Page 0088

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

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