Please note: This archive was last updated in 2005.

RHO archives : Topics : Cervical Cancer Prevention

Overview/Lessons Learned

Introduction

Cervical cancer is an important women's health problem, especially in developing countries, where an estimated 190,000 women die from the disease each year (Pisani et al. 1999). It is the third most common cancer worldwide and the leading cause of death from cancer among women in developing countries. At least 466,000 new cases are identified each year; roughly 80 percent are in developing countries. Rates are highest in Central America, sub-Saharan Africa, and Melanesia (Path/Outlook 2000).

Unlike many cancers, cervical cancer is preventable. It can be prevented by using relatively inexpensive screening and treatment technologies to detect abnormal cervical tissue before it progresses to invasive cancer.

An important reason for the sharply higher cervical cancer incidence in developing countries is the lack of effective screening programs aimed at detecting precancerous conditions (dysplasia) and treating them before they progress. It has been estimated that only about 5 percent of women in developing countries have been screened for cervical dysplasia in the past 5 years, compared with some 40 to 50 percent of women in developed countries.

The vast majority of cases are caused by human papillomavirus (HPV), a sexually transmitted agent that infects the cells of the cervix and slowly causes cellular changes (dysplasia) that can result in cancer. These changes can be relatively mild ones that often do not progress and may even regress. Larger, deeper lesions (severe dysplasia) are more likely to progress to cancer (Nasiell et al. 1986; Holowaty et al. 1999). Women generally are infected with HPV in their teens, 20s, or 30s; the disease can take up to 20 years after HPV infection to develop. Cervical cancer starts with an in situ stage that can be treated, but then progresses to invasive disease that is always fatal where surgery and radiation therapy are unavailable.

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The traditional approach to prevention

Cervical cancer prevention efforts worldwide have focused on screening women at risk of the disease using Pap smears and treating precancerous lesions. Where screening quality and coverage have been high, these efforts have reduced invasive cervical cancer by as much as 90 percent (Gustafsson et al. 1997).

Most developing counties, however, have been unable to implement comprehensive, Pap smear screening-based programs. In countries where Pap smear screening is available, it often is accessible only to a� small proportion of women through private-sector health care providers, or it is offered primarily to young women through maternal and child health or family planning clinics where the population being screened generally is not at high risk (Robles et al. 1996). These approaches have had little effect on morbidity and mortality, and generally are not as cost-effective as centrally organized screening programs implemented by the public sector (Fahs et al. 1996). A cost-effectiveness study of Pap screening services in Vietnam suggested that costs for establishing de novo pap screening may be reasonable in some settings with additional support from international funders (Suba et al. 2001).

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Emerging strategies

Some countries have redesigned their cervical cancer screening programs to be more successful and effective. Strategies have been developed to limit screening to women at highest risk of high-grade dysplasia, to reduce the frequency of screening among women who have had at least one normal smear, and to recommend regular follow-up rather than treatment for young women with mildly abnormal smears. Even screening women in their 30s once in a lifetime can have a significant effect on mortality (Murthy et al. 1993; Goldie et al. 2001; Mandelblatt et al. 2002). Modified screening and treatment strategies, an increased emphasis on improving the accuracy of the tests, planning for follow-up of clients, and evaluation of the program are key to program success. A 1998 workshop in Kenya on the prevention and control of cervical cancer in East and southern Africa discussed these issues and developed local plans of action. [View a PDF of the meeting report. PDF file requires Adobe Acrobat Reader.]

Several alternative approaches to cervical cancer screening also have been proposed and are being evaluated in research studies. These include visual screening (both magnified and unmagnified visual screening) to identify cervical lesions without reliance on cytology; HPV tests that may be able to identify women at high risk for cervical cancer, and automated Pap screening machines to identify subsets of Pap smears that should be examined by cytologists. These approaches are being evaluated for clinical effectiveness, acceptability to clients and health care providers, and cost-effectiveness (see the Screening: assessment of alternative approaches key issue for more information).

In 1997 representatives of three international nongovernmental organizations working to prevent cervical cancer in developing countries met with representatives of USAID and identified ten research questions felt to be of highest priority in guiding strategy development for preventing cervical cancer in low-resource settings (Sherris 1999).

In 1999, with support from the Bill & Melinda Gates Foundation, the Alliance for Cervical Cancer Prevention was formed to take the critical next steps in clarifying, promoting, and implementing effective prevention strategies, in partnership with developing-country counterparts.

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Lessons learned

In order to reduce cervical cancer morbidity and mortality, experience shows that, at a minimum, programs with limited resources should strive to:

  • Increase awareness of cervical cancer and preventive health-seeking behavior among high-risk women (30 to 50 is a reasonable target age-group for new cervical cancer control programs with limited resources).
  • Screen all women aged 30 to 50 at least once before expanding services to other age groups or decreasing the interval between screening.
  • Treat women with high-grade dysplasia, refer those with invasive disease where possible, and provide palliative care for women with advanced cancer.
  • Collect service delivery statistics that will facilitate ongoing monitoring and evaluation of program activities and outputs.

Other lessons learned include:

  • Strong management and support for program strategies at all levels of the health care system are essential.
  • Crucial to gaining this support is clearly demonstrating the need and demand for a cervical cancer control program.
  • Demonstrating this need should include analyses of the estimated costs and impact of various program approaches.
  • Health care providers and clients should be involved in program design to ensure that their perspectives are considered and their needs are met.
  • Potential bottlenecks to program functioning (for example, logistical barriers) should be identified and addressed at the start.
  • Effective programs rely on health care providers trained to be sensitive to client concerns and needs.

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