1. Harshad Sanghvi Medical Director, JHPIEGO
Moving from Research to Practice: Expanding Cervical Cancer Prevention in Low Resource Settings
Harshad Sanghvi
Medical Director, JHPIEGO

2. Continuum of Care for Cervical Cancer Control
15 years
30 years
45 years
Screening and
treatment
Vaccination
Cancer
treatment
Source: WHO 2006

3. SINGLE VISIT APPROACH: STEPS
1 Counseling
2 Speculum Exam to see Cervix
3 Apply 3-5 % Acetic Acid to Cervix
4 Inspect Cervix for acetowhite lesions
5 Discuss results with the woman. Offer treatment option if positive

4. SINGLE VISIT APPROACH: STEPS
6 Speculum exam to re-view cervix
7 Apply Cryoprobe and freeze for 3 minutes
8 Defrost for 5 minutes
9 Re-freeze for 3 minutes
10 Post treatment and followup instructions
Cryotherapy
Before and After

5. Results of CECAP SAFE study
5999 clients recruited in 9 months, 58.6% at village health centers
Of the 798 (13.3%) VIA positive, 738 (92.5%) received cryotherapy
An additional 18/51 women classified as indeterminate received cryotherapy
Of 4 suspected cancers, 1 was confirmed.
4.4% of women made an unscheduled post treatment visit, 2.2% requiring minor treatment
No major complication was noted
Correlation between Nurses and Gynecologists on VIA finding and treatment decision was 93% and 92% respectively
Nurses could effectively mount a comprehensive cervical cancer prevention program: could be trained to detect and treat precancer.
Require 5 days training All training materials and Program implementation guides available from JHPIEGO
Source RTCOG/JHPIEGO Cervical cancer prevention group: The Lancet, March 2003

6. Thailand Results to Date
Upto March 2006, approximately 180,000
women in age group (30-45 yrs ) tested
with VIA
8-10% of those women offered treatment
with cryotherapy
2.2 % minor complication rate. No major complications
Thirteen provinces now using this approach and women highly satisfied with decision to be tested
Some districts now approaching 50% coverage
Fully integrated into MOH program with insurance subsidising costs

7. CERVICARE Program: Ghana
Problem
Screening largely unavailable
Treatment of precancer available only at large hospitals
Intervention
8 rural midwives trained in visual inspection and cryotherapy: the single visit approach. SVA fully integrated in RH services
Result
Over 48 months, 19,326 women have been tested
1456 (91.7%)received cryotherapy immediately or return visit
16 cervical cancer patients identified (downstaging)
Note: these nurses are offering additional service of SVA in addition to routine tasks
CECAP Program, JHPIEGO 2004, and
Sylvia Deganus, Sydney Adadevoh, Ghana

8. COUNTRY RECEPTIVENESS
Identify and Nurture Support from Key Stakeholders
Professionals
Public Sector
Civil Society
Organize action group to champion Cervical Cancer Prevention
Establish a network of multi-sectoral advocates
Develop and implement awareness campaign
Dr. Kobchitt Limpaphayom, CECAP Director for Thailand with former Permanent Secretary of Ministry of Public Health Dr. Vallop Thaineua and Provincial Health Director Dr. Kamron Chasiri at a 2004 dissemination meeting in Cha-am, Thailand

9. Capability Development: Site Selection
Establish selection criteria
Political Commitment
Management support
Personnel to train
Access to referral center
Minimum infrastructure
Geography
Client base
Conduct site visits
Recommend sites
Assessment team conducting
a visit to a
rural health center in Malawi

10. Capability Development: Demand Generation
Communication campaign
Develop targeted messages
Integrate CECAP message into General Health Messages
Multimedia Coverage
Community Outreach
Community events
Educational talks within health facility
Outreach activities by health facilities
Referral from other health services
Community Durbar Festival held in Rural Ghana to raise awareness about cervical cancer prevention services

11. Capability Development: Human Resources
Develop cadres of:
Local champions capable of advocating for cervical cancer prevention at the local, regional/provincial and national levels;
Trained Service providers to deliver screening and treatment;
Clinical Supervisors who can provide quality assurance and manage referrals; and
Local (regional/provincial) training teams to conduct training courses, maintain quality and ensure adherence to performance standards.
VIA and cryotherapy course for new service providers in Kumasi, Ghana

12. Capability Development: Training
Training Step 1
Conduct 3-day VIA and Cryotherapy clinical skills course for physician supervisors
Conduct 10-day VIA and Cryotherapy clinical skills course for service providers
Training Step 2
Conduct Clinical Training Skills course to develop 1st generation clinical trainers
Conduct Advance Training Skills course to prepare
VIA : Most difficult aspect of training: learning curve for decision making, identifying SCJ, manipulating the cervix fully,
During training make sure trainees see lots of normal cases (or images) (90%)
Cryotherapy:
Following repeated practice on models: require between 2-4 cases to achieve competency.
Most difficult aspect of training : degree of pressure, the wait for defrosting between two freezes
Gas Supply can be a rate-limiting step
CO2 vs. Nitrous Oxide : also both have different nozzle types
Commercial grade Co2 needs drying chamber
Reliable local suppliers critical
Cryotherapy Equipment:
Infrequent breakdown with good maintenance
Must create local capacity for repair and maintenance
Thai nurses practice clinical skills during a training session.

13. Capability Development: Service Delivery Model
Step 1: Service Site Preparation
Physical and environmental setup
Equipment and instruments
Supplies
SOP
Step 2: Service Provision
Operational Time
Record Keeping and Retrieval
Use of Performance Standards
Monitoring
Ghanaian provider practices clinical skills during a training course.

14. Supporting High Quality Program Performance
Functional health information system for cervical cancer;
Responsive referral system;
Operational Repair and Maintenance Center;
Sustainable Quality Assurance process;
Defined monitoring and evaluating program indicators

15. Are the Limitations of the Solution Acceptable
Selected Key Conclusions: Alliance For Cervical Cancer Prevention (ACCP)
Prevention programs based on visual screening or HPV testing can be cost effective
Cryotherapy is a safe and effective method and can be delivered by a range of health providers, including non-physicians.
The single visit (screen-and-treat) approach is safe and effective in low resource settings. This is a major paradigm shift in cervical cancer prevention

16. Are the Limitations of the Solution Acceptable
ACOG/SOGC/RCOG/FIGO Policy Statement
Validates the “single-visit approach,” which links a detection method with an immediate management option, as a safe, acceptable and cost-effective approach to cervical cancer prevention
Calls for obstetric-gynecologic organizations worldwide to advocate for sustainable cervical cancer prevention programs
Obstet Gynecol, March 2004