Other > Journal Blog
Lancet Global Health. 2017 November 10
Fotheringham C
Lancet Global Health. 2017 November 10
Journal Article > ReviewAbstract Only
BMJ Sex Reprod Health. 2022 November 7; Volume 49 (Issue 2); 118-128.; DOI:10.1136/bmjsrh-2022-201526
Nicholls EJ, McGowan CR, Miles S, Baxter LM, Dix L, et al.
BMJ Sex Reprod Health. 2022 November 7; Volume 49 (Issue 2); 118-128.; DOI:10.1136/bmjsrh-2022-201526
BACKGROUND
Most cervical cancer can be prevented through routine screening. Disparities in uptake of routine screening therefore translate into disparities in cervical cancer incidence and outcomes. Transmasculine people including transgender men experience multiple barriers to cervical screening and their uptake of screening is low compared with cisgender women. Comprehensive evidence-based guidelines are needed to improve cervical screening for this group.
METHODS
We searched for and synthesised clinical and programmatic guidelines for the provision of cervical screening for transmasculine patients.
FINDINGS
The guidelines offer recommendations addressing: (1) reception, check-in and clinic facilities; (2) patient data and invitation to screening; (3) improving inclusion in screening programmes; and (4) sexual history taking, language and identity. Guidelines offer strategies for alleviating physical and psychological discomfort during cervical screening and recommendations on what to do if the screening procedure cannot be completed. Most of the guidelines were from and for high-income countries.
DISCUSSION
The evidence base is limited, but existing guidelines provide recommendations to ensure life-saving screening services are available to all who need them. We were only able to identify one set of guidelines for a middle-income country, and none for low-income countries. We encourage the involvement of transmasculine people in the development of future guidelines.
Most cervical cancer can be prevented through routine screening. Disparities in uptake of routine screening therefore translate into disparities in cervical cancer incidence and outcomes. Transmasculine people including transgender men experience multiple barriers to cervical screening and their uptake of screening is low compared with cisgender women. Comprehensive evidence-based guidelines are needed to improve cervical screening for this group.
METHODS
We searched for and synthesised clinical and programmatic guidelines for the provision of cervical screening for transmasculine patients.
FINDINGS
The guidelines offer recommendations addressing: (1) reception, check-in and clinic facilities; (2) patient data and invitation to screening; (3) improving inclusion in screening programmes; and (4) sexual history taking, language and identity. Guidelines offer strategies for alleviating physical and psychological discomfort during cervical screening and recommendations on what to do if the screening procedure cannot be completed. Most of the guidelines were from and for high-income countries.
DISCUSSION
The evidence base is limited, but existing guidelines provide recommendations to ensure life-saving screening services are available to all who need them. We were only able to identify one set of guidelines for a middle-income country, and none for low-income countries. We encourage the involvement of transmasculine people in the development of future guidelines.
Journal Article > CommentaryFull Text
Int J Gynecol Cancer. 2021 June 2; Volume 31 (Issue 12); 1606-1607.; DOI:10.1136/ijgc-2021-002743
Chilinda G, Massamba L, Meja S, Ngo C, Dupre PF
Int J Gynecol Cancer. 2021 June 2; Volume 31 (Issue 12); 1606-1607.; DOI:10.1136/ijgc-2021-002743
Conference Material > Abstract
Rieux C, Koudika MH
Epicentre Scientific Day Paris 2021. 2021 June 10
The emergence of chronic communicable diseases is a new health issue facing resource-limited countries and the medical organizations working in them. Cancer in particular has the greatest inequalities in survival and epidemiological predictions are worrying. It is estimated that by 2040, the number of new cancer cases and deaths in the poorest countries will double and more than 1.2 million new cases are expected. In 2018, MSF OCP has decided to get involved in the fight against cancer by developing operational projects and investing in access to prevention, diagnosis and treatment.
In Mali, the oncology project, dedicated to cervical and breast cancers (representing 30% of cancers of both sexes), built in partnership with Malian colleagues and Ministry of Health, started at the end of 2018 with palliative care, then support for screening, histopathology laboratory and specific treatments (surgery, chemotherapy, radiotherapy). In 2020, MSF provided specific care for 542 patients (366 breast cancers and 176 cervical cancers) and performed 2828 palliative consultations and 3260 tumor wounds care.
This experience confirmed the lack of financial and geographical access to screening and care facilities leading to diagnoses at very advanced stages and the complexity of management and multidisciplinary care pathways. This type of project implies new ways of working for MSF: the development of a holistic and patient-centered approach, long-term projection and working in partnership with national actors and international experts. Research, an essential element, needs to be developed around several axes: epidemiological, therapeutic trials and the introduction and evaluation of technological tools to improve diagnosis and management such as telemedicine and artificial intelligence. Finally, the issues of access not only to treatment but also to diagnosis and prevention are one of the major added values that MSF could bring to the fight against cancer.
KEY MESSAGE: Cancer is one of the new challenges that MSF has decided to tackle and for which new ways of working and research are needed.
This abstract is not to be quoted for publication.
In Mali, the oncology project, dedicated to cervical and breast cancers (representing 30% of cancers of both sexes), built in partnership with Malian colleagues and Ministry of Health, started at the end of 2018 with palliative care, then support for screening, histopathology laboratory and specific treatments (surgery, chemotherapy, radiotherapy). In 2020, MSF provided specific care for 542 patients (366 breast cancers and 176 cervical cancers) and performed 2828 palliative consultations and 3260 tumor wounds care.
This experience confirmed the lack of financial and geographical access to screening and care facilities leading to diagnoses at very advanced stages and the complexity of management and multidisciplinary care pathways. This type of project implies new ways of working for MSF: the development of a holistic and patient-centered approach, long-term projection and working in partnership with national actors and international experts. Research, an essential element, needs to be developed around several axes: epidemiological, therapeutic trials and the introduction and evaluation of technological tools to improve diagnosis and management such as telemedicine and artificial intelligence. Finally, the issues of access not only to treatment but also to diagnosis and prevention are one of the major added values that MSF could bring to the fight against cancer.
KEY MESSAGE: Cancer is one of the new challenges that MSF has decided to tackle and for which new ways of working and research are needed.
This abstract is not to be quoted for publication.
Conference Material > Abstract
Haider A, Goossens S, Desforges C, Chilinda G, Osman H, et al.
International Papillomavirus 2024. 2024 November 12
INTRODUCTION
MSF is providing cervical cancer screening in Blantyre and Chiradzulu districts in Southern Malawi in the catchment area of 10 health centres. Improved screening strategies under diverse recruitment models are introduced to increase HPV screening coverage at health centres and with outreach activities.
METHODS
Under PAVE study, self-collected vaginal swabs are tested by an isothermal amplification PCR assay followed byvisual inspection, imaging, and histological assessment for HPV +ve women. Women living <5km from health centers are recruited opportunistically during routine visits. After HPV test, they are advised either to wait onsite (test-and-wait model) or called back in two days’ time (test-and-call model) for triage and treatment visit.Women living>10km from health centers are offered HPV test, triage, and treatment in community settings by outreach teams (mobile-clinic model). A fourth model for women living 5-10km from a health center with HPV testing in their communities followed by a triage and treatment visit at respective health centers (mobile-lab model) is not yet implemented.
RESULTS
As of April 2024, over 2000 women have undergone HPV screening across all active sites. Key insights from the experience are focused at: i)streamlining patient flow during opportunistic recruitment at health centers,ii)improving HPV results communication, iii)effectively tracing women back for triage and treatment visits using phone and community based tracing, iv)ensuring provision of stable internet for effective and real time data collection and synchronization, v)reducing gaps in logistics and quality assurances at HPV lab particularly in mobile lab setup, vi)ensuring real-time quality histopathology review of cervical biopsies for case management,and vii)continuous monitoring of patients and data flow to ensure quality of screening, compliance, and effective case management.
CONCLUSIONS
Diverse HPV-based screening strategies are key to achieve good screening coverage, and subsequently reducethe cervical cancer morbidity and mortality in southern Malawi.
Conference Material > Poster
Haider A, Goossens S, Desforges C, Chilinda G, Osman H, et al.
International Papillomavirus 2024. 2024 November 12
Journal Article > ResearchFull Text
PLOS Med. 2020 November 19; Volume 17 (Issue 11); e1003378.; DOI:10.1371/journal.pmed.1003378
Asgary R, Staderini N, Mthethwa-Hleza S, Lopez Saavedra PA, Garcia Abrego L, et al.
PLOS Med. 2020 November 19; Volume 17 (Issue 11); e1003378.; DOI:10.1371/journal.pmed.1003378
BACKGROUND
Cervical cancer is among the most common preventable cancers with the highest morbidity and mortality. The World Health Organization (WHO) recommends visual inspection of the cervix with acetic acid (VIA) as cervical cancer screening strategy in resource-poor settings. However, there are barriers to the sustainability of VIA programs including declining providers’ VIA competence without mentorship and quality assurances and challenges of integration into primary healthcare. This study seeks to evaluate the impact of smartphone-based strategies in improving reliability, reproducibility, and quality of VIA in humanitarian settings.
METHODS AND FINDINGS
We implemented smartphone-based VIA that included standard VIA training, adapted refresher, and 6-month mHealth mentorship, sequentially, in the rural Shiselweni region of Eswatini. A remote expert reviewer provided diagnostic and management feedback on patients’ cervical images, which were reviewed weekly by nurses. Program’s outcomes, VIA image agreement rates, and Kappa statistic were compared before, during, and after training. From September 1, 2016 to December 31, 2018, 4,247 patients underwent screening; 247 were reviewed weekly by a VIA diagnostic expert. Of the 247, 128 (49%) were HIV–positive; mean age was 30.80 years (standard deviation [SD]: 7.74 years). Initial VIA positivity of 16% (436/2,637) after standard training gradually increased to 25.1% (293/1,168), dropped to an average of 9.7% (143/1,469) with a lowest of 7% (20/284) after refresher in 2017 (p = 0.001), increased again to an average of 9.6% (240/2,488) with a highest of 17% (17/100) before the start of mentorship, and dropped to an average of 8.3% (134/1,610) in 2018 with an average of 6.3% (37/591) after the start of mentorship (p = 0.019). Overall, 88% were eligible for and 68% received cryotherapy the same day: 10 cases were clinically suspicious for cancer; however, only 5 of those cases were confirmed using punch biopsy. Agreement rates with the expert reviewer for positive and negative cases were 100% (95% confidence interval [CI]: 79.4% to 100%) and 95.7% (95% CI: 92.2% to 97.9%), respectively, with negative predictive value (NPV) (100%), positive predictive value (PPV) (63.5%), and area under the curve of receiver operating characteristics (AUC ROC) (0.978). Kappa statistic was 0.74 (95% CI; 0.58 to 0.89); 0.64 and 0.79 at 3 and 6 months, respectively. In logistic regression, HIV and age were associated with VIA positivity (adjusted Odds Ratio [aOR]: 3.53, 95% CI: 1.10 to 11.29; p = 0.033 and aOR: 1.06, 95% CI: 1.0004 to 1.13; p = 0.048, respectively). We were unable to incorporate a control arm due to logistical constraints in routine humanitarian settings.
CONCLUSIONS
Our findings suggest that smartphone mentorship provided experiential learning to improve nurses’ competencies and VIA reliability and reproducibility, reduced false positive, and introduced peer-to-peer education and quality control services. Local collaboration; extending services to remote populations; decreasing unnecessary burden to screened women, providers, and tertiary centers; and capacity building through low-tech high-yield screening are promising strategies for scale-up of VIA programs.
Cervical cancer is among the most common preventable cancers with the highest morbidity and mortality. The World Health Organization (WHO) recommends visual inspection of the cervix with acetic acid (VIA) as cervical cancer screening strategy in resource-poor settings. However, there are barriers to the sustainability of VIA programs including declining providers’ VIA competence without mentorship and quality assurances and challenges of integration into primary healthcare. This study seeks to evaluate the impact of smartphone-based strategies in improving reliability, reproducibility, and quality of VIA in humanitarian settings.
METHODS AND FINDINGS
We implemented smartphone-based VIA that included standard VIA training, adapted refresher, and 6-month mHealth mentorship, sequentially, in the rural Shiselweni region of Eswatini. A remote expert reviewer provided diagnostic and management feedback on patients’ cervical images, which were reviewed weekly by nurses. Program’s outcomes, VIA image agreement rates, and Kappa statistic were compared before, during, and after training. From September 1, 2016 to December 31, 2018, 4,247 patients underwent screening; 247 were reviewed weekly by a VIA diagnostic expert. Of the 247, 128 (49%) were HIV–positive; mean age was 30.80 years (standard deviation [SD]: 7.74 years). Initial VIA positivity of 16% (436/2,637) after standard training gradually increased to 25.1% (293/1,168), dropped to an average of 9.7% (143/1,469) with a lowest of 7% (20/284) after refresher in 2017 (p = 0.001), increased again to an average of 9.6% (240/2,488) with a highest of 17% (17/100) before the start of mentorship, and dropped to an average of 8.3% (134/1,610) in 2018 with an average of 6.3% (37/591) after the start of mentorship (p = 0.019). Overall, 88% were eligible for and 68% received cryotherapy the same day: 10 cases were clinically suspicious for cancer; however, only 5 of those cases were confirmed using punch biopsy. Agreement rates with the expert reviewer for positive and negative cases were 100% (95% confidence interval [CI]: 79.4% to 100%) and 95.7% (95% CI: 92.2% to 97.9%), respectively, with negative predictive value (NPV) (100%), positive predictive value (PPV) (63.5%), and area under the curve of receiver operating characteristics (AUC ROC) (0.978). Kappa statistic was 0.74 (95% CI; 0.58 to 0.89); 0.64 and 0.79 at 3 and 6 months, respectively. In logistic regression, HIV and age were associated with VIA positivity (adjusted Odds Ratio [aOR]: 3.53, 95% CI: 1.10 to 11.29; p = 0.033 and aOR: 1.06, 95% CI: 1.0004 to 1.13; p = 0.048, respectively). We were unable to incorporate a control arm due to logistical constraints in routine humanitarian settings.
CONCLUSIONS
Our findings suggest that smartphone mentorship provided experiential learning to improve nurses’ competencies and VIA reliability and reproducibility, reduced false positive, and introduced peer-to-peer education and quality control services. Local collaboration; extending services to remote populations; decreasing unnecessary burden to screened women, providers, and tertiary centers; and capacity building through low-tech high-yield screening are promising strategies for scale-up of VIA programs.
Conference Material > Abstract
Ronoh Y, Some D, Ortuno R, Kuwenyi K, Mupepe T, et al.
MSF Scientific Days International 2020: Research. 2020 May 20
INTRODUCTION
Cervical cancer is now largely a preventable disease; however, implementation of highly sensitive molecular screening technologies in low-resource settings is partly hindered by the need for intensive investment in equipment and highly trained, skilled laboratory personnel. Resource limitations often preclude the possibility of same-day screening and treatment, as recommend by WHO. We sought to assess the diagnostic accuracy of self-collected versus nurse-collected high vaginal samples (HVS) for human papillomavirus (HPV) screening using GeneXpert, for within-country validation and to further inform its scale-up within routine point-of-care testing in primary healthcare systems.
METHODS
Consenting women presenting for routine cervical screening in selected health facilities in Gutu District, Zimbabwe, were asked to provide three HVS obtained at the same time on a single visit; the first, self-collected, and the following two, nurse-collected. Nurse-collected HVS were tested with GeneXpert (Cepheid, Sunnyvale, USA) and Cobas HPV (Roche, Pleasanton, USA; used as the reference test), whilst self-collected HVS were tested only using GeneXpert. Those testing positive on the reference test were offered visual inspection with acetic acid and cervicography (VIAC). Women with a positive VIAC examination were offered cryotherapy or loop electrosurgical excision procedure.
ETHICS
This study was approved by the MSF Ethics Review Board.
RESULTS
279 participants consented to provide HVS; none reported discomfort or side effects during or after swabbing. Among nurse-collected HVS, 11/279 participants were found positive on genotyping for HPV-16 using Cobas HPV, and nine of 279 were positive using GeneXpert. Eight out of 279 were identified on genotyping for HPV-18/45 using both platforms. The sensitivities of testing for HPV-16 and 18/45 using GeneXpert as compared to the reference test, Cobas, were 89% (95%CI 53-100) and 63% (95%CI 25-92) respectively. The sensitivity of self- and nurse-collected HVS for HPV-16 tested using GeneXpert, as compared to the reference test, was 89% (eight of nine; 95%CI 52-100). Specificity was 100% (95%CI 97-100), with a positive predictive value of 89% (95%CI 52-100), and negative predictive value of 100% (95%CI 97-100). However, sensitivity for detection of HPV-18/45 was 68.3% (95%CI 34-100).
CONCLUSION
Performance of cervical cancer screening using self-collected HVS tested with GeneXpert is comparable to that with nurse-collected HVS. Integrated GeneXpert platforms are already in wide use, enabling rapid diagnosis of tuberculosis, detection of HIV viral load, and early infant diagnosis of HIV, using a single piece of equipment. Deploying GeneXpert for HPV screening using self-collected HVS could help to provide timely results, especially in settings where VIAC is unavailable.
Cervical cancer is now largely a preventable disease; however, implementation of highly sensitive molecular screening technologies in low-resource settings is partly hindered by the need for intensive investment in equipment and highly trained, skilled laboratory personnel. Resource limitations often preclude the possibility of same-day screening and treatment, as recommend by WHO. We sought to assess the diagnostic accuracy of self-collected versus nurse-collected high vaginal samples (HVS) for human papillomavirus (HPV) screening using GeneXpert, for within-country validation and to further inform its scale-up within routine point-of-care testing in primary healthcare systems.
METHODS
Consenting women presenting for routine cervical screening in selected health facilities in Gutu District, Zimbabwe, were asked to provide three HVS obtained at the same time on a single visit; the first, self-collected, and the following two, nurse-collected. Nurse-collected HVS were tested with GeneXpert (Cepheid, Sunnyvale, USA) and Cobas HPV (Roche, Pleasanton, USA; used as the reference test), whilst self-collected HVS were tested only using GeneXpert. Those testing positive on the reference test were offered visual inspection with acetic acid and cervicography (VIAC). Women with a positive VIAC examination were offered cryotherapy or loop electrosurgical excision procedure.
ETHICS
This study was approved by the MSF Ethics Review Board.
RESULTS
279 participants consented to provide HVS; none reported discomfort or side effects during or after swabbing. Among nurse-collected HVS, 11/279 participants were found positive on genotyping for HPV-16 using Cobas HPV, and nine of 279 were positive using GeneXpert. Eight out of 279 were identified on genotyping for HPV-18/45 using both platforms. The sensitivities of testing for HPV-16 and 18/45 using GeneXpert as compared to the reference test, Cobas, were 89% (95%CI 53-100) and 63% (95%CI 25-92) respectively. The sensitivity of self- and nurse-collected HVS for HPV-16 tested using GeneXpert, as compared to the reference test, was 89% (eight of nine; 95%CI 52-100). Specificity was 100% (95%CI 97-100), with a positive predictive value of 89% (95%CI 52-100), and negative predictive value of 100% (95%CI 97-100). However, sensitivity for detection of HPV-18/45 was 68.3% (95%CI 34-100).
CONCLUSION
Performance of cervical cancer screening using self-collected HVS tested with GeneXpert is comparable to that with nurse-collected HVS. Integrated GeneXpert platforms are already in wide use, enabling rapid diagnosis of tuberculosis, detection of HIV viral load, and early infant diagnosis of HIV, using a single piece of equipment. Deploying GeneXpert for HPV screening using self-collected HVS could help to provide timely results, especially in settings where VIAC is unavailable.
Journal Article > ResearchFull Text
BMC Public Health. 2022 February 14; Volume 22 (Issue 1); 295.; DOI: 10.1186/s12889-022-12547-9
Gerstl S, Lee L, Nesbitt RC, Mambula C, Sugianto H, et al.
BMC Public Health. 2022 February 14; Volume 22 (Issue 1); 295.; DOI: 10.1186/s12889-022-12547-9
BACKGROUND
Cervical cancer (CC) is the fourth most common cancer among women worldwide and Malawi has the world's highest rate of cervical cancer related mortality. Since 2016 the National CC Control Strategy has set a screening coverage target at 80% of 25-49-year-old women. The Ministry of Health and Médecins Sans Frontières (MSF) set up a CC program in Blantyre City, as a model for urban areas, and Chiradzulu District, as a model for rural areas. This population-based survey aimed to estimate CC screening coverage and to understand why women were or were not screened.
METHODS
A population-based survey was conducted in 2019. All resident consenting eligible women aged 25-49 years were interviewed (n = 1850) at households selected by two-stage cluster sampling. Screening and treatment coverage and facilitators and barriers to screening were calculated stratified by age, weighted for survey design. Chi square and design-based F tests were used to assess relationship between participant characteristics and screening status.
RESULTS
The percentage of women ever screened for CC was highest in Blantyre at 40.2% (95% CI 35.1-45.5), 38.9% (95% CI 32.8-45.4) in Chiradzulu with supported CC screening services, and lowest in Chiradzulu without supported CC screening services at 25.4% (95% CI 19.9-31.8). Among 623 women screened, 49.9% (95% CI 44.0-55.7) reported that recommendation in the health facility was the main reason they were screened and 98.5% (95% CI 96.3-99.4) recommended CC screening to others. Among 1227 women not screened, main barriers were lack of time (26.0%, 95% CI 21.9-30.6), and lack of motivation (18.3%, 95% CI 14.1-23.3). Overall, 95.6% (95% CI 93.6-97.0) of women reported that they had some knowledge about CC. Knowledge of CC symptoms was low at 34.4% (95% CI 31.0-37.9) and 55.1% (95% CI 51.0-59.1) of participants believed themselves to be at risk of CC.
CONCLUSION
Most of the survey population had heard about CC. Despite this knowledge, fewer than half of eligible women had been screened for CC. Reasons given for not attending screening can be addressed by programs. To significantly reduce mortality due to CC in Malawi requires a comprehensive health strategy that focuses on prevention, screening and treatment.
Cervical cancer (CC) is the fourth most common cancer among women worldwide and Malawi has the world's highest rate of cervical cancer related mortality. Since 2016 the National CC Control Strategy has set a screening coverage target at 80% of 25-49-year-old women. The Ministry of Health and Médecins Sans Frontières (MSF) set up a CC program in Blantyre City, as a model for urban areas, and Chiradzulu District, as a model for rural areas. This population-based survey aimed to estimate CC screening coverage and to understand why women were or were not screened.
METHODS
A population-based survey was conducted in 2019. All resident consenting eligible women aged 25-49 years were interviewed (n = 1850) at households selected by two-stage cluster sampling. Screening and treatment coverage and facilitators and barriers to screening were calculated stratified by age, weighted for survey design. Chi square and design-based F tests were used to assess relationship between participant characteristics and screening status.
RESULTS
The percentage of women ever screened for CC was highest in Blantyre at 40.2% (95% CI 35.1-45.5), 38.9% (95% CI 32.8-45.4) in Chiradzulu with supported CC screening services, and lowest in Chiradzulu without supported CC screening services at 25.4% (95% CI 19.9-31.8). Among 623 women screened, 49.9% (95% CI 44.0-55.7) reported that recommendation in the health facility was the main reason they were screened and 98.5% (95% CI 96.3-99.4) recommended CC screening to others. Among 1227 women not screened, main barriers were lack of time (26.0%, 95% CI 21.9-30.6), and lack of motivation (18.3%, 95% CI 14.1-23.3). Overall, 95.6% (95% CI 93.6-97.0) of women reported that they had some knowledge about CC. Knowledge of CC symptoms was low at 34.4% (95% CI 31.0-37.9) and 55.1% (95% CI 51.0-59.1) of participants believed themselves to be at risk of CC.
CONCLUSION
Most of the survey population had heard about CC. Despite this knowledge, fewer than half of eligible women had been screened for CC. Reasons given for not attending screening can be addressed by programs. To significantly reduce mortality due to CC in Malawi requires a comprehensive health strategy that focuses on prevention, screening and treatment.
Conference Material > Video
Rieux C, Koudika MH
Epicentre Scientific Day Paris 2021. 2021 June 10