Cervical Cancer Screening and diagnosis do not occur in the same facility
"Women are referred to a gynaecologist at a higher facility; this is a major reason for loss to follow-up". Dr. Suneeta Krishnan shares with PatientsEngage her findings and recommendations of the implementation science research project to promote the adoption and effective scale-up of cervical cancer prevention in India.
1. According to you, which screening method is the most cost-effective?
According to the World Health Organization (WHO), screening for cervical cancer through visual inspection and treatment of precancerous lesions is a cost-effective intervention and a “best buy.” However, it is important to keep in mind that costs and effects vary depending on how an intervention is implemented, on context, and scale of implementation.
2. According to you, which screening method is the most practical?
In many settings in India, visual inspection-based screening by frontline health workers such as nurses is the most practical approach. As noted by WHO and others, once a system for screening has been established and as laboratory infrastructure is improved, a better performing test – HPV test – can be introduced.
3. What are the challenges faced by the HPV vaccination program?
Cost and financing mechanisms are a major challenge. Vaccines are expensive but India has just entered into a new strategic partnership with GAVI, the global vaccine alliance, which also includes support for introducing the HPV vaccine. Additional challenges, include limited information and misconceptions about the vaccine and cervical cancer prevention among many key stakeholders including policy makers, community members and health care providers.
[For more HPV vaccines in India, click here ]
4. Are vaccines prices likely to go down or be subsidized for the marginalised community?
In light of the new strategic partnership with GAVI, it appears that vaccines will become available through the public health system to economically disadvantaged, marginalized communities.
5. A modeling study recommended screening adult women two to three times per lifetime in addition to administering pre-adolescent vaccination, and found that this combination (assuming 70% coverage for both strategies) yielded a 56% to 63% reduction in cancer incidence . Is this a possible model to adopt in India?
This is absolutely the kind of approach that India will need to adopt – offering screening to adult women now, and substantially reducing the numbers of women at risk for cervical cancer in the future by offering vaccination to adolescents.
6. The Oncologist paper mentions the need for “identifying best practices in quality assurance” in pre- and post-screening practices. Can you elaborate on that?
Please see the World Bank HNP Knowledge Brief (see file attachment below) on promoting quality cervical cancer screening and treatment. Our review indicated that high quality screening programs are women-centered, implemented by competent staff, robustly linked to diagnostic and treatment services, and adherent to implementation standards. Tools have been developed to facilitate on going assessment and improvement service quality such as COPE. Screening efforts outside of research settings in India are largely focused on implementation and coverage – important issues but quality assurance is critical for ensuring impact.
7. What are the lessons (good and bad) to be learned from the Tamil Nadu project?
The TN project has demonstrated that implementing cervical cancer screening in India at scale (state-level) is feasible. The project has also shown that a systematic approach to implementation is critical to success. This approach includes assessing state and local level needs, implementing the program as a pilot/demonsration project and refining the plan based on experiences, and developing operational guidelines and protocols and a human resource plan during the planning phase. The project has also shown that a comprehensive strategic communication strategy is essential – for example, to facilitate mobilization of women and create demand for services and improve provider-patient communication so that diagnostic and treatment follow-up rates increase. Overall, the project highlights the common challenges of implementing cervical cancer screening – ensuring linkages between different levels of health care (primary, secondary and tertiary), assuring adequate and competent human resources are retained, establishing robust monitoring and evaluation systems.
8. What caused the low outcome of results and follow-ups in brief?
A few challenges were faced: ensuring that all the infrastructure and human resources were in place to offer diagnosis and treatment; having strong mechanisms for promoting follow-up – human resources, community awareness and support, and possibly financial incentives. Screening and diagnosis do not occur in the same facility when screening happens at the primary care level. Women are referred to a gynaecologist at a higher facility; this is a major reason for loss to follow-up.
9. Is the project being improved and scaled up to cover the entire state of Tamil Nadu? What is the estimate date of implementation?
Yes, the project has been strengthened based on the experiences of the two district pilot and has already been scaled across all districts of Tamil Nadu.
10. Do you think the government needs to play a bigger role in Cancer screening in India?
The Tamil Nadu experience demonstrates that the government can play a major role. Governmental role is key to ensure equitable access to these services. Women living in remote areas, who are marginalized and disadvantaged rely on public health services.
11. Anything else you would like to add?
Although it is key for the government to take a leadership role in promoting cancer screening, large scale coverage and impact can be achieved only through partnerships between the government and other stakeholders. For example, a key potential stakeholder is the Federation of Obstetricians and Gynecologists of India (FOGSI) which has a large membership across the country of private practitioners; these practitioners are well positioned to conduct screening and diagnosis. Working with non-governmental organizations will be key to raising awareness and addressing fear and stigma related to cervical cancer in the community, and creating demand for screening services.
Related article: Does HPV vaccine prevent Cervical Cancer?
Dr Suneeta Krishnan is a social epidemiologist at RTI International and country director for its India subsidiary, Research Triangle Institute Global India Private Limited. In recognition of her research and community service, Dr Krishnan received the 2004 U.S. Presidential Early Career Award for Scientists and Engineers. Dr Krishnan holds a doctorate and master's degree in epidemiology from the University of California at Berkeley.