Please note: This archive was last updated in 2005.

RHO archives : Topics : Cervical Cancer Prevention

Program Examples

The cervical cancer programs in developing countries listed below illustrate some of the strategies developed to overcome obstacles and what has been learned from program experience.

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  • Chile: Challenges and lessons learned from a cervical cancer screening and treatment program.
  • Colombia: Challenges and lessons learned from a nationwide cervical cancer control program.
  • Costa Rica: Research project investigating the role of HPV infection and its cofactors in the etiology of high-grade cervical neoplasia.
  • India: A cervical cancer screening project effectively using a network of community resources.
  • Kenya: Barriers and successes encountered in a cervical cancer control project.
  • South Africa: Challenges to a nationwide screening project and recommendations to improve cervical cancer screening.
  • Thailand: Using mobile units to improve cervical cancer screening among rural women.
  • Vietnam: Assessing the cost-effectiveness of a five-year interval Pap screening program.

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Chile

Cervical cancer is one of the leading causes of mortality in women over 35. Individuals in Chile began working toward a cervical cancer screening, diagnosis, and treatment program in the 1960s; only in the past decade, however, has a coordinated program with monitoring and evaluation been implemented. Having data to show the impact of services has helped the cervical cancer prevention program win official recognition and greater government support.

The major challenges identified by the Chilean program were:

  • retaining highly motivated and trained professionals in the program;
  • keeping resources focused on high-risk groups;
  • improving registration of pre-invasive and invasive cancer;
  • allocating adequate resources for community work, mass media, and cytology labs to continue increasing coverage;
  • overcoming cultural barriers to Pap smears;
  • including private labs in the cytology quality control program; and
  • integrating services with other women's health promotion programs.

Lessons Learned

  • All screening programs should follow the principles of public health interventions from the beginning. It took 20 years to realize that the cervical cancer screening program in Chile was having little effect, and another 8 years to convince the majority of health care professionals that new strategies were research-based and cost-effective.
  • Success breeds success. Better coordination and guidelines, improved quality control, and more focused screening have helped the program optimize resources and become successful. As the program has shown improved results, the government has been more willing to provide administrative and financial support.

For more information, please contact:
Dr. Cecilia Sepulveda, Cancer and Tobacco Unit, Ministry of Health, Santiago, Chile
Fax: 56-2-638-2238

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Colombia

Colombia is in the midst of an epidemiological transition, and many aspects of women's health are improving markedly. Yet cervical cancer remains a serious health problem throughout the country, despite efforts to make screening more widely accessible.

The Colombian public health system, private organizations such as PROFAMILIA (a family planning nongovernmental organization), and the Colombian National League Against Cancer have been offering Pap smears since the mid-1970s. In 1990, after earlier efforts failed to show a significant impact on cervical cancer morbidity and mortality, a five-year, nationwide cervical cancer control program was initiated with the goal of reducing the incidence of invasive cervical cancer by 25 percent. The three main program objectives were to:

  • To provide Pap smears to 60 to 90 percent of women aged 25 to 69 within a three-year period, with special emphasis on reaching women of low socioeconomic status.
  • To provide follow-up to 90 percent of all women obtaining Pap smears through the program.
  • To establish reference centers for diagnosis and treatment of women with precancerous lesions.

The major challenges of Colombia's cervical cancer control program were:

  • Expanding cervical cancer screening to women beyond their childbearing years. (The health system traditionally has offered cervical cancer screening primarily to women during their peak childbearing years, which, in Colombia, is before age 35.)
  • Training enough cytologists to meet program demand. (There continues to be a shortage of trained cytotechnicians, particularly in certain parts of the country. Pressure from the medical pathologists association for a mandatory four-year training program in cytotechnology has complicated efforts to train more cytotechs quickly.)
  • Improving quality of care, particularly in terms of treating women with respect and paying attention to their concerns. (Efforts are underway to integrate quality-of-care issues into all program components.)
  • Developing an effective information system so that the impact of the program on Pap smear coverage and, ultimately, mortality and morbidity can be evaluated.

Lessons Learned

  • Bottlenecks to program implementation should be identified at the start. In the Colombian program, the shortage of cytotechnicians was a key barrier to meeting program needs. In addition, the growing demand from women asking for Pap smears put pressure on the system to train more cytologists. In most countries, developing systems to ensure the growing availability of cytotechs is a key program need.
  • It is crucial to develop an effective information system that allows for regular evaluation of program activities and achievements. This evaluation allows for identification of both program successes and program activities that need to be improved.
  • Women living in poorer, less accessible areas often are at highest risk for cervical cancer. Special strategies must be devised to reach these women. In Colombia, strategies such as special "cytology days" in shanty towns have been initiated using radio, megaphones, and church calls to encourage women to attend.
  • It is important to remember that the challenges of offering effective cervical cancer screening, diagnostic, and treatment services are not primarily technical challenges, but rather social and cultural ones. Cultural issues in local communities and in the medical/health communities can influence program success. Dr. Margarita Ronderos Torres concludes that "working together, respecting each other to deliver technology safely, efficiently, and effectively, is probably the key to success."

For more information, please contact:
Dr. Margarita Ronderos Torres, Scientific Investigator, Epidemiology Division, Instituto Nacional de Cancerolog�a, Calle 1, No. 9-85, Bogotá, Colombia
Telephone: 57-1-289-5270; Fax: 57-1-280-2021

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Costa Rica

Guanacaste is a rural province in northwest Costa Rica. Guanacaste has reported consistently high rates of invasive cervical cancer, despite the existence of a national cervical cancer screening and treatment program. During the five-year period from 1988 to 1992, incidence rates of invasive cervical cancer ranged from 23.5 to 45.1 per 100,000 women. This is higher than average in Costa Rica and at least four times higher than comparable rates in the United States. The main difference between high and low-incidence areas in Costa Rica may be related more to varying prevalence of risk factors than to the intensity of screening.

In an attempt to better understand why cervical cancer incidence in Guanacaste has remained high despite the availability of screening and treatment, the Costa Rican Foundation for Education in Medical Sciences—a part of the CCSS—is implementing a six-year study in the province to investigate the role of HPV infection and its co-factors in the etiology of high-grade cervical neoplasia, and also to evaluate new cervical cancer screening technologies. This study is being carried out in collaboration with (and with funding from) the U.S. National Cancer Institute.

The major challenges encountered during this research project were:

  • Limited experience of investigators and administrators with regard to contract negotiation and management.
  • The high cost of maintaining the number of full-time staff necessary to achieving high follow-up rates.
  • Ensuring standard protocols for colposcopic evaluation and pathologic evaluation of specimens.
  • Limited expertise in procuring equipment and materials from the United States, which has led to unexpected delays and additional expense.

The preliminary findings from this study are that:

  • It is possible to achieve high participation in cervical cancer screening programs and necessary follow-up through personal attention to patients, flexible clinic schedules, and allocation of resources for follow-up. (Participation rates have been above 93 percent for all components of the study including interviews, exams, and biological sample collection.)
  • Several new screening techniques are available, which may enhance the impact of cervical cancer prevention programs in developing countries. Until their cost is reduced, however, these new technologies may not be affordable to nonresearch programs.

For more information, please contact:
Dr. Concepci�n Bratti, Principal Investigator, Proyecto Epidemiológico Guanacaste, Apdo. 1253-1007, San José, Costa Rica
Telephone: 50-6-296-1036; Fax: 50-6-296-1465

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India

Editor's Note: The cervical cancer screening strategy implemented in the program example below involves simply looking at the cervix for signs of cervical cancer. This strategy, also known as "downstaging," attempts to identify cervical cancer at an earlier, more treatable stage. (Stage I means that the carcinoma is confined to the cervix, stage II means the carcinoma extends beyond the cervix, but has not extended to the pelvic wall, stage III means the tumor involves the lower third of the vagina or has extended to the pelvic wall, and stage IV means the carcinoma has extended beyond the true pelvis. For a more detailed description of cervical staging, see the NIH Consensus Statement on Cervical Cancer (http://odp.od.nih.gov/consensus/cons/102/102_statement.htm.) Other investigators who have evaluated the use of downstaging in detecting cervical cancer have concluded that it is not a useful procedure for cervical cancer control (Nene et al. 1996). Nonetheless, this example illustrates an effective use of a network of community resources to promote a cervical cancer program.

Cervical cancer is the most common cancer among women in India, with approximately 71,600 new cases occurring each year. In 1985, staff of the Department of Gynaecologic Oncology at the Kidwai Memorial Institute of Oncology initiated an effort to develop an appropriate strategy of the control of cervical cancer in India.

Phase I of the project started in 1991 and involved two studies to assess the feasibility of using the existing public health infrastructure to downstage cervical cancer. The goal of the study was to determine the effectiveness of female health personnel in communicating health information, performing visual inspection, and in triaging cervical abnormalities. Women who were identified with a cervical abnormality were referred to the institute, where they received appropriate treatment for visible lesions and further investigations (including Pap smear and colposcopy) if no lesion was visible. The study found that health workers in primary health centers could perform visual inspection of the cervix, but that the additional responsibility of raising awareness about cervical cancer and encouraging local women to visit the health center for screening was more than the health personnel could handle. They noted that the success of the intervention depended a great deal on having a female provider at the primary health center who was interested in the project and willing to put effort into its implementation. They also found that many women needed the consent of their husbands or mothers-in-law to have a health test, suggesting a need for more active education of men and family members about the importance of cervical cancer screening.

In phase II of the project, two nongovernmental organizations, PRAXIS and ADATS, collaborated with the institute to develop a broad-based collaborative approach to cervical cancer screening. The two organizations disseminated information about cervical cancer and encouraged women to seek cervical screening by trained health workers. This approach allowed more women to be recruited for screening and enabled primary care staff to screen larger numbers of women than in the earlier study.

A recent component involved an assessment of awareness about early detection of cervical cancer among urban underprivileged women. A Knowledge, Attitudes, and Practices Survey was administered to a representative sample of women fitting this description. Over 80 percent of the women were not aware of cancer and more than 99 percent had never heard of a test for cancer. Some 70 percent stated that they would be interested in undergoing such a test, however. This component of the project also involved implementation of an early detection program for cervical cancer in an urban setting, but there is no record of the accuracy of the examination or the analysis of women's compliance in seeking testing or being referred for treatment.

Lessons Learned

  • Success of the intervention depended on having a female medical officer at each site interested in the project.
  • The responsibility of creating a demand for services should not be placed solely on the health workers.
  • More empowerment of women and more education for men is necessary for large numbers of women to be able to receive health treatment.

Some of the future plans for new and continued activities in this program in India are:

  • Promoting collaborations between the Kidwai Institute and additional organizations to promote early detection of cervical cancer.
  • Recruitment of private institutions, hospitals, or local gynecologists interested in providing referral services for the project.
  • Involving female "panchayat" members to impart health education messages and to ensure that primary health centers provide cervical cancer services to women.

For more information, please contact:
Dr. Elizabeth Vallikad, Professor, Department of Obstetrics and Gynaecology, St. John's Medical College and Hospital, Sarjapur Road, Bangalore 560 034, India
Email: [email protected]

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Kenya

The limited data available suggest that cervical cancer is a serious problem in Kenya. Hospital-based registries indicate that the disease accounted for 8 to 20 percent of all cancer cases from 1981 to 1990. At Kenyatta National Hospital in Nairobi, which has the country's only radiotherapy unit, more than 500 cases are referred for treatment every year. Since many women are unable to travel to Nairobi from other parts of the country for diagnosis and treatment, this figure likely represents a very small proportion of the total number of women in need of care. In fact, limited research suggests that over 600,000 women throughout Kenya may have cervical dysplasia, a significant portion of whom may have high-grade or severe dysplasia, thus requiring treatment to prevent cancer from developing.

In 1992, the Kenya Medical Women's Association (KMWA) initiated the Well-Woman Clinic in Nairobi, in collaboration with the Family Planning Association of Kenya, to provide a variety of interventions to improve women's health. The first intervention that was introduced was cervical cancer screening. In 1994, KMWA established its own facility to support the expansion of cervical cancer and other services. A baseline study was conducted during the first phase of the project (May through December 1994) in which 520 women were screened. Of these women, about 2.9 percent� had atypia, 5.4 percent had CIN I, 3.3 percent had CIN II, 2.3 percent had CIN III, and 0.5 percent were diagnosed with cancer.

Major barriers encountered by KMWA in establishing a cervical cancer control program include:

  • A national health policy that does not directly address cervical cancer as a priority, which in turn lessens the emphasis on cervical cancer in medical education programs.
  • Inadequate provision of equipment and supplies for screening in public health clinics.
  • Lack of accurate incidence and prevalence data for planning.
  • Misinformation about the disease on the part of women and health care providers.
  • Poverty, which makes health care inaccessible to many women.

Although limited in scope, KMWA's efforts have been successful largely because of the following:

  • Screening and treatment are kept affordable because KMWA members (gynecologists and pathologists) offer their consultation services for free.
  • Referral of cancer cases to either public or private hospitals for management is arranged through the network of KMWA members working in these facilities. As a result, women who need follow-up receive it quickly and easily.
  • Research activities have funded the training of KMWA gynecologists to perform colposcopy, as well as to become trainers themselves. Training for nurses in taking Pap smears also has been conducted.
  • Functioning networks with other organizations to share resources, materials, and technical skills have allowed the program to reach more women.

For more information, please contact:
Dr. Lucy Muchiri, Coordinator, WWC and Secretary, KMWA Council, Kenya Medical Women's Association, Kodi Road, PO Box 49887, Nairobi, Kenya
Telephone: 254-2-506-287; Fax: 254-2-503-239

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South Africa

Cervical cancer is the most common cancer among women in South Africa and accounts for about 25 percent of cancer deaths among black South African women. Death rates among women being treated for cervical cancer vary by race and geographic location. Though data are sketchy, information from Cape Town suggests that the peak incidence of dysplasia occurs among women in the 29 to 39 age group. A cervical cancer screening research project in Soweto (an urban township) revealed extremely high rates of CIN and invasive cancer in women aged 40 to 60, and unexpectedly high rates of dysplasia among teenagers.

South Africa has not had great success to date in implementing effective cervical cancer screening efforts. In the 1970s, the Department of Health advocated that Pap smears be done only if the cervix looked abnormal, a policy that was abandoned because, in general, by the time a clinician notices growths or discharge, cancer is already advanced. In the 1980s, the availability of Pap screening services was further curtailed as cervical cancer deaths were decreed to be less serious than other health challenges. In 1989, a policy to screen women once in their lifetime at age 40 was initiated, but no coordinated mechanism to implement the policy was developed. Therefore, services remain variable. Although screening is theoretically available at Ob/Gyn, family planning, and ante- and postnatal� clinics, little routine screening occurs in the public sector. In general, women have to initiate screening by specifically requesting a Pap smear.

As a first step toward developing a rational plan for promoting and implementing a national cervical cancer screening program, researchers from the Women's Health Project at the Center for Health Policy, Department of Community Health at the University of Witwatersrand Medical School in Johannesburg, reviewed the cost-effectiveness of various screening assumptions, including screening interval. A summary of these findings was presented in a policy paper entitled Toward a National Screening Policy for Cancer of the Cervix in South Africa. This document concludes that the current practice of opportunistic screening and treatment of precancerous and cancerous lesions is not a rational use of resources. A policy aimed at screening either 100 percent or 60 percent of all women over age 20 every five years would be at least as cost-effective as the current policy of treatment without an organized screening program. Another important finding is that use of specialists to perform Pap smears is not a practical or cost-effective approach.

Some of the major challenges to developing a national screening program in South Africa that have been identified are:

  • Education of women: Any policy to increase screening should include an education program.
  • Integrating services: Any planned screening program should be integrated into the existing clinic system.

Some of the key recommendations for cervical cancer programs in South Africa are applicable to most programs working to improve cervical cancer control:

  • Increase the number of women having Pap smears (coverage) rather than focusing on more frequent screenings.
  • Develop effective quality-control systems in obtaining and interpreting Pap smears.
  • Ensure appropriate follow-up of abnormal smears.
  • Ensure that Pap smear services are effectively integrated into the existing health care infrastructure.
  • Train providers to improve sensitivity toward client issues and concerns.

For more information, please contact:
Dr. Sharon Fonn or Ms. Barbara Klugman, Women's Health Project, c/o SAIMR, P.O. Box 1038, Johannesburg 2000, South Africa
Telephone: 27-11-489-9917; Fax: 27-11-489-9922

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Thailand

Cervical cancer is the most common type of cancer among women in Thailand. In the early 1990s, a mobile unit program was developed in the Mae Sot District, Tak Province, to improve screening coverage and knowledge of cervical cancer among rural Thai women.

Since the 1970s, cervical cancer screening in the Mae Sot District hospital has been performed mainly through the maternal and child health/family planning services. A one-week mass screening campaign in which women can receive a Pap smear at no charge has been conducted in the hospital since 1986. Despite the availability of these services, a 1991 survey of women aged 18 to 65 revealed that only 21 percent knew about the Pap test, and only 20 percent had ever been screened.

In order to improve screening coverage in rural Thailand and to increase awareness of cervical cancer, a mobile unit program was established in 1993. Supported by the Provincial Health Office, the mobile screening unit targeted women between the ages of 25 and 60. Mobile unit activities included providing education, asking health center workers and trained village health communicators to invite women personally to the screening program, and collecting Pap smears throughout all 54 rural villages in the district. Pap smears were provided free of charge and were obtained by trained public health nurses under the supervision of the project physician at the health center or the village primary school in each village. All Pap slides were sent to the cytology laboratory at the hospital. After the first campaign was conducted in January and February 1993, another campaign was implemented in 1996.

To evaluate the program's effect on knowledge and use of cervical cancer screening, the results of three interview surveys of women aged 18 to 65 were compared. The first survey was completed in January 1991, before the program had been established; the second was completed in January 1994, one year after the first screening campaign; and the third was completed in January 1997, one year after the second campaign. Survey results include:

  • The percentage of women who could identify cervical cancer as the most common cancer in women rose from 31 percent in 1991 to 66 percent in 1994 and 69 percent in 1997.
  • The belief that women can have asymptomatic cervical cancer increased from 20 percent in 1991 to 53 percent in 1993 and 64 percent in 1997.
  • The proportion of women who knew about the Pap test rose from 21 percent in 1991 to 57 percent in 1994 and 76 percent in 1997.
  • Of the women who knew about the Pap smear, the proportion who understood that it could detect asymptomatic cervical cancer grew from 78 percent in 1991 to 92 percent in 1993 and remained at 92 percent in 1997.
  • The proportion of women who had ever had a Pap test increased from 20 percent in 1991 to 58 percent in 1994 and 70 percent in 1997.
  • The mobile unit screening program became the most commonly reported service for Pap screening among rural Thai women.
  • The mobile unit effectively targeted older women. More smears of women older than 25 and particularly women older than 45 were taken by the mobile unit than by the other screening services.
  • The mobile unit accounted for 85 percent of all cervical intraepithelial neoplasia (CIN) III and all invasive cancer identified among the Pap smears examined in the district from 1992 to 1996.

Lessons Learned

  • Health education, personal invitation, and smear-taking activity are crucial components of cervical cancer screening programs.
  • A mobile unit program may provide effective screening for early detection of cervical cancer among women in rural areas where existing screening services cannot reach at-risk female populations (particularly older populations).

For more information, please contact:
Dr. Swaddiwudhipong, Department of Community and Social Medicine, Mae Sot General Hospital, Tak 63110, Thailand
Telephone: 66-55-531229; Fax: 66-55-533046

Information adapted from Swaddiwudhipong, W. et al. A mobile unit: an effective service for cervical cancer screening among rural Thai women. International Journal of Epidemiology 28:35-39 (1999).

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Vietnam

Cervical cancer is the leading cause of cancer-related death among women in the Socialist Republic of Vietnam. Until recently, Vietnam was one of many developing countries in which Pap smear screening programs were virtually nonexistent. The absence of Pap screening programs in developing countries such as Vietnam is due in part to the belief that costs to implement such programs would be prohibitively expensive. The cost-effectiveness of implementing conventional Pap screening in a developing country had never before been formally examined.  This summary describes the results from a study of the cost-effectiveness of a five-year interval Pap screening program in Vietnam, assessed from a societal perspective using decision analytic methods.

The Viet/American Cervical Cancer Prevention Project, initiated in 1993 by physicians in Vietnam and the United States, supports the development of a comprehensive, cost-effective cervical cancer prevention program in Vietnam. The organization completed a cost-effectiveness analysis in 1999 that estimated that building a nationwide Pap screening program in Vietnam (based on five-year intervals between screenings) would average less than US$150,000 (1999 constant-value) annually during the ten years assumed necessary to develop the program. This figure includes costs for salaries, disposable supplies, equipment, clinic space, laboratory space, and overhead related to Pap smear screening and preventive treatment. It does not include costs of training by international consultants for community mobilization, cytology, or treatment. The estimate also excludes costs associated with the treatment and care of women with invasive cervical cancer. (Women in Vietnam with invasive cervical cancer currently are treated with surgery and radiation therapy.)

Annual program-maintenance costs were estimated to average less than US$0.092 per woman in the target screening population (women 30 to 55 years of age), an amount that appears affordable for the 1999 average per-capita income of US$300. At this level of investment, the Viet/American Cervical Cancer Prevention Project estimated that cervical cancer incidence and mortality in Vietnam would be reduced by 37 percent with participation by 60 percent of women in the target screening population, and by 58 percent with participation of 100 percent of women in the target screening population. With 70 percent program participation, cost-effectiveness will be US$725 per DALY. Staffing requirements for the fully established nationwide program will include 292 Pap test collectors, 204 cytotechnologists, 133 secretaries, 35 pathologists, and 9 gynecologists. Budget and personnel requirements will be considerably lower if only high-risk geographic areas are targeted.

Based on the study results, the Viet/American Cervical Cancer Prevention Project instituted de novo population-based Pap screening in Ho Chi Minh City and in Hue. Pilot-scale Pap screening programs have been established in Hanoi and in Danang.

Program Challenges

Some of the challenges to developing a successful screening program in Vietnam include:

  • developing effective community-outreach methods to maximize the level of participation among women in the target screening population;
  • implementing and maintaining effective quality-control and quality-assurance programs, particularly in the centralized cytology laboratories;
  • improving curative treatment services for women who are discovered to have invasive cervical cancer; and
  • maintaining excellent working relationships among diverse groups and institutions in order to ensure the success of cervical cancer prevention efforts in Vietnam.

Implications for Other Programs

  • The study results suggest that Pap smear screening programs can be developed in some settings, such as Vietnam, with a relatively low level of investment, assuming external assistance is available for training and technical assistance.
  • While the effectiveness and cost of some alternatives to the conventional Pap test in developing countries are still being investigated, the results from the Vietnam cost analysis seem to suggest that the implementation of conventional Pap screening services in developing countries such as Vietnam could be inexpensive and cost-effective.
  • Results of a well-designed cost-effectiveness analysis can provide persuasive evidence that can help gain support for cervical cancer prevention activities.
  • Training of non-physician providers to provide cytologic screening services is a cost-effective strategy.

Some of the most critical barriers to the expansion of cervical cancer prevention services in any country are social and political obstacles to organizing the coalitions needed to secure participation, and will remain so irrespective of the screening methodology eventually employed in any nation.

For more information, please contact:
Dr. Eric Suba, President and Executive Director, The Viet/American Cervical Cancer Prevention Project, 2295 Vallejo Street, Suite 508, San Francisco, CA 94123 USA
Telephone: 650-742-3162; Fax 650-742-3055; Email: [email protected]

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