Evaluation of a 5-year cervical cancer prevention project in Indonesia: Opportunities, issues, and challenges

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1 bs_bs_banner doi: /jog J. Obstet. Gynaecol. Res. Vol. 39, No. 6: , June 2013 Evaluation of a 5-year cervical cancer prevention project in Indonesia: Opportunities, issues, and challenges Young-Mi Kim 1, Fransisca Maria Lambe 3, Djoko Soetikno 3, Megan Wysong 1, Ana Isabel Tergas 2, Presha Rajbhandari 3, Abigael Ati 3 and Enriquito Lu 1 1 Jhpiego/USA, Johns Hopkins University, 2 Johns Hopkins Medical Institute, Baltimore, Maryland, USA; and 3 Jhpiego/ Indonesia, Johns Hopkins University, Jakarta, Indonesia Abstract Aim: The Cervical and Breast Cancer Prevention (CECAP) Project sought to develop a national model for cervical cancer prevention in Indonesia based on visual inspection with acetic acid (VIA) to detect abnormal changes in the cervix. The purpose of this study was to evaluate a pilot project introducing VIA and cryotherapy in Indonesia and to identify lessons learned that could be applied to the national scale-up of cervical cancer prevention services. Material and Methods: Fifty-four months (July 2007 to December 2011) of service records at 17 health centers were abstracted and analyzed. The data were used to calculate the proportion of all women aged who received VIA screening, the VIA-positive rate, the treatment rate, and the interval between screening and treatment. Results: The women screened during the project included 24.4% of the total female population in the target age group in the catchment area. Throughout the 5-year project, 83.1% of VIA-positive women sought cryotherapy. During the last 18 months of the project, after data collection tools were revised to more accurately reflect when cryotherapy was received, 13% of women were treated on the same day that they were screened. Among the 74% of women treated within 1 month of screening, the mean interval between screening and treatment was 7.2 days. Conclusion: As cervical cancer prevention services are scaled up throughout Indonesia, changes in the service delivery model and program management are needed to increase screening coverage, promote a single-visit approach, and ensure the quality of services. Key words: cancer prevention, cancer screening, cervical cancer, cryotherapy, Indonesia. Introduction Cervical cancer is the second leading cause of cancer deaths among women in developing countries, although it is preventable when detected and treated in its early stages. 1 In Indonesia, there were over new cases of cervical cancer and almost 7500 deaths due to the disease in In response, the Ministry of Health (MoH) launched the Cervical and Breast Cancer Prevention (CECAP) Project in January 2007, in partnership with Jhpiego and the Ford Foundation. The goal of this 5-year project was to develop a national model for cervical cancer prevention and breast cancer awareness. Cervical cancer prevention was based on implementing low-cost but effective methods of early detection at public health centers (or puskesmas). From the start, the CECAP Project worked at the national level toward the development and dissemination of Received: May Accepted: November Reprint request to: Dr Young-Mi Kim, Jhpiego, an affiliate of Johns Hopkins University, 1615 Thames Street, Baltimore, MD 21231, USA. ymkim@jhpiego.net The Authors

2 Cervical cancer prevention in Indonesia policy, service delivery, and training guidelines on cervical cancer screening and treatment that are applicable nationwide. The CECAP service delivery model relies on visual inspection with diluted acetic acid (VIA) to screen for abnormal changes in the cervix followed by cryotherapy or a referral to a hospital for further evaluation and/or advanced care when needed. Providers were trained to dilute a commercial brand of acetic acid with water to produce a 5% solution. VIA offers a welltested and cost-effective alternative that requires less infrastructure, training, equipment, and specialized personnel than cytology-based screening. 2 9 Because VIA screening results are available immediately, women with precancerous lesions can be treated during the same visit rather than having to return at a later date. A single-visit approach (SVA) that links VIA screening with immediate cryotherapy by a trained provider has been proven safe, feasible, cost-effective, and acceptable to women. 4,10 14 It also minimizes loss to follow-up and helps ensure that all women with precancerous lesions receive treatment The CECAP Project was implemented on a pilot basis in Karawang District, which is located approximately 1.5 h east of Jakarta. Karawang was selected as a demonstration site because of the high number of cervical cancer cases seen at the district hospital and the existence of multiple risk factors for cervical cancer, including early onset of sexual activity, high incidence of sexually transmitted infections (STI), and proximity to commercial sexual activity. At the end of the project in 2011, an evaluation was conducted in Karawang to assess outcomes and identify lessons learned that could be applied to the national scale-up of cervical cancer prevention services in Indonesia. This report focuses on one arm of the evaluation: the analysis of routine service statistics collected at participating health centers. It answers the following research questions: 1 What percentage of women in the target age group (30 50 years) in the community was screened? 2 What proportion of VIA-positive women received cryotherapy? 3 How effective were service providers in screening and treating women promptly? Methods Pilot activities in Karawang District CECAP services, including VIA screening and cryotherapy, were implemented at 17 of Karawang District s 47 public health centers. Each health center serves from eight to 15 villages. The health centers selected were located in both rural and urban areas and were geographically dispersed across the district to maximize access to cervical cancer screening and treatment. CECAP services were introduced at four health centers in 2007, followed by an additional eight health centers in 2008 and five health centers in The evaluation included all 17 facilities. The service model, guidelines, and training package developed at the national level, based on Jhpeigo packages in other countries, were implemented in Karawang. A team of two or three physicians and midwives who were the primary providers for reproductive health services at each facility were trained in VIA and cryotherapy, using a competency-based approach. Depending on the size of the facility, they represented a smaller or greater proportion of all providers at the facility. The project: (i) included refresher training, which included a review of relevant knowledge and classroom simulation and clinical practice to strengthen identification of significant acetowhite lesions; (ii) offered mentoring and coaching during refresher training; (iii) provided essential equipment and supplies; (iv) developed an information system for the health center level; and (v) trained staff in documenting, recording, and reporting relevant data. Eleven of the 17 health centers implemented the Standards-Based Management and Recognition quality improvement process, which uses detailed standards to guide essential tasks performed by health-care workers and identify and address weaknesses in service delivery. 19 During the final year of the project, midwives at eight health centers were trained to perform cryotherapy. This marked a change from previous policy, which limited the performance of cryotherapy to doctors. Advocacy and behavior change communication formed an essential part of the CECAP Project. Activities focused on raising awareness of cervical cancer and gaining broad support from stakeholders and the community for screening and treatment. Advocacy teams were established at the national, district, and subdistrict levels. The project also recruited the help of volunteer community health workers, called kaders, who go house-to-house to promote various health services. To increase the number of women screened, health centers began holding mobile outreach events once or twice a year in each village. Kaders publicized the events, which were held in the village midwife s 2013 The Authors 1191

3 Y-M. Kim et al. house, and encouraged women to go for screening. From 10 to 60 women attended each event, which included a group counseling session followed by VIA screening. Cryotherapy was not offered because of the difficulty of transporting the CO 2 tanks. Instead, women who screened positive were referred to the health center for cryotherapy. While health center service statistics routinely included mobile outreach events, they did not record the location where each woman was screened; however, providers observed that relatively few women sought screening at health centers. Rather, they reported that most women were screened at outreach events. Data collection and analysis Fifty-four months (July 2007 to December 2011) of service records on cervical cancer screening and treatment at all 17 health centers were abstracted and analyzed. Data included the number of women who received VIA screening and the results of that screening (normal, precancerous lesions, or suspected cancer). For women who tested positive for precancerous lesions, data included the number who pursued cryotherapy during the same or a later visit, the results of a repeat VIA test conducted by doctors before they performed cryotherapy, and the number who received cryotherapy (if the repeat test was negative, women were not treated with cryotherapy). Early data collection forms did not indicate the patient s age or the timing of cryotherapy in relation to the initial screening. The forms were changed in the summer of 2010 to show how much time elapsed between screening and cryotherapy treatment. To help explain the quantitative data, we sometimes refer to findings from qualitative research conducted as part of the CECAP evaluation. The methods and results of that research, which explored factors affecting women s decisions regarding cervical screening and treatment, are fully reported elsewhere. 20 Results Screening coverage Table 1 shows that the number of women screened annually grew sharply in the early years of the project as more health centers began participating. Once all 17 health centers had implemented the CECAP model, the number of women screened annually rose from in 2009 to in 2010, before falling to in Table 1 CECAP service data on VIA screening and cryotherapy, Among eligible VIA-positive women, number (%) who: Among women screened, number (%) who were: Did not seek cryotherapy Sought cryotherapy VIA-positive Suspected of having cancer Number of women screened Dates Number of health centers implementing CECAP July Dec (3.5) 0 (0) 17 (63.0) 10 (37.0) Jan Dec (3.2) 21 (0.4) 109 (69.4) 48 (30.5) Jan Dec (1.6) 43 (0.4) 147 (89.6) 17 (10.4) Jan Dec (1.6) 43 (0.3) 247 (91.8) 22 (8.2) Jan Dec (1.6) 38 (0.3) 158 (79.4) 41 (20.6) Total (1.8) 145 (0.3) 678 (83.1) 138 (16.9) Women were eligible for cryotherapy if they were VIA-positive, their lesions did not occupy more than 75% of the cervical surface, and they were not suspected of cervical cancer. Includes women who made a separate trip to a health facility for cryotherapy after screening, as well as women who received cryotherapy on the same day as screening. Data collected in February 2012; women who returned for treatment after that data are not included. CECAP, Cervical and Breast Cancer Prevention; VIA, visual inspection with acetic acid The Authors

4 Cervical cancer prevention in Indonesia Table 2 Cumulative screening coverage among women aged 30 50, , by health center Health center Total female population aged Number of women aged screened Ciampel Pangkalan Jatisari Cilamaya Rengas Dengklok Telagasari Kota Baru Klari Cikampek Pedes Karawang Tempuran Tirta Jaya Tirta Mulya Lemah Abang Batu Jaya Cibuaya Total Percent of population screened Over the course of the 5-year project, a total of women received VIA screening, including women in the target age group of years. They represented 24.4% of the total female population aged in the catchment area of the 17 health centers. Cumulative screening coverage in the target age group exceeded 40% at two health centers. Less than 20% of the target population was screened at seven health centers (Table 2). Results of VIA screening Among all women screened from 2007 to 2011, 1.8% tested positive for cervical dysplasia (Table 1). The VIA-positive rate was highest during the first 18 months of the project, at 3.5% in 2007 and 3.2% in It fell to 1.6% from 2009 through A total of 145 women, or 0.3% of those screened over the 5-year period, were suspected of having cervical cancer. That proportion remained stable from one year to the next. Women suspected of cancer were referred to the district hospital for further evaluation and advanced care. Follow-up information, including the number of women with a confirmed diagnosis of cervical cancer and the number who received appropriate treatment, is not available. Loss to follow-up According to project guidelines, VIA-positive women are eligible for cryotherapy if they are not suspected of having cervical cancer and if their lesions do not cover more than 75% of the cervical surface or extend into the endocervical canal. Women with larger lesions are expected to be referred to a hospital for treatment; however, there were no records of VIA-positive women with large lesions at participating health centers. Over the course of the 5-year project, the majority (83.1%) of VIA-positive women had cryotherapy (Table 1), but not necessarily on the same day that they were screened. Most women visited a health center at a later date for treatment (see below for data on the interval between screening and treatment). The proportion of women who received cryotherapy rose markedly after 2008, in large part due to a change in how cryotherapy was offered. During the first 2 years of the CECAP Project, obstetrician/gynecologists at the district hospital were responsible for performing cryotherapy. In 2009, general practitioners (GP) began to perform cryotherapy at health centers. This made the service more readily accessible to women, who no longer had to travel to the district hospital for treatment; however, the change in policy did not guarantee that treatment was available on the same day as screening, as each health center typically has only one GP on staff who not only serves as manager, but also has clinical responsibilities for all primary health-care services. In 2009 and 2010, around 90% of VIA-positive women either received cryotherapy the same day they 2013 The Authors 1193

5 Y-M. Kim et al. Table 3 Outcomes for women who came for cryotherapy after screening positive for precancerous lesions Dates Number of women who were VIA-positive and came for cryotherapy During repeat visualization, number (%) of women who were: VIA-negative VIA-positive July Dec (70.6) 5 (29.4) 5 (100) Jan Dec (58.7) 45 (41.3) 44 (100) Jan Dec (34.0) 97 (66) 97 (100) Jan Dec (29.6) 174 (70.4) 174 (100) Jan Dec (20.3) 126 (79.7) 126 (100) Total (34.1) 447 (65.9) 447 (100) Among women who were VIA-positive on a repeat visualization, number (%) who received cryotherapy Includes women who made a separate trip to a health facility for cryotherapy after screening, as well as women who received cryotherapy on the same day as screening. Women who were VIA-negative on a second screening were not offered cryotherapy. VIA, visual inspection with acetic acid. were screened or visited a health center for treatment at a later date. That proportion fell to 79.4% in 2011, leaving about 20.6% of VIA-positive women who never returned to a health center for cryotherapy by the end of data collection in February Cryotherapy rates When VIA-positive women return for treatment at a later date, national guidelines require doctors to perform a repeat VIA test to confirm the presence of precancerous lesions before they conduct cryotherapy. In 70.6% of cases in 2007 and 58.7% of cases in 2008, the repeat VIA test was negative and the women were not treated (Table 3). That proportion fell to 34% of cases in 2009 and continued to decline to 20.3% in Every woman who came for cryotherapy and was found to be VIA-positive on a repeat visualization received cryotherapy. Figure 1 Interval between screening and treatment. Interval between screening and treatment Information on the interval between screening and treatment is available for the 18-month period from July 2010 to December 2011, during which 155 VIA-positive women received cryotherapy. Only 13% of these women were treated on the same day that they were screened, but another 74% received treatment within 1 month of screening (Fig. 1). Among women screened within 1 month, the mean interval between screening and treatment was 7.2 days. According to interviews and focus-group discussions with providers, women, and husbands in Karawang, there are three main reasons why VIApositive women do not receive treatment on the same day as screening: (i) women must travel to the health center to get cryotherapy; (ii) cryotherapy is not consistently available at health centers due to a lack of trained providers, space, equipment, and/or supplies; and (iii) women are required to obtain their husband s consent for the procedure. 20 Discussion Applying lessons learned from the CECAP pilot in Karawang District can help improve the effectiveness, The Authors

6 Cervical cancer prevention in Indonesia quality, and sustainability of cervical cancer prevention services as they are scaled up throughout Indonesia. Routine service statistics from 17 sub-districts in Karawang point to four opportunities to improve service delivery: 1 Intensifying community mobilization and expanding the role of static service delivery sites to increase screening coverage. 2 Incorporating continuous quality improvement to strengthen providers skills. 3 Changing the service delivery model to expand access to SVA. 4 Collecting and utilizing data to strengthen strategic planning and program management. Expanding screening coverage Health centers in Karawang primarily relied on mobile outreach events for VIA screening, which were held only once or twice a year in each village. Although mobile screening services have proven effective in other developing countries, especially for hardto-reach communities, 21 service statistics show that screening coverage remained low in Karawang. The relative infrequency of visits by mobile screening teams may have reduced access to screening in the community. The downward trend in the pace of screening during the final year of the project reinforces the need to try new approaches to increase screening coverage in addition to continuing and even increasing the frequency of mobile outreach. While this study did not investigate alternative service-delivery models, experience in Karawang has led program experts to suggest some promising possibilities that take advantage of the ability of static facilities to offer continuing access to screening between outreach events. One option is to integrate VIA screening into related, routine health services offered at health centers and other static sites. This approach would invite every woman aged who visits a health center, regardless of the reason, to be screened for cervical cancer in a no-missed-opportunities approach. 21 Another possibility is for health centers to partner with private midwives. For example, midwives could be encouraged to bring women for screening and treatment on designated days. Some health centers have even begun training village midwives to perform VIA screening in order to make the service regularly available within the community. These midwives are expected to coordinate their services with nearby health centers offering cryotherapy so that same-day screening and treatment is possible. Experience across developing countries has demonstrated the importance of community involvement to increase participation in cervical cancer screening. 17,22 In Karawang, local advocacy teams and kaders were supposed to meet this need, but they did not function as well as expected, according to interviews with health workers and advocacy team members. 20 Weak leadership, lack of coordination, limited funding, and lack of clarity concerning the function and responsibilities of advocacy teams hampered their ability to promote cervical cancer screening, while competing obligations to other health programs limited most kaders commitment to CECAP activities. Changes are needed to strengthen community mobilization efforts, for example, by arranging stronger leadership and a clear scope of work for local advocacy teams or by offering kaders greater recognition. Partnering with other potential spokespersons in the community, such as religious leaders and high school teachers, could also help disseminate CECAP messages. Improving the quality of services While providers met performance standards during refresher training, three findings raise questions about their technical skills: 1 Only 1.8% of women screened positive, which is low compared to reports in other countries. Elsewhere in Asia, studies have recorded VIA-positive rates of 4.8% in Bangladesh, % in Laos, % in Tamil Nadu, India, 8 and 13.3% in rural Thailand. 12 In addition, the MoH has reported a VIA-positive rate of 4.3% in other parts of Indonesia. This raises the question of whether midwives are missing lesions during the testing process or the base prevalence for cervical precancer is low in Karawang. 2 No VIA-positive women in Karawang were reported to have large lesions. It is not clear whether midwives and doctors do not recognize large lesions, are misreporting them, or are failing to report them. 3 Doctors did not always confirm the presence of cervical lesions in women found VIA-positive by midwives, although differences in test results decreased over time, presumably due to the normal learning curve. One cannot assume that the doctors were more accurate than the midwives. Based on current data, it is impossible to determine whether the lower-than-expected rate of cervical lesions, including large lesions, reflects the true rate of 2013 The Authors 1195

7 Y-M. Kim et al. dysplasia in Karawang or is an artifact of poor provider skills. Examinations conducted during refresher training and mentoring activities found that providers were able to accurately assess the results of VIA tests. Hence, a clinical study is needed to determine the true rate of cervical dysplasia and cervical cancer in Karawang. Additionally, a robust quality assurance mechanism, such as a video link allowing experts to check diagnoses made in the field, could ensure that providers are performing according to standards. If there was evidence that the skills of some or all providers were weak, retraining would be indicated. Experience in other countries shows that it is not difficult to train mid-level providers to perform VIA screening to a high standard, although nurses and midwives may need more practice than doctors and may find it more challenging to make clinical judgments about the need for treatment. 27 Training alone is insufficient, however. Consistent, on-the-job coaching and mentoring by experienced supervisors, as well as peer-to-peer learning, are needed to strengthen providers skills and maintain the accuracy and consistency of VIA screening. Unlike the coaching and mentoring provided by the CECAP Project at training workshops, on-site coaching and mentoring as part of supportive supervision offers providers immediate feedback on their skills and also enables coaches to address other aspects of the work environment that affect performance, such as protocols, equipment, supplies, motivation, and management support. The government health system in Indonesia already offers this kind of on-the-job coaching and mentoring for other maternal and neonatal health interventions; it could be extended to CECAP services at little additional expense. Cervical cancer prevention programs in other lowresource settings have instituted a range of quality assurance procedures. A variety of tools including supportive supervision, peer feedback, weekly meetings to review cases, periodic refresher courses, flash cards featuring photos of healthy and unhealthy cervixes washed with vinegar and other job aids, and regular monitoring with performance checklists have been shown to help providers achieve high performance. 16,27 30 This gives program managers an extensive toolkit from which to select the approaches most appropriate to the setting. In Indonesia, the most pressing need is for ongoing supportive supervision. Clinically competent supervisors, who have been trained on program standards, could check whether providers are correctly interpreting the results of VIA tests, reinforce guidelines regarding large lesions, and determine which provider is correct when test results are not confirmed. Once supervisors identify a problem, they could offer providers coaching, on-thejob training, and close monitoring to correct it, drawing on some of the tools listed above, as needed. Promoting SVA During the final year of the CECAP Project, less than 14% of VIA-positive women received cryotherapy the same day, while 21% had not returned for treatment by February Others faced delays in seeking treatment. The solution is SVA. Indeed, same-day screening and treatment is one of the primary benefits of using VIA rather than Pap smears; however, the CECAP Project was not able to offer SVA to most women because mobile outreach events lacked the equipment and, in most cases, the trained providers needed to perform cryotherapy. Raising the SVA rate in Indonesia will require more trained providers (and an acceptance that lower-level cadres can perform cryotherapy), additional equipment, and arrangements to offer cryotherapy outside of health centers. To make SVA more readily available, the CECAP Project began training midwives in cryotherapy during its final year. Experience in Bangladesh, Ghana, India, Thailand, and South Africa has demonstrated that, with careful training, nurses and midwives are capable of providing cryotherapy safely and effectively ,30 33 Midwives in Karawang were well trained, as demonstrated by high scores on post-tests. Mid-level providers are also acceptable to and sometimes even preferred by women receiving cryotherapy. 34 This is likely to be true in Indonesia as well, given women s preference for female providers for most procedures, particularly more intimate ones, such as VIA screening and cryotherapy. In Indonesia, task shifting offers the additional advantage of training a cadre of providers who are less mobile than doctors and therefore more likely to remain at the health center where they were originally trained. Task shifting in Indonesia faces challenges, however. Regulatory changes are needed to ensure that any trained and qualified provider, regardless of cadre, can operate and freely utilize cryotherapy equipment. In addition, trained midwives must be offered ongoing support and a chance to practice their skills. In Karawang, midwives had little opportunity to perform cryotherapy after they were trained because of the low caseload and the reluctance of some doctors to allow midwives to perform cryotherapy if they were available instead. 20 Ensuring doctors cooperation and The Authors

8 Cervical cancer prevention in Indonesia arranging for trained midwives to provide cryotherapy at multiple sites will be essential to the success of task shifting. Offering cryotherapy at mobile outreach events and village locations wherever minimum safety standards can be ensured is critical to SVA. A project in Thailand has demonstrated that it is feasible for mobile teams to transport CO 2 tanks and equipment between sites and offer cryotherapy services along with screening; 12 however, providers in Karawang are concerned about the efficiency of using portable CO 2 tanks because their small size limits the number of procedures that can be conducted. 20 A program in the Philippines takes a different approach: it permanently stations full-size CO 2 tanks at churches, schools, and health posts, so that providers have somewhere to take and treat VIA-positive women immediately after mobile screening events (Lu E, 2012, unpublished data). Because limited resources make it impossible to supply every health facility and outreach site in Indonesia with cryotherapy equipment, it is crucial to place these units strategically so as to maximize access and coverage. It is also important to encourage sharing of the equipment available, for example, by designating certain health centers to provide cryotherapy for multiple sub-districts. Collecting and utilizing data Routinely collecting service data and tracking key indicators is essential for effective planning and management of cervical cancer prevention programs; it enables managers to monitor performance and improve ongoing service delivery. 21 In Guyana, Côte d Ivoire, and Tanzania, regular review of service data has enabled managers to overcome barriers to screening and treatment and to systematically improve outcomes; each quarter, they compare service statistics against standards set for screening coverage, the VIApositive rate, and the SVA rate (Wysong MW, 2012, unpublished data). Our evaluation revealed numerous weaknesses in data collection at study sites in Karawang District. For example, forms initially did not record the patient s age or the interval between screening and treatment, providers did not report large lesions, and no further information was collected on women suspected of cervical cancer, including whether cancer was confirmed and treatment given. In addition, the limited data available were not routinely or effectively utilized for program management, such as changing intervention strategy. Conclusion The MoH has introduced cervical cancer screening and treatment services based on the CECAP model in 14 provinces across Indonesia, using the guidelines, training modules, and other materials tested in Karawang District. District governments provide all of the supplies and equipment needed and also pay to train providers in VIA and cryotherapy. As a result of these efforts to scale up the CECAP approach, over women in 68 districts across Indonesia received VIA screening from 2007 to 2010; however, only 39.3% of VIA-positive women received cryotherapy. It is important to note that the effectiveness of the services offered outside of the Karawang District have not been evaluated, and other districts may face a unique set of barriers to implementation, which may result in lowerquality services. Lessons learned in Karawang will help cervical cancer prevention programs across Indonesia increase screening coverage, improve the quality of services, expand SVA, and utilize service data for program management. Acknowledgments Financial support for this evaluation came from the Ford Foundation and the Union for International Cancer Control. The authors are grateful to Dr H. Yuska Yasin, MM, Dr Rasim, Dr Hj. Rina Hasriana, Mkes, and Haryanto, SKM from the Karawang District Health Office, Dr Fita Rosemary, Agus from Provincial Health Office, and Dr Basalama Fatum, MKM from MoH/ Indonesia for their contributions. We thank the data collectors, Maulana Hasan and Haryanti Koostanto. Special thanks to Anne Hyre, Alain Damiba, Linda Fogarty, Sharon Kibwana, Jean Sack and Katherine Naugle at Jhpiego for their guidance and review of the report. Thanks to Richard Embry for his collaboration. Special thanks to Adrienne Kols who helped the team with writing and editing the report. We also thank the service providers and CECAP clients who participated in the study. Disclosure No author has any potential conflict of interest. References 1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOB- OCAN Int J Cancer 2010; 127: The Authors 1197

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