Population-level scale-up of cervical cancer prevention services in a low-resource setting: development, implementation, and evaluation of the cervical cancer prevention program in Zambia

Abstract

Background: Very few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries.

Methods: In a public sector cervical cancer prevention program in Zambia, nurses provided visual-inspection with acetic acid (VIA) and cryotherapy in clinics co-housed with HIV/AIDS programs, and referred women with complex lesions for histopathologic evaluation. Low-cost technological adaptations were deployed for improving VIA detection, facilitating expert physician opinion, and ensuring quality assurance. Key process and outcome indicators were derived by analyzing electronic medical records to evaluate program expansion efforts.

Findings: Between 2006-2013, screening services were expanded from 2 to 12 clinics in Lusaka, the most-populous province in Zambia, through which 102,942 women were screened. The majority (71.7%) were in the target age-range of 25-49 years; 28% were HIV-positive. Out of 101,867 with evaluable data, 20,419 (20%) were VIA positive, of whom 11,508 (56.4%) were treated with cryotherapy, and 8,911 (43.6%) were referred for histopathologic evaluation. Most women (87%, 86,301 of 98,961 evaluable) received same-day services (including 5% undergoing same-visit cryotherapy and 82% screening VIA-negative). The proportion of women with cervical intraepithelial neoplasia grade 2 and worse (CIN2+) among those referred for histopathologic evaluation was 44.1% (1,735/3,938 with histopathology results). Detection rates for CIN2+ and invasive cervical cancer were 17 and 7 per 1,000 women screened, respectively. Women with HIV were more likely to screen positive, to be referred for histopathologic evaluation, and to have cervical precancer and cancer than HIV-negative women.

Interpretation: We creatively disrupted the 'no screening' status quo prevailing in Zambia and addressed the heavy burden of cervical disease among previously unscreened women by establishing and scaling-up public-sector screening and treatment services at a population level. Key determinants for successful expansion included leveraging HIV/AIDS program investments, and context-specific information technology applications for quality assurance and filling human resource gaps.

Fig 1. District-level expansion across provinces in Zambia (2006–2014) and projected (in 2016) of the Cervical Cancer Prevention Program in Zambia (CCPPZ).

Fig 2. Clinic-level expansion in the Lusaka province (2006–2014) of the Cervical Cancer Prevention Program in Zambia (CCPPZ).

Fig 3. Performing VIA-based screening augmented by digital cervicography in the clinics of the Cervical Cancer Prevention Program in Zambia (CCPPZ).

Notes: Nurses in CCPPZ clinics initially perform screening using VIA, after which they use a commercial brand (off-the-shelf) hand-held digital camera ( Upper Panel) to take photographs of the cervix (cervigrams). Cervigrams are then displayed on a bedside television or camera monitor in real-time (Middle Panel), permitting magnification and detailed examination of lesion morphology, including size, margin sharpness, proximity to the transformation zone, degree of extension into the endocervical canal, abnormal vasculature (mosaicism, punctations, atypical blood vessels) and gross characteristics suspicious for ICC. Cervigrams are routinely shown to and discussed with patients during the screening procedure after which they are uploaded by nurses to a clinic computer where they can be (i) electronically transmitted using cellphone network lines to off-site experts (after deidentifcation) for rapid distance consultation (telecervicography), when necessary, (ii) batched and later routinely peer reviewed to form the basis of a rigorous ongoing continuing education and quality assurance program, and (iii) stored with the patient’s electronic medical record. Relevant cervigrams are transmitted by screening nurses to the referral clinic by email, after deidentification, where they are accessible by consultants at the time of patient visits. (Lower Panel).

Fig 4. Images of VIA negative, VIA positive-cryotherapy eligible and VIA positive-cryotherapy ineligible lesions from women undergoing screening in the Cervical Cancer Prevention Program in Zambia (CCPPZ).

Notes: Using the following criteria, CCPPZ nurses classify VIA tests results as VIA negative, VIA positive eligible for local ablation with cryotherapy, or VIA positive ineligible for cryotherapy requiring physician evaluation.

1. VIA negative: Absence of an acetowhite lesion with at least one distinct border (Top Panel, Left)

2. VIA positive, eligible for cryotherapy: Acetowhite lesion with at least one distinct border, located within or adjacent to the transformation zone, that: occupies <75% or <3 quadrants of the surface of the ectocervix, is completely visualized, can be completely covered by the largest available cryoprobe tip, has no evidence of abnormal vasculature (punctations, mosaicism, atypical blood vessels) and is not suspicious for ICC (Top panel, right)

3. VIA positive, ineligible for cryotherapy: Acetowhite lesion with at least one distinct border, located within or adjacent to the transformation zone, that has any of the following characteristics:

   1. Occupies ≥3 quadrants or ≥75% of the surface of the ectocervix (Middle panel, left)

   2. Has evidence of abnormal vasculature (punctations, mosaicism, atypical blood vessels) (Middle panel, center)

   3. Cannot be completely covered by the largest available cryoprobe tip (Middle panel, right)

   4. Is suspicious for invasive cervical cancer (Bottom panel, left)

   5. Extends into the endocervical canal beyond complete visualization (Bottom panel, right)

Fig 5. Program process and outcome indicators of the Cervical Cancer Prevention Program in Zambia (CCPPZ).

Panel A (Top, left): Trends in HIV status of screened women over the calendar years 2006–2013. Panel B (Bottom, left): Rates of screening positivity, cryotherapy eligibility and cryotherapy-ineligiblity by age categories and overall. Panel C (Bottom, right): Trends in rates of screening positivity and cryotherapy rates over calendar years 2006–2013. Panel D (Top, right): Trends in rates of ‘same day-services’ and rates of ‘appropriate referral’ over calender years 2006–2013.