV vaccination. Importantly, hrHPV testing can be performed by self-sampling, averting the logistical and human resource challenges associated with clinical exams.

Dr. Adeline Boatin is an MGH obstetrician-gynecologist with over 5years’ experience collaborating with the Obstetrics and Gynecologae Department at Mbarara University of Science and Technology in Mbarara.  Dr. Thomas Randall is a Gynecologic Oncologist at MGH, who also serves as lead consultant to the National Cancer Institute’s Center for Global Health. In this position, he has been working with Uganda’s National Cancer Institute to develop a cervical cancer screening policy. As a global health fellow at Brigham and Women’s Hospital and practicing Ob/Gyn at MGH, I was privileged and excited to join the efforts of Alexcer and Drs. Mayanga, Boatin, and Randall and to introduce the concept of primary HPV testing via self-collected sampling, as an alternative screening strategy.

The challenge is that there is limited experience on implementation of hrHPV self-screening in LMIC.  An important unanswered question is whether community-based self-sampling hrHPV testing can meaningfully improve access to cervical cancer screening.  We were invited by Dr. Alexander Tsai to study the feasibility of HPV screening in a rural community outside of Mbarara.  He has had an over 10-year relationship with community of Nyakabare Parish, and conducts health fairs, which provide an opportunity to screen for HIV, diabetes, hypertension, and lung disease.  There was an opportunity to implement cervical cancer screening, which we determined was acceptable to the community. Our idea was to offer women the opportunity to participate in a study of HPV self-sampling, which would include self-collected screens and follow up using mobile phones. HPV positive women would receive text messages indicating their test results and recommendations for follow up.

The health fair lasted 5 days. In total, we screened over 300 women for cervical cancer and enrolled nearly 160 women into our study. We treated approximately 15 people with abnormal lesions detected by VIA. Some women had early stage cervical cancer and expedited for surgery. The health fair also offered an opportunity for women to receive other health care interventions such as treatment for sexually transmitted infections, contraceptive counseling, and IUD placement.  Some were even able to obtain HPV vaccination.

Although we are still collecting follow up data from the study, almost universally, we had a positive response from the community, and have plans to return for cervical cancer screening in the future. Just not in the rainy season.