WHO Africa Region Cervical Cancer Control Policies and Strategies

Transcription

1 WHO Africa Region Cervical Cancer Control Policies and Strategies Dr. JM. DANGOU WHO-AFRO 1 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

2 The second cause of cancer morbidity and mortality in this Region Worldwide: 528,000 new cases; 266,000 deaths (2012) AFRO: 92,400 new cases; 56,600 deaths (2012) The death ratio in Africa is 67%, while it is 52% globally Projections ,300 new cases; 61,200 deaths Projections ,000 new cases; 83,000 deaths 2 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

3 The second cause of cancer morbidity and mortality in this Region The vast majority of CxCa are caused by: Infection with the Human Papilloma Virus (HPV) 60 71% Other risk factors include: Smoking Immunosuppression, e.g. HIV infection % Africa (n=2,011) HPV type Unhealthy diet (low in fruits/vegetables) Long term oral contraceptives use Multiple full term pregnancies Multiple partners 3 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

4 Natural history of cervical cancer PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY PREVENTION Exposure to HPV infection early in adolescent life Progression to cervical pre-cancer stage Development of invasive cancer cells

5 5 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

6 The core of Cervical Cancer Primary Prevention is immunization of girls against HPV infection HPV vaccination: Girls age 9 13 years Priority given to areas with low access to CxCa screening So far Rwanda and Lesotho included it in national programs About 8 other countries in demo phase Cape Verde Other interventions: Health information and warnings about tobacco use Sexuality education tailored to age and culture Condom promotion/provision for those sexually active Male circumcision 2 Countries wide introduction : Rwanda and Lesotho Nationwide introduction Demonstration project in 2013 Not yet in country EPI Not AFR Seychelles Comoros Mauritius 6 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

7 Secondary prevention entails screening & early diagnosis Currently the best chance of saving lives Traditionally cervical cytology (Pap smear) is known to have reduced incidence in developed countries Visual inspection with acetic acid or iodine is better alternative in this region followed by cryotherapy Services Acetic acid visualization Cervical cytology % countries with capacity 15% Source: 2012 NCD country capacity survey 25% HPV testing for high risk HPV 7 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

8 Tertiary prevention is treatment and care of invasive cancers Most challenging intervention Requires facilities with capacity for ablative surgery, chemotherapy, and radiotherapy Services % countries with capacity Chemotherapy 33% Some capacity for surgery in almost all countries; accessibility remains a major challenge Radiotherapy 20% Source: 2012 NCD country capacity survey Palliative care for advanced cases needs to be established 8 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

9 Understanding cervical cancer in the context of the African Continent High incidence and mortality rates while reliable data difficult to find Low survival rates Poor access to diagnosis, treatment and prevention Shortage of skilled health personnel - exodus of trained staff Institutional framework not clearly defined - Referral mechanisms unavailable Social determinants; disasters; HIV epidemic; etc 9 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

10 Efforts towards Cervical Cancer Prevention and Control Regional consultation on CxCa prevention and control held (2008; 2012; 2013 & 2014) with the objectives of: Raising awareness on CxCa prevention and control Providing policy guidance to countries to develop and implement comprehensive strategies Supporting countries in establishing national coordination committee Supporting introduction of HPV vaccine as primary prevention intervention Building national capacity to increase CxCa screening and treatment coverage 10 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

11 Efforts towards Cervical Cancer Prevention and Control Regional strategy for cancer prevention and control (2008): 1. Policies, legislation and regulations to ensure that all individuals in countries have access to cancer services 2. Establishment of comprehensive NCCP 3. Advocacy, RM and appropriate allocation 4. Mobilization of partners and coordination of interventions 5. Improve the skills of decision-makers, health personnel and care providers at all levels of health systems 6. Primary interventions - cost-effective approaches to reduce exposure to the major RF 7. Screening, early detection and diagnosis at the stages where cancers are curable 8. Diagnosis and treatment strategies ensuring that the majority of patients have access to efficient diagnostic and sufficient treatment facilities 9. Surveillance, research and knowledge management 11 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

12 Efforts towards Cervical Cancer Prevention and Control CxCa in the African Region: Current Situation and ways forward (2010) 1. Develop and implement CxCa prevention and control programmes based on clearly defined policy 2. Mobilize and allocate adequate resources 3. Ensure health promotion and community involvement 4. Improve the knowledge and skills of health personnel 5. Manage advanced cases of cancers 6. Establish an adequate surveillance system, ensure oversight of interventions and assess the impact of prevention programmes 7. Strengthen interdisciplinary collaboration and intersectoral and multisectoral partnerships for synergy of action 12 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

13 Efforts towards Cervical Cancer Prevention and Control Key prevention and control interventions for reducing cancer burden in the WHO African Region (2010) 1. A clear and comprehensive guide in choosing key and costeffective interventions to be implemented according to local settings. 2. Aims to strengthen and accelerate the translation of cancer control knowledge into public health action and serve as a key reference document in developing NCCP 3. Intended primarily for leaders, managers and decision-makers in health and related fields; medical professionals; academic institutions; nongovernmental organizations. 4. Emphasizes the stepwise implementation of priority interventions in the short term, followed by expanded and optimal interventions to be implemented in the medium and long term within the limits of available resources. 13 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

14 Efforts towards Cervical Cancer Prevention and Control Challenges Scarce CaCx control policy, strategies and programmes Limited national capacity CaCx screening methods not available at peripheral level Limited knowledge and skills among health providers Lack of recent and comprehensive national data High cost of immunization against HPV Unaffordability of therapeutic resources and neglect of palliative care Geographical inaccessibility of tertiary prevention Referral mechanisms not clearly defined Weak coordination Heavy economic and psychosocial burden 14 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

15 Cervical cancer and HIV Age-standardised rates <6.2 SSA 22.9 million 49% access to cart in 2010 highest HIV burden WHO Progress report HIV/AIDS 2011 SOURCE: GLOBOCAN 2012, IARC 15 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention

16 HPV HIV association between HIV-related immunosuppression and a higher prevalence, incidence and persistence of HPV infection and correlated higher incidence, persistence and progression of cervical lesions cart also appears to have little, if any, beneficial effect on the evolution of lesions. However, cart does prolong the life expectancy of women with HIV, hence increasing the opportunity for persistent high-risk HPV infection to cause CxCa over time 16 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention 16

17 Performance of screening test among HIV-positive women Test-pos (%) Sensitivity (%) Specificity (%) VIA SA(1) Kenya SA(2) Cytology Kenya SA(2) HPV SA(1) Kenya SA(2) SA(1): N= 956; 15% CIN2/3; by Kuhn et al., AIDS, Kenya: N=498; 25% CIN2/3; by Chung et al., AIDS, SA(2): N= 1202; 26% CIN2/3; Firnhaber et al., PLOS One, Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention 17

18 Conclusions screening HIV-positive women Triaging HPV-positive tests with another screening test (e.g. VIA) will decrease the number of women treated or referred for diagnostic confirmation:.. increase of specificity Kenya study: spec 56% (HPV) to 84% (HPV+VIA).. at the cost of a loss in sensitivity Kenya study: sens 84% (HPV) to 58% (HPV+VIA) Future triaging methods using biomarkers for cell transformation under investigation: HPV E6/E7 messenger RNA HPV E6 protein Cellular p16inka/ki-67 (immunostaining) 18 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention 18

19 Conclusions screening HIV-positive women Screening tests perform similarly as in HIVnegative women, except: Lower specificity for HPV testing, but maintained positive predictive value due to high prevalence of CIN2/3 lesions VIA performs similar (or better), possibly due to larger (hence more visible) lesions Treatment failure is high in HIV-positive women: need for effective monitoring after treatment 19 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention 19

20 Conclusions screening HIV-positive women We need long term follow-up studies to determine efficient screening and treatment algorithms (including screening frequency, use of cryotherapy, LEEP, cold coagulation) WHO: all screening recommendations for the general population apply to HIV-positive women, however with higher screening frequency ( 3 years) Improved infrastructure in HIV care clinics across sub- Saharan Africa offers an ideal opportunity to organise CxCa screening 20 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention 20

21 Conclusions Awareness creation and advocacy Development of comprehensive CxCa plans MoH to lead development and implementation of national comprehensive CxCa prevention and control programmes including tools for M & E Allocation of adequate resources VIA integrated in HIV care and treatment in countries on pilot/research projects - HIV testing systematically proposed when CxCa suspected/diagnosed 21 Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention