SAIA Cervical Cancer Screening

Eighty-seven percent of cervical cancer deaths worldwide occur in low and middle income countries, and cervical cancer is the most common cancer in sub-Saharan Africa (1-4).

Cervical Cancer in Kenya

The significant disparity between cervical cancer outcomes in the United States and low- and middle-income countries (LMICs) is largely attributed to differences in screening (5). While approximately 89% of US women receive cervical cancer screening (7), less than 5% of women in LMICs have been screened (4). Barriers to screening in LMICs include challenges with infrastructure to support screening, competing health interests, lack of education, low health literacy, and poverty (2, 8-12). In addition to the general lack of cervical cancer screening, sub-Saharan Africa (SSA) carries the highest global burden of human immunodeficiency virus (HIV) infection.  Women account for 59% of all people living with HIV (13) and cervical cancer incidence is higher in women with HIV (14). With the advent of antiretroviral therapy (ART), women receiving HIV treatment have increased life expectancy approaching that of HIV-negative women (15). However, cervical cancer rates do not significantly decline despite ART and immune reconstitution (16), and invasive cervical cancer incidence remains high even with ART (17). The aging population of HIV-positive women will continue to face a large lifetime risk of cervical cancer (18). 

Because of the burden of both cervical cancer and HIV infection in SSA, improving implementation of cervical cancer screening and treatment of pre-cancerous lesions in this region is critical.

Existing methods for cervical cancer screening include cytology, human papillomavirus testing (14), and visual inspection methods (19). Pairing screening with treatment of positive screens using cryotherapy or loop electrosurgical excision procedures (LEEP) could prevent progression to cervical cancer (20), and greatly reduce morbidity and mortality in women. To address this implementation gap, simple, scalable, and sustainable interventions are imperative to improve screening and treatment of pre-cancers. The Kenyan Ministry of Health (MOH) guidelines stress the need to strengthen capacity, streamline, and standardize screening, diagnosis, and treatment of cancer (21). To achieve this, our long-term partners in the Mombasa County Department of Health (DOH) are eager to increase rates of cervical cancer screening. We aim to test an implementation science methodology, Systems Analysis and Improvement Approach (SAIA), to address systems barriers to screening and provide quality improvement while relying on existing infrastructure to conduct screening.

Recent Publications and Posters

Study Location

SAIA-CCS is currently being implemented in family planning health clinics across Mombasa County in Kenya.

SAIA-CCS Team

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References:

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6. Sherr K, Gimbel S, Rustagi A, Nduati R, Cuembelo F, Farquhar C, Wasserheit J, Gloyd S, With input from the SST. Systems analysis and improvement to optimize pMTCT (SAIA): a cluster randomized trial. Implement Sci. 2014;9:55. doi: 10.1186/1748-5908-9-55. PubMed PMID: 24885976; PMCID: PMC4019370.

7. Benard VB, Thomas CC, King J, Massetti GM, Doria-Rose VP, Saraiya M, Centers for Disease C, Prevention. Vital signs: cervical cancer incidence, mortality, and screening - United States, 2007-2012. MMWR Morb Mortal Wkly Rep. 2014;63(44):1004-9. PubMed PMID: 25375072.

8. Adefuye AO, Ndip RN. Phytochemical analysis and antibacterial evaluation of the ethyl acetate extract of the stem bark of Bridelia micrantha. Pharmacogn Mag. 2013;9(33):45-50. doi: 10.4103/0973-1296.108139. PubMed PMID: 23661993; PMCID: PMC3647394.

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12. Olson B, Gribble B, Dias J, Curryer C, Vo K, Kowal P, Byles J. Cervical cancer screening programs and guidelines in low- and middle-income countries. Int J Gynaecol Obstet. 2016;134(3):239-46. doi: 10.1016/j.ijgo.2016.03.011. PubMed PMID: 27350227.

13. UNAIDS. The GAP Report. Geneva: Joint United National Programme on HIV/AIDS (UNAIDS), : 2014.

14. Denny LA, Franceschi S, de Sanjose S, Heard I, Moscicki AB, Palefsky J. Human papillomavirus, human immunodeficiency virus and immunosuppression. Vaccine. 2012;30 Suppl 5:F168-74. doi: 10.1016/j.vaccine.2012.06.045. PubMed PMID: 23199960.

15. Marcus JL, Chao CR, Leyden WA, Xu L, Quesenberry CP, Jr., Klein DB, Towner WJ, Horberg MA, Silverberg MJ. Narrowing the Gap in Life Expectancy Between HIV-Infected and HIV-Uninfected Individuals With Access to Care. J Acquir Immune Defic Syndr. 2016;73(1):39-46. doi: 10.1097/QAI.0000000000001014. PubMed PMID: 27028501.

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17. Rohner E, Sengayi M, Goeieman B, Michelow P, Firnhaber C, Maskew M, Bohlius J. Cervical cancer risk and impact of Pap-based screening in HIV-positive women on antiretroviral therapy in Johannesburg, South Africa. Int J Cancer. 2017;141(3):488-96. doi: 10.1002/ijc.30749. PubMed PMID: 28440019; PMCID: 5504282.

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19. Huchko MJ, Sneden J, Sawaya G, Smith-McCune K, Maloba M, Abdulrahim N, Bukusi EA, Cohen CR. Accuracy of visual inspection with acetic acid to detect cervical cancer precursors among HIV-infected women in Kenya. Int J Cancer. 2015;136(2):392-8. doi: 10.1002/ijc.28996. PubMed PMID: 24889387; PMCID: PMC4214890.

20. World Health Organization. WHO guidelines for screening and treatment of precancerous lesions of cervical cancer prevention. South Africa: 2013.

21. Ministry of Public Health and Sanitation, Ministry of Medical Services. National Guidelines for Prevention and Management of Cervical, Breast and Prostate Cancer. Ministry of Health Division of Reproductive Health. , January 2012.