University of Rajarata. Cost effective methods for cervical cancer screening in low resourced countries Dr Romanie Fernando Senior Lecturer (O & G), Faculty of Medicine, University of Rajarata.

Outline of this presentation: Burden of cervical Ca in SL Possible reasons for failure Cost effective alternative Way forward

Cervical cancer burden in SL Female population aged ≥15 yrs 8.24million Annual number of cervical cancers (2012) 1,721 Annual number of cervical cancer deaths 690 Crude incidence rates per 100,000 population 16

Why ??? One woman dies every 4th day due to breast or cervical cancer (MoH) When screening, early detection and treatment reduces the disease burden When we have WWC/gyne clinics island wide: (611 WWC in 2007)

Cervical screening practices in SL Only 1.3% of women aged 25-69 yrs screened within last 3yrs. 1.7% (Urban women) 1.2% (Rural women ) ICO HPV Information Centre

Why is our cervical cancer screening is ineffective today? 1. Women do not know 2. Failures in reporting 3. Failures in follow up Evidence?

Survey of 676 women, (2012): 89% 20-49yrs 88% ≥ secondary education 08% knew correct risk factors (only 2 mentioned HPV) (92% mentioned wrong RF or did not know)

undergrads were surveyed at RUSL, 2015. Concluded: limited knowledge , low screening practices and high worry imply a need for information and awareness programme.

Knowledge and Practices on Breast and Cervical Cancer Screening Methods among Female Health Care Workers: A Sri Lankan Experience RIW Nilaweera, et al A cross-sectional survey was conducted among 219 female health care workers selected from 6 districts in Sri Lanka (2012). Among 169 married workers, 73.4% had never had a Pap smear and only 17.2% had got it done within the preceding 5 years. The study findings suggest that the knowledge and practices on breast and cervical cancer screening methods among female health care workers need to be improved.

Conclusions of the above: Knowledge and Practices about cervical cancer screening among the target population is poor. Failures at WWC : reporting and evaluation

Why have we failed? 1. Screening strategies Screening women in the target population are individually identified and invited to attend screening In SL opportunistic screening, depend on the individual’s decision or on encounters with health-care providers.

Cervical cytology: The most frequent method for cancer screening in SL and accepted practice. “PAP smear” Cost Human resource Technical difficulties Reporting Follow up Evaluation delays have lead to failure of cytological screening. Thus only ~1% of the target population is screened at present.

What are the alternatives for screening? 1. HPV DNA test: is being introduced into some countries as an adjunct to cytology screening (’co-testing’) or as the primary screening test to be followed by a secondary, more specific test, such as cytology. 2. Visual inspection with acetic acid (VIA): VIA is an alternative to cytology-based screening in low-resource settings (’see and treat’ approach).

Visual inspection with acetic acid (VIA) VIA has been singled out as being the best current alternative for cytology in under-resourced settings Studies have validated its efficacy compared with cytology. India , China and Africa: ‘see and treat ‘ approach had reduced ca incidence by 25% and mortality by 35% in 7 yrs

What is VIA/’see & treat’? VIA – visual inspection after 1min following application of 4-5% acetic acid solution. VIA positive women will receive cryotherapy. Cryotherapy – Nitrous oxide + cryosurgical unit used for 3 minutes freez. “cold Gun”

What can be done within our system? Pilot study done among 315 women at ‘budowita’ slums in Dehiwala in 2008 Sep – 2009 March. Available fund was 500,000/= Field workers enrolled women >25 yrs. Blood test – Hb%, FBS, Lipid profile (All women) BP, Breasts, VIA (all women) VIA +ve women : HVS and PAP smear. Cervical lesion + : referred to the CSTH gyne clinic

What was needed for VIA

Out come VIA + = 33 women PAP smear ≥ HIL = 11 Biopsy Ca + = 3. (Gross L + HIL) Initial plan with available funds was to screen 30 women with a mammogram and a PAP smear but change of strategy to VIA proved beyond doubt that VIA is cost effective

Can this be done in our system? yes ! We can

Way forward for cervical cancer screening in SL Formulate strategies by considering: The “target population”- Reach out. Improve K,A,P of health care provider. A more efficient and a cost effective screening method should be introduced. Implement policies – “committed admins” “political commitment” – generate funds

What is K.A.P? Knowledge Attitude Practices

How can we go forward? Accept we have failed miserably. Committed HCW to improve opportunistic screening at every gyane/WWC. Campaign to improve K – target population. Train the health care worker – K,P Feed back system, registry, data base, ect – to make a major impact nation wide. Available funds should be utilised with appropriate plans.

HPV vaccination is been introduced in developed countries at present. Food for thought It is established that: A well-organised cervical screening programmes Widespread good quality cytology/VIA/HPV DNA can significantly reduce cervical cancer incidence and mortality. HPV vaccination is been introduced in developed countries at present.

Thank you !