Latin America to be hosted by the Pan American Health
Organization.
Another challenge is related to the adequacy of the health
information system (HIS) to track screening and treatment
services. In many countries, HIS forms must be adapted to
document the key variables listed by WHO as essential for
monitoring programmes:
‰ the number of women screened for cervical cancer (to
calculate coverage);
‰ the number of women with positive screening results (to
monitor screening test performance);
‰ the number of those with positive results who received
further evaluation and treatment (to evaluate
completeness of care and programme effectiveness).19
In those countries where the data in the HIS is used to
measure the productivity of health providers, if VIA and
cryotherapy are not included in the HIS health providers will
favour other activities in order to get a good evaluation.
Determining the number of women who complete treatment
can be estimated indirectly, since in most countries the
system does not allow the tracking of women with positive
results to see if they received treatment. In the best existing
scenarios we can count the number of women with positive
screening results in a period of time and the number of
treatments in the same period, and then assume that all those
treatments were for precancerous lesions. This
approximation may overestimate treatment completion in
those areas where cryotherapy is used by providers to treat
benign changes of the uterine cervix.
A major limiting factor for expansion of VIA is the capacity
for treatment. VIA has usually been paired with cryotherapy,
since this treatment is easy to provide and has very few
complications.20 However, the cost of the cryotherapy units,
and more importantly the need for a continuous supply of
nitrous oxide or carbon dioxide gas, has created a significant
burden on health systems in developing countries. New
technologies for treatment are currently being explored. One
of them is the CryoPen® (CryoPen, Inc., Corpus Cristi, Texas),
a cryotherapy device that does not need an external supply of
gas; this technology is currently under evaluation and should
be available for developing countries within the next year.
Another option is the cold coagulator, an electricity-powered
device that reaches a temperature of approximately 100 to
120°C; then the heat is applied to the cervical epithelium; the
best results have been obtained when it is applied for 40
seconds.21,22
One approach for optimizing the limited treatment
capacity is based on the organization of service clusters
where several health centres with VIA capacity but no
treatment available are organized around a health centre
with cryotherapy. Women with positive results at any of the
screening sites are immediately counselled and referred to
the facility with cryotherapy for receiving treatment. This
concentration of treatment services is more efficient for
equipment and gas supplies and enables selected providers
to treat enough patients to maintain their skills. An
alternative approach is to have outreach treatment teams
that visit smaller facilities on a rotating schedule, so that
women get treated in a facility close to their home. The
implementation of a follow-up system for referred women is
essential in order to minimize the number of women that do
not complete treatment.
Are there viable alternatives to VIA now?
In the last decade new molecular tests for detecting the
presence of HPV have been developed and approved for
clinical use. The main advantage of the new HPV tests is their
high sensitivity, allowing them to detect most precancer
cases at the first round of screening; however, the specificity
of the new tests is still sub-optimal so many experts
recommend a secondary evaluation of those with positive
HPV results. Another advantage of the molecular tests is
their good predictive value for identifying those women at
higher risk for harbouring disease now, or for developing
disease within the next few years. Correspondingly, women
with a negative result on the HPV test have a very low risk of
developing precancer in the next decade23, which means the
inter-screening period can be extended in these women,
representing a significant reduction in cost and effort for
screening this low-risk group of women.
As described earlier, HPV testing can be done using a
vaginal sample self-collected by women without the need for
a pelvic examination or the use of a speculum. This opens the
possibility for taking screening to the community level,
DISEASE-SPECIFIC CANCER CONTROL
CANCER CONTROL 2014 87
One approach for optimizing the
limited treatment capacity is
based on the organization of
service clusters where several
health centres with VIA capacity
but no treatment available are
organized around a health centre
with cryotherapy