Researchers Aiming to Improve Cervical Cancer Screening in Developing Countries

While cervical cancer is often a preventable and treatable disease in the industrialized world, it continues to be a serious health problem in developing countries. Cervical cancer is the second leading cause of female cancer mortality worldwide, according to the World Health Organization (WHO) statistics. About 510,000 cases of cervical cancer are reported each year, with nearly 80% of these in developing countries. Creating viable screening options in resource-limited countries is one of the first steps to improving these numbers, noted the researchers interviewed for this article.Figure: Micol Salvetto, MSc: “In my opinion the problem with the high rates of mortality and morbidity due to cervical cancer around the world, and in developing countries especially, is not due to the Pap test itself, but to poorly planned, poorly organized, and poorly run national screening programs.”Many scientists find cytology screening to be problematic and are investigating what they believe to be more practical and affordable alternatives such as visual screening and human papillomavirus (HPV) screening. Others think cytology should remain the norm where possible, but that the programs supporting this method should be improved. In addition to these screening methods, most researchers agree that an HPV vaccine may one day help to alleviate the burden of the disease in developing countries. This article, the first in a two-part series, will examine the debate over the use of the Pap smear for developing countries. Part 2 will focus on alternatives to cytology and HPV vaccines. The Problem with Pap “For most developing countries the Pap smear has proven not to be an effective method for screening,” said Jacqueline Sherris, PhD, Strategic Program Leader of Reproductive Health at the Program for Appropriate Technology in Health (PATH) in Seattle. None of the programs initiated have resulted in a reduction of overall disease, she said. The Pap smear has been around for about 50 years and almost no progress has been made with it in developing countries, said Hennie Cronjé, MD, Professor in the Department of Obstetrics and Gynecology at the University of the Free State in Bloemfontein, South Africa. There are a number of obstacles to successful Pap screening in developing countries: Low Sensitivity Requires Follow-Up Because the test's sensitivity is only about 50%, women need to be screened frequently so that physicians can catch abnormalities and false negatives, Dr. Sherris said. Women in developing countries may undergo Pap screening only once or twice in a lifetime, meaning that health care providers may miss detecting precancerous lesions. “Pap screening involves a multistep nature of intervention,” Dr. Sherris explained. The patient undergoes screening, waits for the results while the smear is sent to a lab where it is assessed, and is called back to the clinic for additional treatment if necessary. In developing countries, about 10% to 15% of women are lost at each step of Pap screening, she noted. Expensive & Labor Intensive Additionally, the Pap test is expensive and requires a fair degree of laboratory expertise, Dr. Cronjé said. The cost of maintaining an effective cytologist program is high, agreed Dr. Sherris. Programs have to consider the price of lab staff, equipment, and supplies. Additionally, the call and re-call of patients requires extensive organization, and the workload attached to conducting Pap smears is quite heavy for nurses in busy primary health care clinics, said Dr. Cronjé. Another obstacle is that women from rural areas are living in conditions conducive to poor hygiene, noted Shunro Sonoda, MD, DMedSci, Professor Emeritus of Virology at Kagoshima University in Kagoshima, Japan. Dr. Sonoda has conducted cervical cancer screening research in the Amazon and Andes. Women may need pretreatment with antibiotics for vaginal infections before a precise Pap test is possible, he said. Even in middle resource countries, such as Brazil and Argentina, where screening is based on cytology, infrastructure may not be able to handle the number of women who want a Pap smear. For example, in Brazil, televised public education campaigns encouraging women to get a Pap smear often result in increased visits to clinics, but the health care system can't accommodate all of those who have lesions, said Eduardo L. Franco, MPH, DrPH, Professor of Epidemiology and Oncology Director in the Division of Cancer Epidemiology at McGill University. “The system has to be ready to treat those lesions,” he said. Cultural Differences The exam may also be embarrassing to some women or culturally unacceptable, Dr. Sherris noted. Culture issues sometimes make the acceptance of Pap testing difficult, especially in rural areas where women and their partners may not understand the test or female anatomy, said Micol Salvetto, MSc, a consultant in Managua, Nicaragua for the Central American Health Institute, a nongovernmental institution with branches in Central America. Ms. Salvetto came across several misconceptions in her investigations of cultural acceptance of Pap smears in Nicaragua and El Salvador, she said. “Some women believed that with a Pap smear a piece of their uterus was being removed, and they firmly objected to it. Other women believed that Pap smears were only for promiscuous women or for women with promiscuous husbands.” Some men object to their partner or wife visiting a gynecologist, she added. And as is sometimes the case in developed countries, some women simply don't like the idea of their privacy being invaded, especially by a male doctor. Disdain for gynecologists is a worldwide phenomenon that health care systems encounter, said Paul Blumenthal, MD, Associate Professor of Gynecology and Obstetrics at Johns Hopkins University School of Medicine and Director of the Cervical Cancer Prevention Program at JHPIEGO, a not-for-profit international public health organization. “There's an intrinsic sacrifice of some privacy,” he said. Naturally, one group of people may have a different outlook than another's. For example, Mestizo women are less reluctant to undergo a Pap smear than native Amerindian women, noted Dr. Sonoda. “The latter require strong advice or motivation to accept the gynecological examination and to get their husband's permission,” he said. Lack of Awareness Lack of awareness of cervical cancer is another problem health care providers encounter. Screening for a disease that many people don't understand is challenging, said Dr. Sherris. In many countries, women don't know that cervical cancer is a problem. Women in Kenya, for example, tend to think of breast or stomach cancer as being bigger problems. People worldwide, including those in developed countries, don't understand that cervical cancer is a sexually transmitted disease caused by HPV, she added. Additionally, prevention services are not understood. Seeing a health care provider when you're not ill is not a well-understood concept, Dr. Sherris said. An Alternate View The screening programs that use Pap may actually be contributing to such problems, rather than the cytology test itself, said Ms. Salvetto. She said she believes most qualities needed in a test are already available through the Pap smear. “In my opinion the problem with the high rates of mortality and morbidity due to cervical cancer around the world, and in developing countries especially, is not due to the Pap test itself, but to poorly planned, poorly organized, and poorly run national screening programs.” Her experience in Latin America has taught her that efforts to improve screening programs are limited due to capability and finances. “Donations from donors or international agencies always come with conditions and restrictions, which may or may not be beneficial to the improvement of the existing system,” she explained. Finally, often in these countries efforts and resources are spent on screening, but very little thought is spared for treatment of preinvasive lesions, she said. “Having said that, I can think of one improvement to the current test—an instant result,” she noted. “A test that could provide an instant result would help immensely in ensuring that patients are not lost to follow up.” Exploration of Alternatives Tests involving a single visit approach do have an advantage, Dr. Blumenthal agreed. For this reason, researchers are evaluating a visual inspection approach in lieu of the Pap smear. Health care providers are also compelled to use testing programs that will be much more resource-friendly than Pap testing, he said. HPV screening is another technique being explored, although its implications for cancer prevention programs in developing countries are not yet fully understood, Dr. Sherris said. Overall, cervical cancer tests need to be accurate, with the highest sensitivity and specificity possible. The test needs to be performed in a way that is explained, and be acceptable to patients, she concluded. On the Cover Illustration from 4Woman.gov, the National Women's Health Information Center of the Department of Health and Human Services.FigureComing in Part 2 This is a two-part article. See the next issue for a discussion of the development of visual inspection screening and HPV screening.

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.