Planning and Implementing Cervical Cancer Programs Andreas Ullrich WHO Geneva WHO-IUMSP NCD PROGRAMME MANAGERS SEMINAR, 3 - 7 JUNE 2013

Overview Principles of the WHO comprehensive approach From new Evidence in Cervical cancer prevention to new Guidelines From Guidelines to Implementation: country examples

The need for action: cancer screening mostly absent WHO NCD survey 2010

Comprehensive Approach

Continuum of Care Natural History of Cervical Cancer Early detection Diagnosis/ Treatment PREVENTION Early detection Screening Palliative Care

The first-ever comprehensive guide from WHO on cervical cancer control - 2006 Adopted and adapted in many countries, e.g., China, Sri Lanka, Viet Nam, Cambodia, Thailand, Nigeria, Malawi, Zambia, Tanzania, Uganda, some Latin-American countries, and others

The first-ever comprehensive guide from WHO on cervical cancer control - 2006 Key messages: Health education integral part of cervical cancer control Cytology, but not <25 yrs or annually VIA /"See and treat", in pilot settings only HPV testing, in pilot settings only.

Purpose of the update Health education to be expanded HPV vaccines to be included New data on use of screening tests VIA /HPV New data on "See and treat" New data for algorithms (sequential testing) Program planning chapter Four regional workshops to introduce Safe Abortion: Technical and Policy Guidance for Health Systems

NEED FOR UP DATE Conventional pap smear Hybrid Capture® 2 DNA test Visual inspection with acetic acid (VIA) CareHPV rapid DNA test It is not one size fits all Depends on the local infrastructure where the test will be performed and on the treatment capacity and follow-up

Choice of a test need to be based on: Effectiveness of the test (sensitivity/specificity) in the target group. Capacity to reach (coverage) a significant proportion (100%) of target group Local infrastructure where the test will be used Balance between performance of the test vs. coverage Capacity of the health system to ensure treatment Cost Should take into consideration the new environment of HPV vaccines introduction

From interventions to policies Cervical cancer prevention = mandatory part of national health planning and monitoring UN General Assembly on NCD 2011 World Health Assembly 2013

Essentials for program planning HPV_UNFPA_Strategies for referral_nov10 Essentials for program planning National policy Resources allocated, insurance coverage Public education Health education for target groups Screening = organized Screening linked with treatment, referral system Heath information system (cancer registries) Choices depend on test, health infrastructure, socio-economic context, regulations and norms, disease burden

Screening program options HPV_UNFPA_Strategies for referral_nov10 Screening program options Age: WHO recommends 30+ unless HIV+ Frequency: depends on test and resources, achieve high coverage Which test: depends on resources and infrastructure Care provider: doctor, nurse, midwife, technician Treatment: cryotherapy suitable for most lesions and easy for non-physician to learn; need LEEP for large or advanced lesions Community outreach: interpersonal through community health workers or women’s groups; local radio; posters Choices depend on test, health infrastructure, socio-economic context, regulations and norms, disease burden

Cervical Cancer Prevention Programmes: Operational framework Community level Palliative care Awareness, Communication PHC level VIA VIA VIA VIA Secondary level Training VIA and cryotherapy Treatment Tertiary level Monitoring /Evaluation

Introduction of HPV vaccines Two vaccines available, licensed and WHO- pre qualified: Cervarix (16/18) and Gardasil (16/18 + 6/11) Up to 30% of Cervical cancer are cause by other types than 16/18 Both vaccines require 3 doses over 6 months

Introduction HPV vaccines (continued) Both vaccines are preventive only , target 9- 13 year old girls Post vaccination follow up exists only for 9 years HPV in HIV positives is safe

HPV Introduction challenges Priority setting fro HPV Cost of vaccine/delivery Target population/delivery system Coordination with introduction other vaccines and inclusion in national multiyear plan (cMYP) HPV is part of an integrated plan fro cx prevention

Case report Ghana No systematic screening, opportunistic cytology (district), VIA pilot project, HPV introduction: Demonstration project Gardasil, GAVI demonstration project Challenges: limited human resources, low awareness, socio-cultural beliefs

Case report Senegal No systematic screening, 7 pilot VIA projects, one HPV pilot, HPV introduction: GAVI demonstration project Challenges: late presentation of cx, poor coordination between various donor activities, absence of data;

Case report Nigeria National NCCP, National CX policy, Capacity building VIA, 6 screening delivery centers, Advocacy awareness campaigns HPV introduction program, Challenges: reach out to rural communities, lack of cancer registries, scaling up screening to national coverage (PHC)

Lessons learnt program planning Cross Ministerial coordination Cross program coordination > integration of services Participation of key local stakeholders

Resources WHO guidelines and costing tools WHO Regional offices / country offices focal points Regional capacity building initiatives (e. g. EUROMED) WHO partners UNFPA, PATH, GAVI, Pink-Red Ribbon, JHPIEGO, CDC….

Conclusion Cervical cancer is part of the NCD agenda New options for cervical cancer prevention suitable for a variety of settings Cross over of existing programs (reproductive health, immunization, adolescent health, cancer control )is essential (from vertical to horizontal cross fertilization)