PATH's Cervical Cancer Prevention Action Planner

Lessons related to successful screening strategies

Key lessons relating to program strategies are summarized below. Detailed guidance for developing screening and treatment programs can be found in the Alliance for Cervical Cancer Prevention's (ACCP) Planning and Implementing Cervical Cancer Prevention and Control Programs: A Manual for Managers.

Audience research: An overarching lesson is that data from formative research—including client and provider needs assessments and health facility assessments—are extremely valuable when designing cervical cancer screening and treatment programs and educational materials.

While formative research can be organized in a rigorous and formal manner when human and financial resources allow, even rapid and simple studies can yield findings that are useful and can ensure that women, their families, and community organizations are consulted about the kinds of services that are most accessible and attractive to them. With that information program managers may actively address anything that impedes maximum use of services.

PATH's Conducting Formative Research for HPV Vaccination Program Planning provides guidance in selecting appropriate audience research methods and strategies for any type of cervical cancer prevention programming (vaccination or screening and treatment).

National program guidelines: It also is clear that national cervical cancer prevention guidelines, which have been endorsed and promoted by local medical professional organizations and especially OBGYNs, provide valuable technical and political support for program planners.

Such guidelines can help designers match screening modalities with specific situations. For example, the guidelines may endorse cytology (Pap) in areas where the infrastructure supports it (perhaps in the capital city) and promote VIA or HPV testing in other areas. The Strategic Plan for Cervical Cancer Prevention and Control in Uganda is a good example.

Guidelines may also support "task shifting"—training nurses and other non-physicians to screen clients (using VIA or HPV-DNA testing) and in some cases to treat them as well (using cryotherapy). It will be difficult to develop the human resources needed for large-scale screening efforts if clinical services can only be performed by physicians.

Improving treatment follow-up: A weakness in many screening programs has been the link between screening and treatment, and especially ensuring access to treatment in a timely manner. Data clearly show that the longer the gap between the screening test, obtaining the test result, and obtaining treatment services, the more a program suffers from "loss to treatment"—women who screened positive but never returned for treatment, and who one day may find themselves suffering from invasive cervical cancer.

Treatment of screen-positive women is best achieved in a single visit. But if treatment is not possible during the same clinic visit, it should be arranged as soon as possible, and as conveniently as possible for the women, so as to reduce loss to treatment.

Offering treatment services at or near the health facility where women were screened has been shown to improve access to treatment, but not all clinics can afford cryotherapy equipment, or have the volume of patients needed to justify such an expense. Furthermore, not all precancer cases are treatable with cryotherapy and some women will require treatment with LEEP, cold knife conization, or other procedures only available at higher-level facilities.

When screening results are not immediately available (e.g., with Pap or HPV DNA), it is crucial to develop an effective system to follow up with women, provide their test results and, most importantly, to offer treatment to screen-positive women. Effective recall systems can be difficult in situations where people do not commonly have telephones. And even when it is possible to call, sometimes the cost of a phone call was a barrier, as PATH found in Uganda. Each program or clinic will need to design a follow-up system best suited to local conditions.

Increasing convenience for women: Standard clinic hours may not be convenient for women who work in the fields or in a factory or an office. For example PATH has observed that in some countries women have more time available in the afternoon, but clinics offer screening only in the morning. Access to screening may be enhanced by offering women’s health services at times when women are more likely to be able to attend—on holidays or times when women may routinely come to town (such as on market days).

Equipment and supplies: Repairing broken cryotherapy equipment and maintaining sufficient supplies of vinegar (for VIA) and carbon dioxide (CO2) or nitrous oxide (N2O) gas for cryotherapy also has been a challenge. In order for cryotherapy to be sustainable, it is advisable to develop local capability for repairing or replacing the equipment. And while it would seem that something as inexpensive and common as vinegar should be easy to procure, if it is not included on standard Ministry of Health resupply forms—or in the clinic’s budget—managers report having to go to the market to purchase vinegar using their own money.

Monitoring: Plans for quality-control monitoring should be considered from the beginning of the program development process. Monitoring helps identify areas that require additional support or supervision (e.g., higher or lower than expected positivity rates and low same-month treatment rates). However, routine monitoring of screening and treatment can be difficult to implement if overall health information systems are weak.

Messaging: When promoting screening services, emphasize that:

  • A positive screening result does not usually signify cancer; it most often signifies a precancerous (early) condition.
  • When cervical cancer is treated during the precancer stage, treatment tends to be fast, painless, and effective, often without any surgery.
  • Screening and early treatment can prevent the "loss of the womb." Surgery is more likely when cancer is allowed to advance.
  • Cervical cancer does not result in obvious symptoms until the cancer has advanced. At that point it is difficult to treat. It is important to be screened even if you feel healthy.
  • Women who come for screening and the age of those women should be consistent with recommendations in your country.
  • If your formative research shows that families are concerned about the safety of screening, when offering pelvic examinations, reassure women that the instruments have been sterilized and that there is no reason to worry about "catching" cancer during screening or that existing cancer would spread more rapidly after screening (PATH research has found that some people believe this).
Photo: Heng Chivoan

Additional resources

Print version: Cervical cancer screening and treatment in low-resource settings (PDF, RHO Cervical Cancer website)

Watch videoScreening and Treatment of Precancerous Lesions video and transcript

Screening and treatment (RHO Cervical Cancer website)

World Health Organization: Comprehensive Cervical Cancer Control: A guide to essential practice (PDF)

Planning and Implementing Cervical Cancer Prevention and Control Programs: A Manual for Managers (PDF)

Evidence-Based, Alternative Cervical Cancer Screening Approaches in Low-Resource Settings

Strategic Plan for Cervical Cancer Prevention and Control in Uganda (PDF)

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