Overview of Cervical Cancer Screening and
Treatment program
Takele Deressa (BSc, MPH)
November 2023, Adama
Outline
Introduction
Cervical cancer, HPV and HIV
Preventing cervical cancer
National strategy
key service delivery indicators
Roles and responsibilities of WHB
Challenges
Cervical screening tools
M Introductionagnitude of the Problem
Cervical cancer is a leading cause of mortality among women
worldwide
In 2020, an estimated 604 000 women were diagnosed with
cervical cancer worldwide and about 342 000 women died from the
disease.
The burden will increase to almost 460,000 deaths by 2040, a nearly
47% increase over 2020 level(Globocan 2020)
Introduction...
This increase will also be inequitable, with nearly 90% of deaths
occurring in low- and middle-income countries.
The vast majority of these countries are in sub-Saharan Africa,
Melanesia, South America, and South-Eastern Asia.
Every 2 minutes one women dies of cervical cancer-tragedy
preventable death
Introduction...
In Ethiopia cervical cancer is the second most frequent form
of cancer and the leading cause of cancer deaths
Every year there are an estimated 7445 new cases and close to
5,338 deaths due to cervical cancer in the country
Majority of cancer cases ( over 80%) are detected at late stage,
predominantly due to lack of information about CxCa and lack
of preventive services.
Magnitude of the Problem
Why cervical cancer screening
Public health problem
morbidity and mortality
Affects women of
reproductive age
Has long precancerous
stage
Proven interventions ,
screening and treatment
WHO elimination strategy of cervical cancer
In May 2018,World Health
Organization (WHO) Director-
General, issued a call to action
for the elimination of cervical
cancer.
In November 2020, launched
the Global strategy to accelerate
the elimination of cervical
cancer, including the following
targets for each of the three
pillars for 2030:
Natural history of HPV infection and cervical cancer
99.7% of case linked to human papillomavirus (HPV)
HPV is one of the most prevalent STIs
– 70-80% women will be exposed to HPV
Serotypes 16, 18, 31, and 45 are the most common with serotype
16 accounting for 70% of worldwide cases
Persistent infection with hr HPV is the most important risk factor
for the development of cervical precancer and cancer.
Natural history …
HIV/AIDs, HPV Infection, and Cervical Cancer
HPV and HIV have cross interaction with each other
Increased incidence of HPV in HIV seropositive women
1 out of 5 HIV infected women develop dysplasia within 3yrs
In HIV endemic populations, cervical cancer screening may be
positive in up to 15-20% of women
HIV accelerates the progression of precancerous lesions
HIV positive women were six times more at risk to develop CxCa
Risk Factors for HPV and Cervical Cancer
Sexual activity before age 20-cervix with very exposed
transformation zone (TZ)
Multiple sexual partners
Exposure to sexually transmitted infections (STIs)
Smoking
Immunosuppression (e.g. HIV/AIDs, corticosteroid use)
Prevention of cervical cancer
Primary prevention
Secondary prevention
And tertiary care as well as palliative care and all the
activities that support these interventions.
Programmatic interventions over the life course to prevent
HPV infection and cervical cancer
Primary prevention
Primary prevention of HPV transmission needs to focus on
reducing behaviors that are risk factors for disease transmission:
Discourage adolescent girls from early sexual activity
Discourage smoking especially in adolescents
Vaccination against HPV for Girls promising result
Promote condom usage
Secondary Prevention
Women who are already infected with HPV should be screened
for precancerous cervical lesions
Screening methods include:
Pap smear (classic or liquid based)
Visual screening utilizing acetic acid/Luogol Iodine
HPV tests
Automated cytology screening (colposcopy)
What is screening for cervical cancer?
Screening in general is defined as the application of a test on an
apparently asymptomatic healthy population to identify those
with high-risk of having or developing a particular disease.
Screening test positive women need to have further
investigations to confirm the diagnosis.
To screen for cervical cancer, apparently healthy women
belonging to a specified age group are tested routinely,
irrespective of whether they have any symptom or not. The
tests applied are called the screening tests.
Why is it necessary to screen women for cervical
cancer?
In African women, cervical cancer ranks second after breast
cancer.
The cancer causes a large number of deaths among women in
the South-East Asia and African regional countries
Cervical cancer affects women at a relatively younger age
causing great personal, social and economic loss.
Screening helps to detect the cancer at a potentially curable
precancerous stage.
Detection of the precancerous conditions and appropriate
treatment help prevent the cancer and avoid untimely deaths of
Screening tests
Pap smear
VIA/VILI
HPVDNA testing
Cytology
Cytology screening for cervical cancer has been effective in
reducing cervical cancer incidence in countries with high-
coverage and high-quality screening programs.
Replicating the success of cytology based screening programs in
high income countries has proven difficult in resource poor
countries.
Visual inspection of the cervix
VIA/VILI uses 3-5% acetic acid applied over the cervix, and
see for the presence of dense, well outlined white lesion on the
cervix
VIA is a low cost, low tech approach to cervical cancer screening
Allows immediate treatment of precancerous lesion with
ablative (cryo, TA or excisional (LEEP) methods in a single
visit approach (SVA).
Safe, feasible and acceptable alternative to cytology based
screening with comparable sensitivity and it is cost effective
(Goldie et al 2005)
Visual inspection...
Acetowhite changes that
appear quickly and recede
quickly – more likely squamous
metaplasia or inflammation
Acetowhite changes that last
longer than 1 minute after
removing acetic acid are Acetic
acid prevents more likely
precancerouscervical cancer
VILI
HPV DNA Test
• HPV testing is much more accurate and effective in identifying
women at greater risk of developing precancerous cervical
lesions
• HPV test samples can be taken by a health provider or the
woman herself (self-sampling).
• Processing of HPV tests is automated, results do not require
subjective interpretation, and thus more objective results are
given with HPV testing than other screening tests.
Treatment for precancerous lesion
Cryo, TA and LEEP are the most commonly recommended
outpatient treatment options for precancerous lesion of the
cervix for screen and treat program.
WHO recommends cryotherapy or Thermal Ablation as
the first choice treatment for women who are screen positive
and eligible.
In women who have lesion not eligible cryotherapy or
Thermal Ablation , WHO recommends LEEP where
available.
Cryotherapy
Cryotherapy is a relatively simple, safe, acceptable and
inexpensive method to destroy precancerous lesions by
freezing.
This is accomplished using a special instrument that
delivers gas CO2 to a cryotip applied to the cervix and
freezes the abnormal tissue.
The procedure does not require electricity or anesthesia and
takes approximately 15 minutes
Position Probe on Cervix
Probe Frost and Defrost
Thermal ablation
Potentially more suited to low resource
settings
It utilizes electricity, including battery
power,
The technology is simple
The treatment is shorter, and might therefore
be more acceptable to women and care
providers.
Ablative treatemnt
Pretreatme Immediately After 4 Months
nt following
cryotherapy
Eligibility criteria for cryo & TA
Not suspicious for cancer
Can see the entire lesion
Lesion occupies <75% of the cervix
Cryotip covers the lesion or <2mm of the lesion extends
beyond the edge of cryotip
Eligibility...
No anatomical deformity of the cervix that prevents good
application of cryotip
Client is not pregnant
Client is more than 12 weeks post-partum
Counseling & its importance on Cervical Cancer Prevention
Women who are being tested for cervical cancer with VIA need
accurate information
Healthcare providers should encourage all women, between the
ages of 30 and 49, to be screened for cervical cancer
What cervical cancer is, what causes it, and the risk factors for
developing?
How to prevent cervical cancer
What can be done to prevent cervical cancer, with emphasis on
precancerous lesions or disease
The National Strategy
Ethiopia
The ‘Screen and treat’ (‘See and treat’) or ‘’single visit’’
the preferred approach
the national strategy method to reduce cervical cancer
Using a screening test that gives immediate results (VIA)
followed by “on the spot” treatment (using cryotherapy/TA) of
detected lesions, without any further tests unless a suspected
cancer and non eligible clients.
Rationale for the strategy
Can effectively identify most precancerous lesions,
Is noninvasive, easy to perform and inexpensive,
Can be performed by all levels of healthcare workers in
almost any setting,
Provides immediate results that can be used to inform
decisions and actions regarding treatment,
Requires supplies and equipment that are readily available
Common self questions is SCJ visible ,is lesion fully visible ,is
there endocervical extension ,could the probe reach the lesion
Age-Related Changes
in the T-Zone: Reproductive Years
When a woman
becomes sexually
active at a young
age (age < 20) more
of the vulnerable
types of cells are
exposed and
therefore she has a
higher chance of
becoming infected
with HPV.
Chapter 3: Pathophysiology of Cervical Cancer
Chapter 3:
Pathophysiology of
Cervical Cancer key service Delivery IndicatorsS with bench
marrks
Screening Coverage : Percentage of women aged 30–49 years who
have been screened at least once since age 30
Screening Rate: Percentage of women aged 30–49 years who have
been screened with VIA/ HPV in reporting period.
Screening Test Positivity: Percentage of screened women aged
30–49 years with a positive result
key service Delivery Indicators...
Treatment Rate: Percentage of screen-positive women
completing appropriate treatment
Post treatment follow-up rate
Cervical cancer screening coverage
Age specific cervical cancer incidence rate
key service Delivery Indicators...
Screening rate-Percentage of women aged 30–49 years who
have been screened for the first time with VIA/ HPV in
reporting period.
Total screening rate = total # first screened with VIA/HPV____ X 100%
# of target population for specific place (HF/ Woreda) in the
reporting period
key service Delivery Indicators...
VIA test positivity-Percentage of VIA/ HPV -screened women
aged 30–49 years with a positive result
Screening Positivity rate=
Total screened positive with VIA/HPV X 100% Total #screened
for VIA /HPV for specific place (HF/ Woreda) in the reporting period
key service Delivery Indicators
Teatment rate-Percentage of VIA-positive women who have
received treatment in the reporting period
Treatment rate=
# Total # treated with Cryo/TA/LEEP______
Total # of precancerous lesions eligible for Cryo/TA/LEEP in the reporting period
Planning
3C
Atleast 5 clients/ day for HC&
10 clients for Hosp.
Roles and responsiblities of WHB
Conducting regular supportive supervision & mentorship
recording
service interruption...
Organizing HE programme ( both community & HF)
Monitoring HF plan, performance & weekly, biweekly, monthly
report
Advocacy on cervical cancer screening using different opportunities
Regular awarness creation and screening service for d/nt gov.t
sector workers
Challenges/Gaps
Poor attention given for service ( management & service provider)
Low cervical cancer screening
Trained man power turn over
Cxca room was not open during all working hour(duty off…)
Low awareness of clients, Refusal of client
HPV DNA reagent stock out
Low engagement of facility management on CxCa screening
Low Counseling/HE session for CxCa
Tools for ccp
GALATOOMAA
