Friday, June 27, 2014

Cervical Cancer Screening in Haiti

Over the past two decades, numerous reports1-5 have promoted technological solutions to cervical cancer prevention in under resourced areas, i.e. HPV testing vs. cytology vs. visual inspection with acetic acid (VIA). Medicine For Peace has screened more than three thousand women at the Alma Mater Hospital and in rural dispensaries in the Gros Morne region in northwest Haiti. We have used the VIA (screen and treat) method, and have concluded that the success of a cancer screening program has less to do with the technology employed than with addressing systemic deficiencies in health care delivery, and in overcoming socio-economic obstacles resulting from deeply rooted poverty. We suggest a number of critical activities that can facilitate a successful cervical cancer screening campaign, and concurrently raise the level of health care delivery.

·    Educate continuously. There is a cohort of women who present for cancer screening immediately. However, the majority is recalcitrant, and will only respond to innovative, continuous cancer awareness education. We promote our cervical cancer screening before women’s groups, in churches, in the market, on the radio, and by public announcements in villages using a megaphone. The message is specifically directed to cervical cancer prevention, but broadly encourages women to take responsibility for their own health.

Intermittent education programs promoting periodic screening are inadequate in impoverished, high risk areas.

·    Build an infrastructure. Establishing a consultant referral network and providing transportation for patients to access that network are key components of a successful program. Skilled cyto-pathologists, radiologists, and cancer surgeons, all within travelling distance, should be incorporated into the program. When local expertise is needed, but not available, e.g. palliative care, we have assumed that responsibility.

Reliable transportation of patients and specimens is part of the infrastructure, and when patients are too ill to take public transportation, we provide them access to the hospital ambulance. Funds are budgeted in the screening program to pay for transportation, tests, consultations, medication, and surgery.

In order to minimize the number of patients lost to follow-up, we have developed a computer-based tracking system so that we aware of the dates of patient return visits, as well as pending laboratory results, and consultation reports.

·    Promote women’s health, not just cervical cancer prevention. In addition to colposcopy, a medical history, a complete physical examination, and screening for STI’s are performed. All patients with STI’s are treated immediately, and patients are referred to specialists when necessary. The screening visit is an opportunity to educate women on leading a healthy life style, also. To insure a high level of care, it is important to develop a working clinic manual containing a set of screening and treatment algorithms that are understood and agreed upon by all physicians and nurses working in the program.

·    Don’t presume you are saving lives: keep statistics. We maintain patient data on spreadsheets to assess disease incidence, complication rates (after cryosurgery), and patient compliance and follow-up. The database is shared with the hospital’s AIDS program so all HIV+ women are scheduled for periodic colposcopic exams. We periodically biopsy aceto-white lesions before cryosurgery to confirm our clinical diagnoses are correct. All new patient charts are reviewed by a senior staff member every three months. Since most rural health facilites do not have rigorous quality control, a well designed and implemented cancer screening program is an opportunity to encourage other health providers and hospital administrators to institute hospital wide quality assurance measures.

In summary, a successful cervical cancer screening program should not only lower cancer incidence rates, but bring large numbers of women into the health care system and improve the level of health care they receive.

We declare that we have no competing interests.

Michael V. Viola, Clarice Carroll

Medicine For Peace, Washington, DC, 20015, and Alma Mater Hospital, Gros Morne, Haiti

  1. Ferlay J, Shin HR, Bray F, et al. Estimates of world wide burden of cancer in 2008:GLOBOCAN 2008. Int J Cancer 2010: 127:2893-2917.
  1. Sankaranarayanan R, Esmy, PO, Rajkumar R, et al. Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomized trial. Lancet 2007: 370: 398-406.
  1. Burns A, Sanghvi H, Lu R, et al. Saving women’s lives from cervical cancer. Lancet 2011: 377:1318.
  1. Sankaranarayanan R, Neme BM, Shastri SS, et al. HPV screening for cervical cancer in rural India. N Engl J Med 2009; 360: 1385-1394
  1. Goldie S, Gaffican L, Goldhaber-Fiebert J, et al. Cost effectiveness of cervical cancer screening in five developing countries. N Eng J Med 2005; 353: 2158- 2168.