Transcript Single visit approach - IARC Screening Group

Moving from Research to Practice:
Expanding Cervical Cancer Prevention in
Low Resource Settings
Harshad Sanghvi
Medical Director, JHPIEGO
Continuum of Care for Cervical Cancer
Control
15 years
Vaccination
Source: WHO 2006
30 years
Screening and
treatment
45 years
Cancer
treatment
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SINGLE VISIT APPROACH:
STEPS
1 Counseling
2 Speculum Exam to see
Cervix
3 Apply 3-5 % Acetic Acid
to Cervix
4 Inspect Cervix for
acetowhite lesions
5 Discuss results with the
woman. Offer
treatment option if
positive
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SINGLE VISIT APPROACH:
STEPS
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Speculum exam to re-view cervix
Apply Cryoprobe and freeze for 3 minutes
Defrost for 5 minutes
Re-freeze for 3 minutes
Post treatment and followup instructions
Cryotherapy
Before and After
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Results of CECAP SAFE study
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5999 clients recruited in 9 months, 58.6% at village health
centers
Of the 798 (13.3%) VIA positive, 738 (92.5%) received
cryotherapy
An additional 18/51 women classified as indeterminate
received cryotherapy
Of 4 suspected cancers, 1 was confirmed.
4.4% of women made an unscheduled post treatment visit,
2.2% requiring minor treatment
No major complication was noted
Correlation between Nurses and Gynecologists on VIA
finding and treatment decision was 93% and 92%
respectively
Source RTCOG/JHPIEGO Cervical cancer prevention group: The Lancet, March 2003
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Thailand Results to Date
Upto March 2006, approximately 180,000
women in age group (30-45 yrs ) tested
with VIA
8-10% of those women offered treatment
with cryotherapy
2.2 % minor complication rate. No major
complications
Thirteen provinces now using this approach
and women highly satisfied with decision to be
tested
Some districts now approaching 50% coverage
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CERVICARE Program: Ghana
Problem
• Screening largely unavailable
• Treatment of precancer available only at
large hospitals
Intervention
• 8 rural midwives trained in visual inspection
and cryotherapy: the single visit approach.
SVA fully integrated in RH services
Result
• Over 48 months, 19,326 women have been
tested
• 1456 (91.7%)received cryotherapy
immediately or return visit
• 16 cervical cancer patients identified
(downstaging)
CECAP Program, JHPIEGO 2004, and
Sylvia Deganus, Sydney Adadevoh, Ghana
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COUNTRY RECEPTIVENESS
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Dr. Kobchitt Limpaphayom, CECAP Director
for Thailand with former Permanent
Secretary of Ministry of Public Health Dr.
Vallop Thaineua and Provincial Health
Director Dr. Kamron Chasiri at a 2004
dissemination meeting in Cha-am, Thailand
Identify and Nurture
Support from Key
Stakeholders
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Professionals
Public Sector
Civil Society
Organize action group to
champion Cervical Cancer
Prevention
Establish a network of
multi-sectoral advocates
Develop and implement
awareness campaign
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Capability Development: Site Selection
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Establish selection criteria
• Political Commitment
• Management support
• Personnel to train
• Access to referral
center
• Minimum infrastructure
• Geography
• Client base
Conduct site visits
Recommend sites
Assessment team conducting
a visit to a
rural health center in Malawi
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Capability Development: Demand
Generation
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Communication campaign
• Develop targeted messages
• Integrate CECAP message
into General Health
Messages
• Multimedia Coverage
Community Outreach
• Community events
• Educational talks within
health facility
• Outreach activities by
health facilities
• Referral from other health
services
Community Durbar Festival held in
Rural Ghana to raise awareness
about cervical cancer prevention
services
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Capability Development: Human
Resources
VIA and cryotherapy course
for new service providers in
Kumasi, Ghana
Develop cadres of:
• Local champions capable of
advocating for cervical cancer
prevention at the local,
regional/provincial and national
levels;
• Trained Service providers to deliver
screening and treatment;
• Clinical Supervisors who can provide
quality assurance and manage
referrals; and
• Local (regional/provincial) training
teams to conduct training courses,
maintain quality and ensure
adherence to performance standards.
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Capability Development: Training
Training Step 1
• Conduct 3-day VIA and Cryotherapy clinical skills course
for physician supervisors
• Conduct 10-day VIA and Cryotherapy clinical skills
course for service providers
Training Step 2
• Conduct Clinical Training
Skills course to develop 1st
generation clinical trainers
• Conduct Advance Training
Skills course to prepare
Thai nurses practice clinical skills during a
training session.
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Capability Development: Service Delivery
Model
Step 1: Service Site Preparation
• Physical and environmental setup
• Equipment and instruments
• Supplies
• SOP
Step 2: Service Provision
• Operational Time
• Record Keeping and
Retrieval
• Use of Performance
Standards
• Monitoring
Ghanaian provider practices clinical skills
during a training course.
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Supporting High Quality Program
Performance
• Functional health information system for
cervical cancer;
• Responsive referral system;
• Operational Repair and Maintenance
Center;
• Sustainable Quality Assurance process;
• Defined monitoring and evaluating program
indicators
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Are the Limitations of the
Solution Acceptable
Selected Key Conclusions: Alliance For Cervical
Cancer Prevention (ACCP)
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Prevention programs based on visual screening
or HPV testing can be cost effective
Cryotherapy is a safe and effective method and
can be delivered by a range of health providers,
including non-physicians.
The single visit (screen-and-treat) approach is
safe and effective in low resource settings. This
is a major paradigm shift in cervical cancer
prevention
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Are the Limitations of the
Solution Acceptable
ACOG/SOGC/RCOG/FIGO Policy Statement
•Validates the “single-visit approach,”
which links a detection method with an
immediate management option, as a safe,
acceptable and cost-effective approach to
cervical cancer prevention
•Calls for obstetric-gynecologic
organizations worldwide to advocate for
sustainable cervical cancer prevention
programs
Obstet Gynecol, March 2004
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