CERVICAL CANCER "An NCD We Can Overcome" - Therese LETHU - Geneva Health Forum 2020
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CERVICAL CANCER “An NCD We Can Overcome” Therese LETHU Global Health Objectives
Acronyms GHO ..........................................................Global Health Objectives CKC............................................................Cold Knife Conization EVA System ..............................................Enhanced Visual Assessment GFATM ......................................................Global Fund Against Aids, Tuberculosis and Malaria HPV ...........................................................Human Papillomavirus HUG ..........................................................Hospitals University of Geneva ICT..............................................................Information and Communication Technology ITU..............................................................International Telecom Union IAEA ..........................................................International Atomic Energy Agency IARC...........................................................Agency for Research on Cancer LEEP...........................................................Loop Electrosurgical Excision Procedure mHealth ....................................................Mobile Health MOH .........................................................Ministry of Health NCD ..........................................................Non Communicable Disease OIF ............................................................International Organization of the Francophonie Pap smear..................................................Papanicolaou test PEPFAR .....................................................The U.S. President's Emergency Plan for AIDS Relief SMS............................................................Short Message Service STI ..............................................................Sexual Transmitted Infection TB ..............................................................Tuberculosis UNICEF .....................................................United Nation’s Fund for Children UNAIDS ....................................................The Joint United Nations Program on HIV/AIDS UNFM .......................................................Université Numérique Francophone Mondiale UNFPA ......................................................United Nations Population Fund UNDP.........................................................United Nations Development Program USNCI .......................................................Us National Cancer Institute VIA..............................................................Visual Inspection with Acetic Acid VILI .............................................................Visual Inspection with Lugol's Iodine WHO..........................................................World Health Organization
Cervical Cancer in Africa :
“An NCD We Can Overcome”
“This was the theme of the round table we organized in Geneva
with various experts to highlight the way forward.
This is the report of the discussion”.
22 May 2016 - 3.30 to 6.30 pm
Starling Hotel, Geneva
Geneva - July 2016
Therese LETHU
Global Health Objectives
1
AGENDA
Thérèse Lethu, Executive Director, Global Health Objectives:
Welcoming words and moderator..........................................................................P.3
Michel Sidibé, Executive Director, UNAIDS:
HIV/HPV Interactions: new opportunities for joining forces...................................P.4
Prof John-Paul Bogers, Coordinator of The WAKA-HPV Project:
A promising public and private approach at regional level....................................P.7
Dr Sharon Kapambwe, National Coordinator Cancer Prevention,
Ministry of Health, Zambia:
Lessons learned from experience...........................................................................P.9
Curtis Peterson, VP Global Health Mobile ODT:
Screening cervical cancer using mobile phones.....................................................P.13
Dr Anne-Caroline Benski, Obstetrician/gynecologist, University Hospital of Geneva:
Innovative Mobile Health System for HPV Screening in Low Income Countries....P.14
Dr Ophira Ginsburg, WHO:
The new UN Global Joint Program for Cervical Cancer Prevention and Control..P.16
Dr Qhing Qhing Dlamini: Afya Health Management Associates:
The way forward......................................................................................................P.17
Discussion: key insights.................................................................................................P.18
Therese Lethu:
Conclusions.............................................................................................................P.24
2
Therese Lethu, Executive Director, Global Health Objectives (GHO):
Welcoming words and overview
According to WHO, screening and treatment of cytology (Pap test). Molecular-based HPV diagnos-
pre-cancerous lesions to prevent cervical cancer is tics are being tested in research and pilot projects in
one of the “best buy” for addressing NCDs preven- a number of countries to clarify the diagnostic, cli-
tion and control, while reducing premature deaths nical, and programmatic implications of HPV scree-
by 25% by 2025. Taking into account current and ning for cervical cancer prevention. In addition, two
projected burden of disease, cost-effectiveness, certified HPV vaccines provide new powerful tools
fairness, technical knowledge and feasibility of new to scale up current programs, with the potential to
interventions, cervical cancer programs have pro- prevent 70% all cases. (Newer vaccines which tar-
ven to be cost-effective and high-impact initiatives.get more of the cancer-causing subtypes of HPV will
eventually be able to prevent a greater proportion
Cervical cancer remains the most common type of cases, for example Gardisil 9, which targets 9 sub-
of cancer among women in sub-Saharan Africa: af- types, currently prohibitively expensive for most
fecting as high as 22%. In the WHO AFRO region, countries).
every year, 34 out of every 100 000 women are dia-
gnosed with the disease and 23 out of these die HIV/HPV co-infection is another opportunity to in-
[REF Globocan/IARC]. Human papil- tegrate screening of cervical can-
loma virus (HPV) is the primary cause cer into existing HIV testing and
of cervical cancer. While most infec- counseling, care and treatment
tions with HPV are cleared by the bo- services. According to scientific
dy’s immune system, some infections sources, there is a higher inci-
persist and lead to cervical dysplasia, dence, greater prevalence and
pre-cancers and ultimately invasive longer persistence of HPV in-
cancer Despite being one of the few fection amongst HIV infected
types of cancer that can be prevented women. Research is ongoing
with a vaccine and by screening with to develop more effective and
simple treatment of pre-cancers, cost-effective methods of scree-
more than 95% of affected women ning and treatment, but cryothe-
have never been screened for the rapy, large loop excision of the
disease. Cancer control programs are not yet part transformation zone (LEEP/LLETZ), and cold knife
of existing primary sexual and reproductive health conization (CKC) are standard practices depending
care services. Knowledge and awareness of this on the clinical situation and the setting*.
disease remains poor, and facilities for prevention,
diagnosis and treatment are still widely inadequate. Our roundtable highlighted new major strategic
As a result, most of women are diagnosed at the and technologic steps for advancing screening and
advanced stage and this incidence is on the increase treatment of cervical cancer in Africa, raising awar-
in some countries. eness and providing key data to help political lea-
However, new strategies to both primary and se- ders, partners and funders to take action.
condary prevention have been scientifically proven Prior to the sixty-ninth World Health Assembly, held
over the last decade. The approaches, tools and in Geneva, from 23 to 28 May 2016, the roundtable
equipments for new screening methods, vaccina- enabled Commonwealth member countries’ dele-
tion, treatment and awareness should create addi- gates to participate in the discussion. An interactive
tional opportunities for innovative actions, syner- exchange provided an overview of current interven-
gies and promising partnerships. tions and research as it relates to cervical cancer in
Africa. Particular emphasis was placed on assessing
Such interventions should help increase access for the enabling environment for those strategies to
women aged 30–49 years to early treatment and succeed, exchanging experiences and knowledge
screening to identify precancerous lesions, as re- for optimizing results, including standard data col-
commended by WHO guidelines. Available scree- lection and analysis for quality control.
ning tests include a Human Papillomavirus (HPV) *http://www.who.int/reproductivehealth/publications/can-
test, Visual Inspection with Acetic Acid (VIA), and cers/cervical-cancer-guide/en/
3
Michel Sidibé, Executive Director, UNAIDS:
HIV/HPV Interactions: new opportunities for joining forces
As Executive Director of UNAIDS, since 2009, technologies, programmes and entry points that
Michel Sidibé’s vision of zero new HIV infections, are mobilized for HIV prevention, treatment, care
zero discrimination and zero AIDS-related deaths and support can be successfully combined with
has been integral in securing HIV as a priority of other sexual and reproductive health services, in-
political agendas. Having spent more than 30 cluding those for cervical cancer – as highlighted
years in public service, M. Sidibé’s ideas of sharedin the 2016 Political Declaration on HIV and AIDS,
the UNAIDS Strategy 2016-2021 and the United
responsibility, global solidarity and the critical role
of the civil society and community mobilization, in-Nations Secretary General’s 2016 report.
cluding meaningfully engaging women living with The 2016 Political Declaration on HIV and AIDS
HIV and the women’s rights movement, have [PD] («On the Fast-Track to Accelerate the Fight
been embraced by the international community, against HIV and to End the AIDS Epidemic by
including most affected countries. His experience 2030»), emphasizes the importance of addressing
as far as it concerns the lessons learned from the the linkage between HIV and HPV infections, and
fight against the HIV/AIDS epidemic could help HIV-cervical cancer co-morbidity. To guarantee
advance the prevention and treatment of cervical the sustainability of HIV prevention, treatment,
care, and support services, information and edu-
cancer in Africa and is of great value to our discus-
sion. cation, the PD calls for the integration of those
services with national health systems and services
Cervical cancer is the most common cancer in to address co-infections and co-morbidities, inclu-
women in sub-Saharan Africa and globally is the ding prevention, screening and treatment for cer-
fourth most common cancer in women. Every year vical cancer and HPV.
527,624 women are diagnosed
with cervical cancer and 265,653 While introducing the round-
women die from the disease. The table discussion entitled “An
majority of new cervical cancer NCD that we can overcome”,
cases (85%) and deaths (88%) oc- Michel Sidibé emphasized the
cur in low-income and middle-in- movement from “just AIDS”, as
come countries. This is a largely underlined in the UN Secretary
preventable tragedy thanks to General’s 2016 report and re-
the HPV vaccine, and curable if minded of the SG’s call to scale
detected and treated early. Cer- up and monitor collaboration
vical cancer is four to five times across HIV and other health is-
more common among women sues, including cervical cancer,
living with HIV than women who by adopting medium-term tar-
are HIV-negative. Women living gets towards 2030, such as: 1)
with HIV are also more likely to to screen every woman living
have an increased risk of developing precancerous with HIV for cervical cancer by 2020, 2) Re-screen
lesions, those lesions to progress rapidly to inva- women living with HIV whose screening results
sive cervical cancer and a recurrence of precance- are negative (no precancer) within three years,
rous lesions after treatment. With the increased and 3) to reduce by 25% cervical cancer deaths
longevity of HIV-positive women on anti-retroviral and all other NCDs related mortality by 2025. ”We
therapy (ART), their risk of exposure to HPV fur- are not there yet, but a few years back, we we-
ther elevates, providing the time required for pro- ren’t even dreaming of such a target on HIV. Today
gression to cervical cancer. we are completely bringing HIV out of isolation,
Addressing HIV-HPV co-infection and HIV-cer- for better integration and greater accessibility to
vical cancer co-morbidities as well as prevention those most in need. So we need to also fast-track
of both and integration of HIV and cervical can- the response for the cervical cancer as well as get-
cer prevention, screening and treatment services ting back to zero and making sure that we reach
are, thus, an effective and efficient approach for the 90-90-90 goals”.
responding to these diseases. Many of the same
4
Integration 1.5 million in 2010 to 1.1 million in 2015. Over 50%
of patients now have access to treatment. In addi-
Based on the lessons learned from HIV and tuber tion, 2.5 million people were newly infected with
culosis service integration, Michel Sidibé stressed HIV, which is a real progress in ten years, including
the importance of further integration: “We learned a reduction of up to 50% for newborns. Those
very early that we were treating people affected major outcomes have been made possible thanks
with HIV and we were letting them die from tu- to a local collaborative organization designed to
berculosis. So integration with medical health scale up the programme activities. This commu-
and women’s sexual and reproductive health nity-centred and –based strategy should also be
programmes, among others, is very important. critical to successfully implement and extend any
We learned that integration is very cost-effective programme on sexually transmitted diseases pre-
to help reach more people”. Collaboration and vention and treatment, including cervical cancer.
integration between HIV and tuberculosis pro- The integration of services must include advocacy
grammes has led to a big increase in HIV testing and information, including age-appropriate com-
for tuberculosis patients. prehensive sexuality education and communica-
Those found to be HIV-positive are started as tion regarding HPV and cervical cancer.
soon as possible on ART, which has been proven
to reduce the number of deaths in tuberculosis “Furthermore, our experience related to fighting
patients more than waiting until the tuberculo- stigma and discrimination related to HIV and
sis treatment is completed. Isoniazid preventive AIDS is crucial to overcome cervical cancer’s
therapy reduces the rate at which people living challenges and move forward”. UNAIDS Exe-
with HIV develop tuberculosis, even if they are cutive Director mentioned the home-based care
also taking ART. Molecular diagnostic platforms strategy as another successful people-centered
for tuberculosis (geneXpert), which increase the and community-based service delivery approach:
yield especially in patients with dual infection, are “In doing so, we need to work with faith com-
now also beginning to be used for HIV viral load munity actors, and community based partners
and infant DNA-based HIV testing. In many coun- to extend our reach”. According to Michel Sidi-
tries, the number of deaths among people living bé, it is necessary to leverage existing opportu-
with HIV have declined, in particular, thanks to the nities, experience and synergies within the HIV/
reduction in the number of tuberculosis-related AIDS programmes to accelerate progress towards
deaths among people living with HIV, which have cervical cancer programmes, including screening,
fallen by 32% since 2004. prevention and care, especially in Africa, the re-
gion in greatest need.
M. Sidibé reminded of another lesson from the
global AIDS response, particularly, the key role Decentralisation
that community partnerships, civil society activism
and advocacy, and community mobilization play, M. Sidibé has additionally highlighted the impor-
and the high return in investments in commu- tance of decentralization of services and strategic
nity-led service delivery and human resources for information, including data on barriers to acces-
universal health coverage to strengthen people- sing HIV and cervical cancer services. “Early, we
centred service delivery. Furthermore, he reaf- understood that we needed to decentralize data
firmed that the collaboration and partnerships collection and the prevention and care process,
forged between the women’s rights movement including clinical and laboratory services, to
and networks of women living with HIV were cri- reach out to the greater number of people at the
tical in ensuring that gender equality, women’s community level”. The lesson of decentralizing
empowerment, sexual and reproductive health, clinical and laboratory services is very important
and rights were prioritized as part of the global as far as it concerns cervical cancer programmes.
HIV response. “We can share our experience re- “We should start filling more data on cervical can-
garding access to treatment at large scale, es- cer related to HIV- HPV co-infection’s scientific
pecially in changing the service delivery concept evidence, HPV field research, quality control and
completely by creating the demand and the transparency including stigma and discrimination,
ownership at the community level”, said Michel so that we can think about how to deal with these
Sidibé. The HIV treatment coverage had increased issues which are keeping women away from both
from 24% in 2010 to 54% in 2015. As a result, the services for HIV and cervical cancer, in so many
number of AIDS deaths had been reduced from places”.
5
90-90-90 targets to apply the lessons learned from the accelerated
treatment scale up to non-communicable disease
Based on the progress made in the AIDS response programmes, namely cervical cancer. “For the first
globally, M. Sidibé underlined both the need and time we put almost 17 million people on treatment,
opportunities for countries to accelerate efforts to in a few years, providing the support needed to en-
end the AIDS epidemic by 2030. sure that those chronic care programmes can work
The goal is to reach the 90-90-90 targets in 2020, in resource limited settings. As highlighted in the
namely: 90% of people living with HIV to know their Secretary General’s report, the failure to control the
status, 90% of people who know their status to ac- AIDS epidemic will undermine efforts to end tuber-
cess HIV treatment and, 90% of people on treat- culosis and reduce rates of maternal and child mor-
ment to achieve viral suppression, and proposed tality, hepatitis C and cervical cancer».
FFFFF
UNAIDS JOINS CERVICAL CANCER INITIATIVE
UNAIDS is joining with Cervical Cancer Action (CCA)—a global coalition to stop cervical cancer among
women and girls in developing countries—to launch a new five-year initiative.
Taking Cervical Cancer Prevention to Scale: Protecting All Women and Girls, an initiative spearheaded
by Ambassador Sally Cowal, is convening a partnership committed to prioritizing investments in the
health of women and adolescent girls. It will build momentum for action on global cervical cancer pre-
vention over the next five years.
FFFFF
Sally Cowal, Senior Vice president,
Global Health,
American cancer Society
“US$ 3.65 billion over 10 years for cervical cancer
control to save the lives of countless women and
girls is not beyond us, integrating these invest-
ments with hiv prevention and control leverages
multiple benefits.”
FFFFF
* Ferlay, J, Soerjomataram, I, Dikshit, R et al. Cancer incidence and mortality worldwide: sources, methods and major patterns
in GLOBOCAN 2012. Int J Cancer. 2015; 136: E359–E386.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero
new HIV infections, zero discrimination and zero AIDS-related deaths.
UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNES-
CO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by
2030 as part of the Sustainable Development Goals.
FFFFF
6
Prof John-Paul Bogers, Coordinator of the WAKA-HPV Project:
A promising public and private approach at regional level
As a coordinator of the WA- in Africa, African countries
KA-HPV program and an will increasingly introduce
experienced pathologist, Pr HPV vaccines into their na-
John-Paul Bogers, of the Uni- tional immunization pro-
versity of Antwerp, in Belgium, grams. Therefore, they need
explained how this promising baseline data on the locally
multi-country program was set existing HPV types. Howe-
up, its evolution and impact, ver, most of those countries
the successful factors needed lack comprehensive and valid
to reach its objectives, as well data on this issue. In addition,
as the way to go forward. Africa may also host various
unexplored types which are
The WAKA - HPV Program is designed to: uniquely founded in various cancers and benign
• set up a HPV reference centre; lesion. Countries such as Uganda and Kenya which
• establish a HPV research network within have documented HPV infections have benefitted
the African region - taking VLIR-UOS, from collaborative work with Northern countries.
the Flemish Interuniversity Council’s collaborations “In Kenya, we identified specific topics to discuss
as a stepping stone. mainly about laboratories, implementing quality
monitoring in these labs and setup quality pro-
”We started this initiative in the University of grams. A priority was given to collect valid HPV
Antwerp. Since the 90s, we have been developing data to generate epidemiological information for
projects on HPV in all these countries, and so the public health purposes, monitor HPV vaccination
idea was to start talking to each other. In 2010, impact and conduct training on HPV testing and
the initial focus of the project was on infectious genotyping. As almost 90% of HPV burden is in
diseases, with various topics including HIV/HPV as low-income countries, we are in urgent need of
one of the most important, in close cooperation getting this data in order to define and steer our
with the University of Limpopo and the University interventions. Thus, we decided to talk together,
of Antwerp, where I was leading the HPV topic. to join forces and build a network”.
Based on the external reviewers, we put the focus
on Sexually Transmitted Infections, such as HPV, HPV refence center
Chlamydia, etc. As the primary goal at that time,
we decided to set up a research consortium with As a result of those preliminary steps, the WA-
laboratory facilities and public health expertise in KA-HPV program was launched to set up a HPV re-
STIs, specifically for Sub-Saharan Africa”, said Pr ference center for the region, based in South Afri-
Bogers. ca, and also to establish a research network within
African countries. “The WAKA-HPV collaboration
“We had a few Masters and PhD students, and started as a cooperation of all these countries and
one of the PhD projects was specifically on HPV. their HPV projects. It was initially supported by
PhDs can potentially drive a part of this project, as North-South cooperation grants from the Flemish
after graduation, they can reach levels where they government and European funds. In addition to
are influential and can help communities. Then we South Africa, where the program was launched,
wanted to build capacities not only in people, but it was extended to Ethiopia, Kenya, Burundi, De-
also in technical and interpretation equipment, mocratic Republic of Congo, Uganda, Zambia,
collaboration and cytology: it was some kind of and then to Malawi, and Ghana. We also started
integration as Michel Sidibé was talking about”. cooperation with Pathologists without Borders, an
Italian NGO, to strengthen the laboratory capaci-
As HPV is the main, almost unique cause of cer- ties”.
vix carcinoma in adult women and due to the The goal of this network was to exchange com-
high incidence and mortality rate of the disease plementary research projects, to standardize and
7
validate protocols and to develop multi-center ini- presentation, insisting on the need for further la-
tiatives. In order to achieve this objective, the pre-boratory capacity in both Human Resources and
liminary step was to strengthen the local laborato- laboratory equipment in Africa. “The center in
ry capacities to improve their quality. “We needed South Africa is designed to be used as a roll-out
more local molecular and cytology capacity, as and support for local initiatives, including for trai-
well as lab quality awareness, to set up laboratory nings and techniques. I strongly believe that PhD
networks and perform Immunology Quality As- students can play major roles in actually steering
sessment. Pr Bogers insisted on awareness as a the process. We’re still far away from solving the
key successful factor “We have to educate people major issue. This is why we need more political
in the laboratories but also the health care pro- support for implementation. Regarding HPV, we
fessionals, on how to handle HPV program, en- still do not really have easy testing possibilities.
dowing them with expertise on HPV testing, ge- We can do self sampling, but not self testing. The-
notyping and HPV typing in their own individual refore, we still need laboratories at the moment.
laboratories”. They can be done locally or centralized. I think lo-
cally and decentralized is a very interesting sug-
Research network gestion from the previous speaker, Michel Sidibé.
We not only still need labs, but high quality labs.
The research network organized several mee- That is my way of looking at the HPV related issue
tings. The kick-off meeting of the WAKA program as one part of the solutions”.
was held in Pretoria, South Africa, in May 2014,
with 29 delegates from sub-Saharan countries, FFFFF
Belgium, and South Africa. At this occasion, on-
going research was discussed, a standardized sur- Fourth WAKA HPV Symposium
vey protocol was defined and a platform website
was created. A three-day workshop was organized in South Afri-
ca for the WAKA HPV AFRICA network members
The second meeting was held in May 2015, in Jo- on September 22/24, 2016, with 25 invited dele-
hannesburg, to discuss previous and ongoing HPV gates of 7 countries. The symposium included a
research, share expertise, collaborate and stren- workshop on practicalities on quality assurance
gthen the WAKA-HPV AFRICA network through and quality control, and the SASGO-meeting. At
collaborations. This occasion was also an oppor- this occasion, the PhD students from each partici-
tunity to showcase the new HPV and STls training pating country presented data to be shown on the
centre for Africa with the participation of some next HPV world congress. A lot of practical issues
key world leaders on HPV. were discussed on cervical cancer research and
lab based research in Low Income Countries and
In Kinshasa, in December 2015, the third mee- academic capacity building.
ting was organized for the WAKA-HPV AFRICA
network members, invited delegates were from FFFFF
Pathologists without borders and the local Ins-
titute Supérieur des Techniques Médicale. The
focus was put on training for pathologists and
cyto-technicians. PhD students from each country
presented data on ongoing or planned research The Program WAKA-HPV Program benefits from a collabo-
projects, as well as presentations from local and rative dynamic team with Prof. Jean-Pierre Van Geertruyden
(University of Antwerp) and Jeffrey Mphahlele / Lisbeth Le-
international delegates on HPV research in their belo (University of Limpopo, in South Africa). Funded by the
institutions and countries. “Four of our PhD stu- Belgian Development Cooperation, VLIR–UOS supports the
dents have worked on HPV programs. We also WAKA HPV program as a model of partnerships between
started reference laboratories, like the one ope- universities, in Flanders and in the South, looking for innova-
ned by the Vice Chancellor of the Health Univer- tive responses to global and local challenges, including Nor-
th-South and South-South cooperation, projects and scho-
sity in Pretoria. It’s an HPV and STI training center larships.
for Africa which was also inaugurated in 2015”. www.uantwerpen.be/en/projects/waka-hpv-africa/
In conclusion, Pr Bogers made a summary of his FFFFF
8Dr Sharon Kapambwe, National Coordinator Cancer Prevention,
Ministry of Health, Zambia:
Lessons learnt from experience
Zambia has the second highest incidence of vical cancer in our country, I would really like
cervical cancer in the sub-Saharan region and to give the context of what was happening in
the sixth highest in the world. In 2003, the 2003: At that time, the physician patient-ratio
First Lady, Maureen Mwanawasa, expressed was 0.12 per1000 with only 25 gynecologists in
her worry regarding the rates of the disease the country. Even though there was a local cy-
among Zambian women amounting to as high tology-based screening, there were no cytolo-
as 30% of all types of cancer. “Other diseases gists. We had almost no screening going on, the
such as cancer need as much at- pap smears were given to women
tention as HIV and AIDS”, she with symptomatic events in public
said. As a result of her political lea- sector and at a cost in private cli-
dership, a program was launched nics”. Dr Kapambwe said before
that year to fight this disease as continuing her comments: “So we
a major public health concern. Dr had a very huge need of human re-
Sharon Kapambwe explained the sources, as far as the doctors were
progress made over the years and concerned, and there was inade-
the challenges to scale up scree- quate laboratory infrastructure for
ning and early diagnosis, such as cytology-based screening. There
inadequate number of specialists was no HPV vaccination available.
in health centres, poor infrastruc- In addition, there was an increase
ture, low laboratory capacity and lack of can- of cervical cancer cases, meaning that the
cer screening tools. Her recommendations are country had competing priorities considering
particularly inspiring for other countries. She that the HIV prevalence was 16.5%. Currently
has been working on this program since the HIV prevalence is 13.3%.”
mid 2000s and she remains equally committed
to further partnerships at regional level. Local field experience corroborates what Michel
Sidibé said regarding the crucial need for an in-
Dr Kapambwe brought to our roundtable discus- creased decentralization and integration of the
sion, her strong field experience with emphasis programs. “Between July and September 2004,
on the implementation modalities, the outco- 150 non-pregnant women accessing HIV treat-
mes and lessons learnt from the cervical cancer ment and care at University teaching Hospital
program, including the various activities of pre- the main tertiary hospital in Zambia, were offe-
vention/awareness, vaccination and treatment. red screening. From the cytological results 19%
“Given the background of the fight against cer- lesions suggestive of cervical cancer ».
Cervical cancer in Zambia in 2003:
- 6th highest in the world, Structures and human resources:
- 2nd highest in Africa, • Physician- patient ratio: 0.12/1,000
- Most common cancer in Zambia (30%), • 25 gynecologists
- Most common cancer in women ( nearly 30%), No gynecological oncology unit
- Cervical cancer screening coveragea doctor who is further away, often in the capital
See and treat city. We also use the eC3 for monitoring as with the
pictures, we can see the areas to be strengthened
Cancer among women was increasing, especially and also for evaluating the program, using the cer-
cervical cancer with 30% of all new cases (Globo- vicograms”.
can and National Cancer Registry); “We had to look
for the most appropriate way to screen women. eC3
In 2006, we started by two government-funded
health centers and then we extended the screening The pictures also help with patient education to
to other facilities with great support from Pepfat strengthen awareness and patient education as a vi-
through CDC, initially targeting HIV infected wo- tal strategy to save women’s lives, particularly in this
men ». As a result of the shortage of physicians in setting as Dr Kapambwe said: “It is especially im-
general, task-shifting was applied to make the best portant particularly that 90% of the women scree-
use of available health workforce. “Same day treat- ned for the first time, have never had a pelvic exam
ment approach was adopted. «See and Treat» to in their lives, apart from the time of their pregnancy
reduce the number of women who would not come and sometimes it is limited to the delivery. Thanks
back for the treatment. In our low-resource setting, to Ec3, women can see the pictures with the camera
the key is to integrate the cervical cancer program and a monitor which lets them know more about
into the existing infrastructure in order to really cervical cancer, and this helps a lot”.
sustain the program”.
“Be healthy, be mobile”
In that context, the method of treatment was se-
lected for it was available, low-cost, accurate and As most of the people actually live in the rural areas,
possible the same day: “We also had to develop the she insisted on the benefits of the mHealth pro-
treatment of pre-cancer lesions looking at the most gram launched in 2015, with the support of WHO
appropriate solution, low-cost and easy to imple- and ITU. Zambia is one of eight pilot countries of
ment, and so we selected cryotherapy. But cost and the so called program “Be Healthy be Mobile” for
avaibility of nitrous oxide have been challenging due testing the feasibility of mHealth to prevent NCDs,
to local constraints”. such as cervical cancer, using SMS-based campaigns.
In the lead facilities in Lusaka, nurses deliver cryo- “We have piloted sending texts messages to women
therapy to the eligible women, but those who do to ensure their access to the right information regar-
not meet the criteria have to be referred. “For wo- ding screening and treatment services”.
men in rural areas, it means going to the provincial
hospital and this has it’s own implications. So we did
As a result of the efforts, over 350,000 women have
the national scale-up in 3 phases, transitioning the
been screened for cervical cancer at least once in
services to the government. The first stage was in
their lifetime. “Our experience confirms the appro-
provincial hospitals where we established nursing
priateness of the use of mobile screening initiatives
assistance, with adequate human ressource in terms
to reach out to a large number of women. HPV
of nurses who are the backbone of the programme.
They’re also now able to do VIA and cryotherapy. vaccination has been among our greatest achieve-
ments. We’re raising the awareness in our country
The second stage is the district hospitals and finally,
the health facilities with basically the VIA and cryo-also with the help of the first Lady Esther Lungu, as
therapy techniques. No center is doing VIA only; well as political and known figures including socio-
the nurses can either do cryotherapy or thermocoa- cultural and traditional leaders who helped mobilize
gulation”. local communities. Over 30000 eligible girls have re-
ceived their doses over the first two years. Our target
In order to improve the strategies, new equipment is 20’000 girls, by the third year. The coverage is 89%
and innovative approaches have been introduced. for the second dose in 2016 which is a drastic impro-
“We used the electronical cervical cancer control vement. To reach our objectives, we strengthened
and the eC3 approach. Monitoring is important school health programs through a specific school-
especially that the nurses are located in different based type of HPV vaccination”.
parts of the country. As we’ve gone through the
country, we’ve seen that VIA is very subjective since Another key outcome is the establishment of a natio-
it depends on the examiner's experience. With the nal cancer control strategic plan 2016-2021 and the
eC3, the nurses can upload the picture and consult costing of a comprehensive cervical cancer care and
10control tool. “We prioritized four types of cancer: in their packages: Right now, even private insu-
breasts, cervix, prostate and retinoblastoma for the rance facilities inform that if women want to go for
next 5 years, in order to be really impactful and also screening, they’ll first need to consult a doctor and
looking at the burden of these cancers, in children be charged a consulting fee, and only after that
and men as well”. they can go for screening. Therefore we need to
look again at these insurance packages, including
Political backing is a key successful factor, as Dr cervical cancer prevention as a package for free”.
Kapambwe insisted while mentioning the remaining
challenges: “If we want continuity, there has to be po- Molecular testing
litical backing, and the First Lady’s office is one of the
key ones helping the cervical cancer prevention pro- This approach should help create a sustainable and
gram move forward. However government cannot coherent strategy: “We need to look at molecular
do it alone. We need partnerships at the local level, testing for further screening, but we also need to
NGOs and international level. Challenges remain, for look at alternative treatment, Zambia imports Ni-
instance pathology services are still inadequate and trous Oxide from South Africa. It’s not only about
surgical skills for early cervical cancer treatment are the cost, it’s also about the supply and when we
lacking. There’s really no way that you can achieve so don’t have it, we have women coming back for
much success without having pathological services in more visits hence the need for thermocoagulation.
So further research and treatments are crucially
any cancer control program. Internet connectivity re-
needed. In line, with our national strategic plan,
mains a challenge but we’re using as much as we can
the cervical cancer treatment program should
of it to help in quality improvement across the sites.
provide an opportunity for breast cancer scree-
It should be better. We need more funding conside-
ning and other NCDs. We also need to define
ring the number of women with cervical cancer in our
referral systems for mobile screening and have
population”. the outreach programs used only to make sure
that we’re ‘mopping up’ the women as fast as we
Dr Kapambwe recommended developing alterna- could. This is because the cancer numbers are so
tive treatment for pre-cancerous lesions methods, huge, we cannot be doing it only with screening
introducing thermocoagulation, providing surgical as it would take us so much time to reach every
oncology training and creating platforms for initiation
of breast cancer screening/NCDs.
She also insisted on the need to create an enabling Integration
environment for women to access prevention ser- of cervical cancer prevention programs into existing
vices, such as a market-based strategy with the in- infrastructure
surers. “Social insurance schemes need to include • VIA as the main approach
• Training nurses/doctors in VIA,Cryotherapy and
prevention cervical cancer and NCDs prevention
LEEP
• Thermocoagulation recently introduced
Level 1 Provincial hospitals Innovation
- Nursing schools, functioning theatre Electronic cervical cancer control/eC3
- VIA, Cryotherapy, LEEP • Point of care/data electronic data collection
• Distance consultation
Level 2 District hospitals • Monitoring and evaluation
- VIA, Cryotherapy +/- LEEP • Continuing medical/patient education
• mHealth awareness program
Level 3 Health facilities Screening
- VIA, Cryotherapy • 350,000 women screened
Treatment • Outreach/mobile screening
No surgical oncology available
- Creation of gynae-oncology unit HPV Vaccination Demonstration Project
- Over 13,000 patients seen at Cancer • 3 year HPVvaccination in selected districts
Diseases Hospital since inception in 2006 • Over 30,000 girls got 3 doses in first two years
- Cervical cancer is the most common • Targeted 20,000 in 2016 ( 89% coverage) for se-
cancer observed (a third of all cases) cond dose
- High demand/only one chemo-radiation centre • New partners and opportunities
- Chemo-radiation centres: currently • School health programs for sustainability and
centralised but decentralisation has started with two reduced cost of delivery.
more chemoradiation planned. • Planned submission to GAVI for national roll out.
11woman. Our Government is fully committed been able to leverage international support and
towards expanding access to cervical cancer resources from PEPFAR and others. Global fund
treatment and care services in all the districts has not yet started releasing funds but allowed
by 2021. Cooperation between countries is very Zambia to include cervical cancer. Final approval is
commendable. It provides us with opportunities expected and then funds will be available through
to learn from each other, creating synergies and Global Fund.
further collaborations. At the regional level, Zam-
bia has already trained over 300 healthcare pro- This will help expand the cervical cancer pro-
fessionals from 14 countries”. gram and integrate it into the health care system
without placing extra burden on it, thus maxi-
Zambia has been a flagship country for the Pink mizing the potential of the “screen and treat”
Ribbon-Red Ribbon Initiative to scaling up scree- approach. This experience should be of great
ning services, HPV vaccination and supporting value to other countries in the region facing the
the Cancer Registry, since 2011. The country has same challenges.
FFFFF
Christine Kaseba-Sata, former first Lady of Zambia
“Cervical cancer is critical and becoming a crisis.
Deaths due to cervical cancer are projected to rise
by 20% by 2020. We need to move as quickly as
we can.”
FFFFF
Strategic plan – Prioritised four types of cancer (Breast, Cervix,
NCDs Strategic plan 2013-2016 Prostate and Retinoblastoma)
– Guidelines on NCDs Office of Registrar created
– Management of NCDs • Supported by NCI up to 2016, govern
– Training of health workers ment onwards
• Not yet population based but enhanced
National Cancer Control strategy operations
– Pilot done on with WHO Costing of comprehen- • Critical for evidence creation and policy
sive cervical cancer care and control tool making
12Curtis Peterson, VP Global Health MobileODT:
Improved screening for cervical cancer by leveraging the power of mobile phones
“No woman should die from cervical cancer. If in low resource settings such as Kenya”.
detected early, cervical cancer can be prevented
and existing early-stage cervical cancer is trea- Apart from Kenya, the Enhanced Visual Assess-
table. MobileODT is committed to bringing ment System is currently being used globally in
mobile cervical cancer screening technology to over fifteen countries, including Nicaragua, Haiti,
all women, everywhere, by producing solutions and Ethiopia. “In Kenya, on February 4th 2016, to
like the EVA System and by continually suppor- mark World Cancer Day, we helped to screen over
ting our partners to strengthen their programs 200 women for cervical cancer in one day”.
and extend their reach”. Curtis Peterson shared
information on the MobileODT’s EVA System, The hardware includes a lens, light source, and an
which uses a low cost, portable colposcope to integrated mobile phone (currently only compa-
strengthen all cervical cancer screening (and treat- tible with the Android operating system). Health
ment) programs, including those using VIA, VILI, providers use the device to visualize the cervix
HPV, and/or Pap. from a distance of approximately 15 centime-
ters. Providers use the EVA Sys-
Experience has shown that large- tem software application to cap-
scale screening of pre-cancerous ture images. Through cellular or
lesions with cytology is difficult to wifi connectivity, providers at the
scale in low- and middle-income point-of-care can send the images
countries due to the lack of spe- to their peers or supervisors for a
cialists and infrastructure. Visual second opinion. Images and pa-
inspection with acetic acid (VIA) is tient information are also uploaded
an inexpensive alternative but sub- to a secure online portal that faci-
jective since it depends on the exa- litates remote image analysis and
miner's competency. Historically, explanations on how to improve
training and supervision for front- diagnosis and treatment.
line health workers performing VIA
has been resource-intensive and sporadic. There- “The use of mobile colposcope along with smart
fore, mobile telemedicine is a very promising tool phones for services, training and collecting data is
in order to support health-care workers performs a real innovative approach to help cervical cancer
cervical cancer screening. screening especially in rural areas. The hardware
and decision support tools within the EVA System
This is why Mobile ODT is promising to boost cer- can reinforce existing programs, like VIA as well
vical cancer screening with the introduction of an as HPV vaccination. Another advantage is that it’s
inexpensive and non-invasive hand-held device possible to better identify risky cases, to avoid
that can help detect early signs of the disease. unnecessary surgery and biopsy, while improving
“The device can be used by nurses and midwives standard data collection, and real time control
conducting VIA with minimal training.” said Mr analysis and evaluation”.
Curtis Peterson. “So our device is most popular
Mobile ODT is: • A lightweight and durable medical device, rechar-
• A mobile colposcope with a reliable light source and geable, with long-lasting battery for up to 10 hours
a powerful lens for enhanced visualization. of continuous examinations.
• A secure application for patient image and data cap- • Information and patient data are securely stored in the
ture for remote consultation, patient tracking, and online portal for designated people to:
referral coordination. • Review patient information and screening decisions
• An encrypted online portal which safely stores for quality monitoring and evaluating as well as analytics.
infomation for real-time program monitoring and • Provide remote clinical supervision and quality assu-
case management. rance.
• API access for electronic medical records systems.
13Dr Anne-Caroline Benski, Obstetrician/gynecologist,
University Hospital of Geneva:
Innovative Mobile Health System for HPV screening in low-income countries
Geneva University Hospitals (HUGs) are the first that, we screen, treat and follow-up on the same
university hospitals in Switzerland and interna- day, insuring a good quality assessment”.
tionally recognized reference. HUGs also act
globally to promote universal access to health- With this objective in mind, the project was
care, in close collaboration with international designed to enable the use of smartphones to
Geneva's organizations such as the WHO. The assist health-care workers and to evaluate the
support to African countries to improve wo- diagnostic reliability and accuracy of cervical exa-
men’s access to cervical cancer screening and mination with smartphone photos of VIA (D-VIA)
care is in continuity of its humanitarian tradi- compared to conventional VIA for women tes-
tion. HUGs contribute to promote early dia- ting positive for HPV. Based on the results, an
gnosis and treatment taking advantage of the educational training and quality assurance pro-
availability of new technologies. gram for health providers for VIA was developed
to scale-up cervical cancer control. The triage by
Dr Anne-Caroline Benski explained her expe- VIA has helped reduce not only an excessive re-
rience through two ongoing pilot projects in Ca- ferral rate but also an excessive treatment delay,
meroon and Madagascar, with an giving the possibility of a "screen
emphasis on process, new tools, (HPV), see (VIA/D-VIA), and treat
and outcomes. As a result, 3000 program” in a single visit or two.
women have been screened and
treated. She also acknowledged “The VIA exam helps us decide
the benefits of mHealth in sca- if we’re going to treat the case
ling up awareness campaign via or not. If the exam is patholo-
text messaging, diagnosis as gical then we decide to do the
well as quality control through thermal coagulation. The device
Electronic Medical Records. used is practical, requiring 60 se-
The methodology developed by conds at 120 degrees, electricity
HUGs is comparable to the Mo- is needed, but it’s a very simple
bile ODT. The pilot projects are device. We also use HPV/DNA
still going on to screen and treat test, followed by the thermal
women in the two countries. A new study of coagulation. We treated HPV 14, 16 and 18, and
mHealth data collection system for women par- the results showed that it was a good solution.
ticipating in a cervical campaign in Madagascar It’s a one-day “screen and treat”, we don’t need
has been launched with a group of 150 patients, to contact the women afterwards, and we also
between June and September 2016. sensitize them at this occasion. For the moment
we’ve been doing both Genexpert and doctor
In those countries, as the previous speaker said, sampling as well as the biopsies and quality
there is a need to focus on low screening and controls too. We’ve been doing questionnaires
loss of follow-up. Dr Benski confirmed this posi- on qualitative and quantitative results and we
tion: “Our program started 10 years ago. One of have very good feedback from the women, pa-
the biggest problems our University found in de- tients and health professional. In the end, a lot of
veloping countries was the use of the Pap smear women, at least in Madagascar, started coming
test, with the delivery of the results of 1-2 weeks, again as they were not stigmatized because
inducing the loss to follow-up. We thought that of HPV results. When they came to the health
it wasn’t ethical to practice screening if we can’t centers, they thought they were going to have
guarantee treatment. Therefore, we decided to surgery to remove their uterus. We explained
apply the C- Entry strategy using m-health to to them what we do and how they can do it
provide mobile phone awareness text-messa- themselves in their settings, showing them the
ging, diagnosis and electronic medical records. images, which made our experience successful.
We wanted to avoid the loss to follow-up, so The electronic medical records were appropriate
14for assessing the quality of care and providing training to increase local capacities for using
relevant statistics for academia. The personal colposcopy.” The tool we used is a very simple
information and other data are uploaded in the image/icon-based application, with a simple per-
cloud medical unit to be used from anywhere sonal form, allowing task-shifting in order not
with an access code. The results of the genXpert to rely on the gynecologists, but just get their
test can be compared and analyzed. The project backup in the nearest health centers, to secure
demonstrated that it is an easy process to imple- quality control. We also intend to bypass the
ment with a high capacity of about four exams pathologists, because, as I said, the idea of our
per hour”. treatment is not to use the cytology test in this
case, just HPV/DNA test and the VIA/VILI on
“First, we developed a smartphone application, the same day. The process with self-sampling
like the ODT or similar to it, to help the diagno- can be extended to rural areas, along with awar-
sis on VIA and VD exam. Then, we looked at eness on cervical cancer and all the STDs, being
the cervical cancer prevention system, which is analyzed on the same day. It is easy and cost ef-
an application to provide the electronic records fective, about 5 cents per sampling”.
and to guarantee the quality assessment of our The device uses any kind of smartphone and a
entire strategy. The first one is called ‘exam’ and 2-3 day training program is provided to explain
the second is called one ‘cc-piece’. We took the how to use the smart phone device and the pho-
images during the exam, they’re not for gyneco- tography for recognizing pathological lesions
logists, but for nurses or midwives with a backup automatically. In addition, the HUG’s team is
control in Switzerland, France or UK, to review working on a mobile clinic, with specific equip-
the images and provide real-time advice about ment, including a gynecological chair to increase
the treatment. We also used these images for the outreach of the greatest number of women
academic information, for further analysis and in rural areas.
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Since 2010 the Department of Gynecology and Obstetrics dé, Cameroon), made it happen supported by the Natio-
of HUG has organized successful workshops with their Ca- nal Committee for the Fight against Cancer in Cameroon
meroonian partners on prevention and screening of cervical and the Ministry of Public Health. First, an inventory of the
cancer, colposcopy, management of pre-invasive lesions knowledge concerning cervical cancer among women and
and vaccination against HPV. health professionals was established by two doctorantes
from Geneva, followed by two Master students on the ac-
The collaborative program dates back to the early 2000’s. In ceptability among women of testing for HPV, using two
2001, HUG along with 3 Cameroonian doctors, two patho- procedures: self-sampling by the woman herself, or sam-
logists and one gynecologist, previously trained in Geneva, pling by a health professional. The work revealed the wide
examined the feasibility of a cytology-based cancer scree- acceptance of self-sampling and the importance of proper
ning in a rural area. In 2008, Pr Patrick Petignat (HUG) and information of women before undergoing the procedure.”
Dr Pierre-Marie Tebeu (University Hospital Center in Yaoun-
FFFFF
Using a smartphone to:
- Access Visual Inspection Acetic Acid (VIA) • Provide training:
and Lugol’s lodine (VILI) o Review images after pathology results,
- Scale up cervical cancer screening and treatment o Academic tool
Cancer (Cervix Prevention System) • Scale up awareness and prevention
• Optimize the quality control of the diagnosis: o Large outreach in rural areas.
o Reviewing the images, o Cost effective
o comparing VIA and VILI,
o having expert opinions
15Dr Ophira Ginsburg, WHO:
The new UN Global Joint Program for Cervical Cancer Prevention and Control
Dr Ophira Ginsburg is a medical oncologist But we need engagement with all partners and
with expertise in cancer epidemiology, preven- high political commitment. Pilot countries in
tion and screening, and a primary focus in wo- each WHO region will be selected through a ri-
men’s health equity and global cancer control. gorous process. We will not be able to fund the
She joined WHO in 2015 to build policy and implementation of all the activities directly, but
programs for women’s cancers, which include we will assist countries in prioritizing and costing
guidance, recommendations, and implemen- activities, while finding ways to access the addi-
tation frameworks on cancer early detection/ tional resources needed through domestic and
screening and management in collaboration international sources, and through innovative fi-
with the WHO International Agency for Re- nancing mechanisms. This is why we’re going to
search on Cancer (IARC), the International Ato- need a lot of collaborative work, with academia,
mic Energy Agency (IAEA,) and other interna- with civil society, etc. We will organize a donor’s
tional partners. conference soon, to kick start the programme
and get the full support from
Dr Ginsburg’s contribution was the international community”.
a great highlight of the round
table discussion as she spoke As a response to what Dr.
about the new UN joint program Kapambwe said about the tech-
on cervical cancer under the nical constraints of the cryothe-
umbrella of the UN inter-agency rapy, especially the challenging
task-force for NCDs to eliminate availability of the gas needed,
cervical cancer as a public health Dr Ginsburg underlined the im-
concern by 2025. portance also of adequate ca-
pacity to treat invasive cervical
“We’ve signed a memorandum cancer. Invasive cervical can-
to provide a framework to assist cer requires more specialized
countries with technical assis- personnel and equipment, and
tance at all levels, from national often includes all three cancer
cancer control, national cervical cancer control, treatment modalities: surgery, medicines (che-
planning and implementation, with the support motherapy), and of particular importance to
of seven UN agencies: IARC, IAEA, UNAIDS, this cancer, radiotherapy. This is why the role
UNFPA, UNICEF, and UN Women”. She des- of the International Atomic Energy Agency is
cribed the purpose of the program, to provide so critical in cervical cancer control, particular-
technical assistance to help countries implement ly in sub-Saharan Africa where resources are
comprehensive cervical cancer programs, inclu- so profoundly limited. “Talking about activities
ding primary prevention with HPV vaccination, from primary and secondary prevention through
screening and treatment. All guidance for scree- to treatment, there is a piece often missing in
ning and treatment are aligned with the WHO the discussions, but I’m glad it came up already
“Comprehensive Cervical Cancer Control: gui- today in our discussions, that is, radiation. The
delines for essential practice, Second edition” IAEA has such an important role to play in terms
also known as our “Pink Book” *, produced in of cancer guidance with radiation safety and also
collaboration with international experts and pu- technical cooperation for radiation medicine.
blished in late 2014”. In the case of cervical cancer, there are certain
phases that are curable if it is radiated properly
Dr Ginsburg is confident towards reaching the within the timeframe; otherwise we need surge-
objectives: the UN joint program will create the ry, plus/minus chemotherapy”.
enabling environment internationally and more
importantly locally: “A comprehensive cancer Regarding what Michel Sidibé said about the in-
control should be possible in many countries. tersection of HIV/HPV and cervical cancer **, Dr
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