Treatment Options for Cervical Cancer in Low Income Countries Dr. Nelly R. Mugo Obstetrician Gynaecologist/ Research Scientist Kenya Medical Research Institute 2016 WE CAN African Breast and Cervical Cancer Advocacy, Education and Outreach Summit Fairview Hotel 22nd April 2016

Can we envision a world where women no longer die from cervical cancer ? Cervical cancer is a preventable disease, when diagnosed early We can treat in the outpatient clinic and effectively prevent cancer events

Increased screening has greatly reduced the incidence of cervical cancer in England Improvements in cervical screening coverage in England have led to a 35% decrease in cervical cancer cases in under a decade Age-standardized incidence of invasive cervical cancer and coverage of screening, England 1971–1995 1971 1975 1980 1985 1987 1990 1995 Year Percentage Incidence rate per 100,000 10 12 14 16 18 100 90 80 70 60 50 40 30 20 Invasive cervical cancer Coverage National call-recall introduced Increased screening has greatly reduced the incidence of cervical cancer in England Improvements in screening can lead to a decrease in incidence of invasive cervical cancer. Background Quinn and colleagues1 assessed the impact of screening on cervical cancer incidence and mortality in women > 19 years of age in England. The overall incidence of invasive cervical cancer remained stable from 1971 to the mid-1980s (3,900 cases/year on average), when the cervical cancer screening programme in England was largely ineffective because of problems with how it was organized. Upon instituting improvements in the screening programme, including the introduction of the national call and recall system and incentive payments to general practitioners, screening coverage increased to around 85%. This resulted in a continuous decline in the incidence of invasive cervical cancer from 1990 onwards. In 1995, the incidence was 35% lower than in the mid-1980s.1 Reference 1. Quinn M, et al. Brit Med J 1999; 318:904–908. Quinn M, et al. Brit Med J 1999; 318:904–908. 3

Why we should invest in preventing cervical cancer 500,000 incident cases of cervical cancer each year 230,000 deaths each year 80% of women with cancer and experiencing cervical cancer death reside in sub Saharan Africa SSA have less than 5% of cancer treatment resources Risk of Ca cervix for a woman in LIC is approx 2-4% Pap smear screening programs have markedly reduced the incidence of ca cervix in Western countries

Kenya situation:- Cancer Average age at presentation for invasive cancer is 42 years In most cases it is diagnosed late (>90% are stage IIB or worse) KNH is the only national hospital with radiotherapy Currently Nairobi city has three private hospitals (AGK, MP Shah, Nairobi Hospital) with radiotherapy units Several regional hospices offer Palliative care Situation expected to improve:  Ministry of Health See and treat approach VIA/VILLI and cryotherapy Colposcopy machines Collaboration with Partners

Treatment options for Pre-Malignant Lesions of the Cervix Cryotherapy LEEP Cone Biopsy Hysterectomy HPV persistence is strongly and consistently associated with high-grade cervical neoplasia, despite differences in HPV persistent measurement and definitions, cervical outcome diagnosis, and other study characteristics.

The mouth of the uterus (cervix) provides access normal on naked eye exam

Sq-columnar junction The early lesion is within a small area of the cervix, can be seen clearly with application of acetic acid or lugols iodine, outlining area for treatment Pre-malignant Cervix with acetic acid (VIA) Lugols iodine changes

SIL = Squamous intraepithelial lesion - CIN : Cervical intraepithelial neoplasia

Done in the clinic, actual procedure very short Treatment: LEEP The wire quickly passed within the borders of the lesion, completely removes the area with early changes- pre cancer Done in the clinic, actual procedure very short

Visual Inspection with Acetic Acid Normal VIA Positive: Aceto White Lesion Instruments for Visual Inspection No power, simple light, can be done in any level of health care Easily followed with cryoyotherapy Suspicious of Cancer

Cryotherapy: freezing technique freezing destroys the abnormal tissue uses gas: nitrogen or carbon dioxide does not require electricity low cost

Appearance after Cryotherapy 2 wks later Iceball-immediate 3 months later One year later

Screen and Treat: is ideal with no repeat visits reduces both direct (facility) and indirect costs (to clients-transport and time) In Zambia: >15 service points, screened 20,000 women over a 2 year period Utilize nurses, with a screen and treat approach Referral for none cryotherapy eligible lesions

In Kenya, there over 10.3 million women at risk for cervical cancer over the age of 15 years, with risk of cervical cancer we have the knowledge and tools to effectively prevent the advent of cancer in their lives

A Team Approach To Cervical Cancer Prevention And Control Cervical cancer control requires a multi- sectoral and multidisciplinary effort. It also requires strong linkages and team work between providers at all levels of health care system Target high risk women with a once or twice lifetime use of a highly sensitive test Emphasis on high coverage (80%) Effective screening programme low resource settings require adequate financial resources adequate infrastructure Trained manpower Surveillance mechanisms for screening, treating, and follow up