Reducing Cervical Cancer in the Sololá Department of Guatemala

Transcription

1 1 Reducing Cervical Cancer in the Sllá Department f Guatemala Intrductin The Bates Fundatin is seeking t fund a prpsal fr a cmprehensive cervical cancer demnstratin prject in Guatemala s Sllá Department. The Bates Fundatin will be investing a ttal f $1,500,000 ver three years t examine the mst effective ways t deliver cmprehensive cervical cancer preventin and cntrl strategies, including the vaccinatin f yung adlescent girls and screening f adult wmen t reduce the burden f cervical cancer in the Sllá Department f Guatemala. Yu are a member f a prpsal writing team at a large glbal health rganizatin based in the United States. A partner rganizatin in Guatemala has just cntacted yu in regards t the prpsal and wuld like t apply jintly fr the award. Unfrtunately, the deadline t present yur prpsal t the Bates Fundatin is nly a week away. Yu and the rest f the team are nw rushing t incrprate the fllwing cmpnents int the prpsal: 1. Wh is yur target ppulatin(s)? Hw will yu reach them? 2. Hw will yu address gender and cultural barriers arund vaccinatin, screening, and treatment? 3. Wh are yur ther stakehlders and hw will yu engage them? 4. D yu have all f the needed resurces t carry ut yur prgram: staffing, infrastructure (labs), supplies, infrmatin systems fr data cllectin, and fllw up care? 5. Des yur prpsal/strategy have a surce f reliable and sustainable funding? 6. What measures will yu put in place t address the need fr quality training and cntinuing educatin? 7. Hw can the prpsal als serve t strengthen the verall health system fr girls and wmen? Overview f Guatemala Gvernment structure: Divided int 22 departments Ppulatin: 14,361,666 Ppulatin density: 117 inhabitants per km2 Grss Natinal Incme per capita: $4,800 A Brief Histry Guatemala gained independence in 1821 which was fllwed by a successin f dictatrships and guerilla uprisings, ultimately culminating in a 36 year lng civil war that ended in 1996 with the signing f the Peace Accrds. During the civil war ver 200,000 citizens were murdered, f which 80% were estimated t

2 2 be Mayan r f Mayan descent. Mistrust f the gvernment is still present in many parts f the cuntry, and it has left a prfund impact n the health and welfare f the indigenus ppulatin. 1 Public Health Challenges in Guatemala 2 High rates f inequality Weak infrastructure Variety f traditins, languages, and cultures Internal displacement f ppulatins has impacted the stability and quality f the healthcare system Backgrund Under-utilizatin f health services High fertility rates Cervical cancer, which is preventable and treatable, is the secnd mst cmmn cancer f wmen wrldwide and a leading cause f cancer deaths amng wmen in develping cuntries. Almst all cases f cervical cancer (99%) are linked t the human papillmavirus (HPV), an easily transmissible and highly prevalent DNA virus. It is estimated that between 50-80% f sexually active wmen will be infected with HPV at least nce during their lifetime, usually between late teenage years and the early thirties. Fr mst wmen with HPV, infectins spntaneusly clear after 6 t 18 mnths, but in a small percentage f cases infectins persist and can eventually prgress t cancer (See Appendix A fr natural histry mdel f HPV and cervical cancer) 3. In terms f preventin, there are tw vaccines currently available t prtect girls and wmen frm the 16 and 18 HPV strains: Merck & C. s Gardasil and GlaxSmithKline s Cervarix. While there are mre than 100 strains f the virus, strains 16 and 18 are respnsible fr apprximately 70% f cervical cancers wrldwide. 4 Hwever, the cst, lgistics, and ther cmpeting health pririties limit availability fr many lw t middle incme cuntries. Cervical cancer can take up t 10 t 20 years t develp, during which time screening and early treatment is highly effective in preventing the nset f the disease. If cervical cancer is nt prevented, it can be treated with cmbinatins f surgery, chemtherapy and raditherapy. Hwever, access t treatment is dependent upn an accurate diagnsis, adequately equipped facilities and skilled health prfessinals, services that are unavailable t mst wmen in develping cuntries. 5 1 (PAHO, Health in the Americas, Vlume II- Cuntriees, 2007) 2 (Cagley, 2008) 3 (Spitzer, 2006) 4 (RHO, 2013) 5 (Actin, 2012)

3 3 Risk Factrs 6 Acquisitin f HPV Age at sexual debut: earlier age f sexual initiatin increases number f lifetime sexual partners Acquisitin f HPV infectin is assciated with increased number f lifetime sexual partners Sexual behavir f male partner Prgressin frm Infectin t Cancer High parity C-infectin with HIV and ther STIs Smking Use f ral cntraceptives Cervical Cancer Distributin and Trends Wrldwide Over 500,000 wmen develp cervical cancer and apprximately 275,000 wmen die frm the disease each year. The vast majrity (88%) f these deaths ccur in develping cuntries. In high incme cuntries, cervical cancer rates have steadily declined due t effective early screening and treatment prgrams that are assisted by health educatin, clinician training, imprved cancer treatment and functining health infrmatin systems. Hwever, in lw and middle incme cuntries, pr perfrmance f the Papaniclau test, limited health systems, plus csts and ther challenges prevent many wmen frm traveling repeatedly fr mre screening and/r fllw-up care. 7 Latin America and Caribbean Regin (LAC) 8 One f the highest incidence and mrtality rates f cervical cancer in the wrld. Wmen frm lwer sciecnmic status are ften unaware f cervical cancer screening r lack access. Absence f cuntry-tailred guidelines fr best practice f cervical cancer preventin and cntrl cntribute t high rates. Cervical cancer cntributes mre years f life lst than any ther cancer, tuberculsis, maternal cnditins, r AIDS in the Latin America and Caribbean regin. Cervical Cancer in Guatemala 9 Cervical cancer is the mst cmmn cancer amng wmen in Guatemala. Apprximately 33.2% f wmen in the general ppulatin are estimated t harbr cervical HPV infectin at a given time. 6 (Almnte, 2008) 7 (Actin, 2012) 8 (PAHO, Cervical Cancer Preventin and Cntrl Prgrams: A rapid assessment in 12 cuntries f Latin America., 2010) 9 (Ferlay, 2008)

4 4 There are 3.8 millin wmen in Guatemala at risk f develping cervical cancer. Guatemala s cervical cancer incidence and mrtality are amng the highest in the Americas, ranking 10th ut f 33 cuntries. The Institut Nacinal de Cancerlgia (Natinal Cancer Institute, INCAN) is the primary referral site fr cancer diagnsis and treatment in Guatemala, and the repsitry fr the cuntry s cancer data which relies primarily n paper recrds. Screening rates vary by regin, but 49% f wmen (ages 25-64) have never had a pelvic exam in Guatemala, and nly 40% are cnsidered t have effective screening cverage. 10 Cmdrnas (midwives) play an imprtant rle, especially in rural areas f Guatemala where they ften serve as facilitatrs fr healthcare services in the area f wmen s health. 11 Sllá Department 12 Lcated in the Western Highlands Indigenus peples cmprise 96% f the ppulatin in Sllá Apprximately 11,000 girls (ages 9-12) Apprximately 50,000 wmen (ages 30-59) Illiteracy amng Mayan wmen is particularly high, with an average f nly 4.4 years f schling Cervical Cancer Cntrl Strategies in Lw Resurce Settings Lw incme cuntries have struggled fr decades t initiate and maintain cervical screening using cytlgy, but nw there is a cmbinatin f new and cst effective tls in rder t help prevent and reduce the burden f cervical cancer. Each f the available methds has its wn strengths and limitatins s the critical issue is t select what is mst apprpriate fr the cntext. Fllwing screening, effective treatment must als be available t prevent disease prgressin and mrtality. 13 HPV Vaccines Gvernments in Latin America and the Caribbean are nw able t purchase the vaccines at a heavily discunted price thrugh the Pan American Health Organizatin s EPI Revlving Fund. 14 The Wrld Health Organizatin recmmends that rutine HPV vaccinatin be included in natinal immunizatin prgrams based n the fllwing key cnsideratins: 15 Preventin f cervical cancer r ther HPV-related diseases, r bth, cnstitutes a public health pririty Vaccine intrductin is prgrammatically feasible 10 (Siteman, 2012) 11 (Cagley, 2008) 12 (PAHO, 2007) 13 (Maine, 2011) 14 (Actin, 2012) 15 (WHO, 2009)

5 5 Sustainable financing can be secured The cst-effectiveness f vaccinatin strategies in the cuntry r regin is cnsidered HPV vaccinatin is targeted t adlescent girls prir t sexual debut HPV Vaccine Challenges Levels f prvider and cmmunity understanding f the need fr vaccine, r even f the burden f cervical cancer that ccurs in their cmmunities Cnvincing cmmunities and families t supprt the vaccine. Ideal age fr HPV vaccine (9-13) range utside f typical vaccinatin campaigns Cmpeting demands fr the intrductin f ther new vaccines Have a knwn duratin f prtectin f at least 5 years; clinical trials are still in prgress t shw the full duratin f prtectin. Lss t fllw up: bth are administered in a series f 3 injectins ver 6 mnths 16 Visual Inspectin with Acetic Acid (VIA) VIA is an effective, lw cst test that can be perfrmed after a relatively brief training. VIA invlves examining the cervix with the naked eye and a bright light after applying diluted acetic acid (3%-5%). When anmalus cervical and uterine tissue cmes int cntact with the acetic acid slutin, it temprarily takes n a whitish clr ( acetwhite ), making it pssible fr the health prvider t knw whether the result is psitive (abnrmal) r negative (nrmal). Because VIA allws diagnsis f abnrmal cells almst immediately, wmen can be treated in the same visit with crytherapy which reduces csts and lss t fllw-up. 17 Accreditatin System Gyneclgists, general practitiners, family dctrs, nursing persnnel, and midwives are authrized under natinal regulatins in Guatemala t perfrm VIA, but rules are mre restrictive fr perfrming crytherapy. Prviders are accredited by San Carls Natinal University, Marian Gálvez University (a private institutin), the Cllege f Physicians and Surgens, and the Guatemala Assciatin f Gyneclgy and Obstetrics (AGOG). 18 VIA Challenges Issues assciated with adequate training, supervisin, quality cntrl, evaluatin, and mnitring Limited availability f crytherapy equipment and the prblems assciated with maintaining it (Maine, 2011) 17 (PAHO, 2012) 18 (Actin, 2012) 19 (Actin, 2012)

6 6 HPV DNA Testing HPV DNA testing is a mlecular apprach t screening that detects the presence f cancer causing types f HPV. This pwerful methd identifies mre psitive cases than the Pap r VIA and culd reduce the amunt f lifetime screenings needed. Uptake has been slw in lw and middle incme cuntries, but the carehpv test develped thrugh a private public partnership and will ptentially allw fr same day testing and treatment in lw resurce settings. 20 Hwever, it is nt advised befre the age f 30 due t lw specificity. If implemented, HPV testing will require a clear triage strategy fr diagnstic fllw-up. Treatment Wmen wh have precancerus lesins n the cervix are usually treated with ne f the fllwing methds which prevent abnrmal tissue frm prgressing t invasive cancer in 85% t 89% f cases. Crytherapy des nt require electricity and can be perfrmed safely and effectively by nurses and midwives. Can be dne at the same day as screening. LEEP (lp electrsurgical excisin prcedure) requires heavier and mre expensive equipment, reliable electricity, and highly skilled prviders. It is assciated with a higher risk f severe bleeding. Cne bipsy general r spinal anesthesia is smetimes used, and cne bipsies are ften dne in a hspital r utpatient surgery clinic. Laser ablatin requires highly skilled prviders, expensive equipment, and electricity. 21 Summary f Assignment Despite having evidence based, cst effective secndary preventin methds, cervical cancer still kills a disprprtinate amunt f wmen in develping cuntries. Hence, the Bates Fundatin will be investing a ttal f $1,500,000 ver three years t examine the mst effective ways t deliver cmprehensive cervical cancer preventin and cntrl strategies, including the vaccinatin f yung adlescent girls and screening f adult wmen t reduce the burden f cervical cancer in the Sllá Department f Guatemala. Yu are a member f a prpsal writing team at a large glbal health rganizatin based in the United States. A partner rganizatin in Guatemala has just cntacted yu in regards t the prpsal and wuld like t apply jintly fr the award. Unfrtunately, the deadline t present yur prpsal t the Bates Fundatin is nly a week away. Yu and the rest f the team are nw rushing t incrprate the fllwing cmpnents int the prpsal since yu will be exp3ected t present yur prpsal n Saturday, February 23: 1. Wh is yur target ppulatin(s)? Hw will yu reach them? 2. Hw will yu address gender and cultural barriers arund vaccinatin, screening, and treatment? 20 (Actin, 2012) 21 (Maine, 2011)

7 7 3. Wh are yur ther stakehlders and hw will yu engage them? 4. D yu have all f the needed resurces t carry ut yur prgram: staffing, infrastructure (labs), supplies, infrmatin systems fr data cllectin, and fllw up care? 5. Des yur prpsal/strategy have a surce f reliable and sustainable funding? 6. What measures will yu put in place t address the need fr quality training and cntinuing educatin? 7. Hw can the prpsal als serve t strengthen the verall health system fr girls and wmen?

8 8 Bibligraphy Actin, C. C. (2012). Prgress in Cervical Cancer Preventin: The CCA Reprt Card. Retrieved frm Almnte, M. (2008). Risk factrs fr Human Papillmavirus Expsure and C-factrs fr Cervical Cancer in Latin America and the Caribbean. Vaccine, 26(11), Cagley. (2008). Culture and Cervical Cancer: Reaching the Mthers, Wives, and Daughters f Quetzaltenang, Guatemala. Ferlay J, S. H. (n.d.). GLOBOCAN 2008 v2.0, Cancer Incidence and Mrtality Wrldwide: IARC CancerBase N. 10. Retrieved frm Gravitt, P. E. (2011). The knwn unknwns f HPV natural histry. The Jurnal f Clinical Investigatin, Maine, D. (2011). Cervical Cancer Preventin in the 21st Century: Cst Is Nt the Only Issue. American Jurnal f Public Health, PAHO. (2007). Health in the Americas, Vlume II- Cuntriees. PAHO. (2010). Cervical Cancer Preventin and Cntrl Prgrams: A rapid assessment in 12 cuntries f Latin America. Washingtn DC. PAHO. (2012). Strategies fr cervical cancer screening with visual inspectin with acetic acid and treatment with. RHO. (2013, January 23). Abut Cervical Cancer. Retrieved frm Siteman, C. C. (2012). Cancer Capacity Building in Guatemala. Retrieved frm Spitzer, M. (2006). Human Papillmavirus: epidemilgy, natural histry, and clincal sequelae. OBG Management, S5-S10. WHO. (2009). Human papillmavirus vaccines: WHO psitin paper.

9 9 Appendix A Frm: J Clin Invest December 1; 121(12): Natural histry mdel f HPV and cervical cancer. HPV is acquired via sexual intercurse ( incidence ), but the majrity f HPV is cleared within 2 years in mst wmen. Apprximately 60% f wmen with HPV DNA detected will develp serum antibdies against HPV (HPV serpsitive), and if cellular samples are cllected during peak viral prductin, mild cytlgic abnrmalities may be detected n Pap smears. A minrity f HPV infectins persists, and individuals with persistent high-risk HPV are at a substantial risk f develping cervical precancer, r CIN3. The CIN3 lesins are the targets f screening, because mre than ne-third f these will prgress t invasive cervical cancer within years. The dashed lines reflect the uncertainty in the natural histry f HPV. Namely, it is unclear whether anti-hpv antibdy develped fllwing natural HPV infectin prtects against reinfectin, and whether lss f HPV detectin reflects virlgic clearance r establishment f viral latency.

10 1 0 Appendix B Wrld Health Organizatin, Department f Reprductive Health and Research and Department f Chrnic Diseases and Health Prmtin Cmprehensive Cervical Cancer Cntrl: A guide t essential practice