1. 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

2. 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

3. 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

4. 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

5. 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

6. 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.

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

8. 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

9. SIL = Squamous intraepithelial lesion - CIN : Cervical intraepithelial neoplasia

10. 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

11. 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

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

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

14. 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

15. 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

16. 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