Journal of Global Health

Building local capacity for cervical cancer prevention in low resource settings: Changing strategy during the COVID-19 pandemic

Early evaluation of a screen-and-treat strategy using high-risk HPV testing for Uganda: Implications for screening coverage and treatment

Uganda has a high burden of cervical cancer and its current coverage of screening based on visual inspection with acetic acid (VIA) is low. High-risk HPV (hrHPV) testing is recommended by the World Health Organization as part of the global elimination strategy for cervical cancer. In this context, country-specific health economic evaluations can inform national-level decisions regarding implementation. We evaluated the recommended hrHPV screen-and-treat strategy to determine the minimum required levels of coverage and treatment adherence, as well as the maximum price level per test, for the strategy to be cost-effective in Uganda. We conducted a headroom analysis to estimate potential room for spending on implementing the hrHPV screen-and-treat strategy at different levels of coverage and treatment adherence (from 10% to 100%) at each screening round, and at different price levels of the hrHPV test. We compared the strategy with the existing VIA-based screen-and-treat policy in Uganda. We calculated headroom as the product of number of life years gained by the strategy and the willingness-to-pay threshold, minus the incremental costs incurred by the strategy. Positive headroom was interpreted as an indication of cost-effectiveness. Compared with VIA-based screening with low 5% coverage, the hrHPV screen-and-treat strategy required at least 30% coverage and adherence for positive mean headroom, and compared with 30% VIA-based screening coverage, the minimum levels were 60%. At 60% coverage and adherence, the maximum acceptable price per hrHPV test was found to be between 15 and 30 international dollars. The hrHPV-based screen-and-treat strategy could be cost-effective in Uganda if the screening coverage and treatment adherence are at least 30% in each screening round, and if the price per test is set below 30 international dollars. The minimum required levels of screening coverage and adherence to treatment provide potential starting points for decision-makers in planning the rollout of hrHPV testing. The headroom estimates can guide the planning costs of screening infrastructure and campaigns to achieve the required coverage and treatment adherence in Uganda.

Strengthening global commitment to eliminating cervical cancer: What lessons from the past can we apply to the future?

Implementing community-based human papillomavirus self-sampling with SMS text follow-up for cervical cancer screening in rural, southwestern Uganda

Self-collected HPV screening may improve cervical cancer screening coverage in low resource countries, yet data guiding implementation and follow-up of abnormal results are sparse. This is a prospective cohort implementation study of HPV self-testing program in Mbarara, Uganda with mobile phones to facilitate result notification and referral for treatment at a regional hospital. The effectiveness of the interventions was analyzed using Proctor's model of implementation. Women were interviewed following screening and at 6 months to assess acceptability and barriers to follow-up. Data were analyzed using descriptive statistics. 159 of 194 (82%) of eligible women underwent HPV self-sampling; of these, 27 (17%) returned positive for high-risk HPV subtypes. We sent SMS messages providing test results and follow-up instructions to all participants. Seventeen (63%) hrHPV-positive participants reported receiving SMS text instructions for follow-up, of whom 6 (35%) presented for follow-up. The most common reasons for not returning were: lack of transportation (n = 11), disbelief of results (n = 5), lack of childcare (n = 4), and lack of symptoms (n = 3). Confidence in test results was higher for self-screening compared to VIA (Likert score 4.8 vs 4.4, Despite the use of SMS text-based referrals, only one-third of women presented for clinical follow-up after abnormal HPV testing.

Benefits and challenges of cervical cancer screening since the implementation of the ‘two cancer’ screening programme in China: findings from Shangyu, Zhejiang in 2019–23

Cervical cancer is the fourth most common cancer in women worldwide. The World Health Organization has long targeted its elimination and stressed the need for enhanced screening coverage and improved treatment rates. The Chinese government initiated the 'two cancer' screening programme for cervical and breast cancer in 2009 for women aged 35-64 years, which Shangyu fully implemented in 2017. We evaluated the programme's progress in Shangyu using data from 2019-23, aiming to suggest feasible improvements and provide general recommendations for regions facing similar challenges. We used data collected and shared by the Shaoxing Shangyu Maternal and Child Health Hospital from 2019 to 2023. The study sample included 59 201 unemployed women aged 35-64 residing in Shangyu, Shaoxing with no previous cervical cancer histories. Following international guidance, we sent their cervical samples for HPV genotyping and liquid cytology testing and asked them to receive colposcopy as needed for eventual diagnosis, which was subsequently categorised into normal, low-grade cervical intraepithelial neoplasia (CIN 1), high-grade cervical intraepithelial neoplasia (CIN 2-3), squamous cell carcinoma (SCC), adenocarcinoma in situ (AIS), and adenocarcinoma (AA). We used logistic regressions to investigate potential associations between participants' demographic characteristics, risks of HPV positivity, and eventual diagnosis. The prevalence of HPV was 11.65% between 2019 and 2023. The three most common subtypes were HPV-52, HPV-16, and HPV-59. Among those who tested positive and received colposcopy, 97.05% had a normal diagnosis, 1.68% had CIN 1, 0.64% had CIN 2-3, 5.74‱ had SCC, 0.68‱ had AIS, and 0.51‱ had AA. Participants aged 50-54 years (adjusted odds ratio (aOR) = 1.19; 95% confidence interval (CI) = 1.02-1.38), 60-64 years (aOR = 1.33; 95% CI = 1.13-1.57), and those who took birth control pills alone (aOR = 2.35; 95% CI = 1.24-4.46) were associated with an increased likelihood of being tested HPV-positive. Older ages, specifically 55-59 years (aOR = 0.53; 95% CI = 0.29-0.96) and 60-64 years (aOR = 0.46; 95% CI = 0.25-0.85), were associated with a decreased likelihood of developing CIN 2-3. Contraceptive use of intrauterine devices alone was associated with an increased likelihood of developing CIN 2-3 (aOR = 1.41; 95% CI = 1.00-1.99). Being in menopause was associated with a decreased likelihood of developing SCC (aOR = 0.2; 95% CI = 0.06-0.65). As the pilot city of the 'two cancer' screening programme, Shangyu saw a gradual yearly increase in cervical cancer screening coverage. However, lack of awareness, reluctance to receive screening and later colposcopy, and underutilisation of screening alternatives undermined further progress. Future medical services and policies should prioritise health education and target neglected groups in both rural and urban areas.

Effects of screening coverage and screening quality assurance on cervical cancer mortality: Implication for integrated framework to monitor global implementation of cervical cancer screening programmes

Cervical cancer is a global health threat and a manifestation of inequality, and screening is an effective intervention. However, little is known about how screening coverage and quality assurance, influence cervical cancer mortality. We aimed to investigate the association between screening coverage, screening quality assurance and cervical cancer mortality among women from countries at different developmental levels. We obtained data on age-standardised mortality from cervical cancer from the GLOBOCAN 2020 database; coverage of cervical cancer screening from World Health Organization (WHO) Global Health Observatory; and cervical screening programme settings and quality assurance from the Cancer Screening in Five Continents (CanScreen5) database. We assessed the dependency of cervical cancer age-standardised mortality on screening coverage and quality assurance by simple and multiple regression models. We also used linear regression models to identify factors that improved the screening coverage. The study included data from 53 countries. Reduced mortality was associated with increased screening programme quality assurance in 22 high-development countries. In 31 low-development countries, screening coverage in women aged 30-49 years was inversely associated with cervical cancer mortality. Political commitment (documentation of the cervical cancer screening policy as law) and financial support (treatment services provided free of charge) positively associated with screening coverage. Screening programmes need strengthening commensurate with local resources and context. Priority should be given to improving screening coverage through stronger political commitment and financial support in low-development countries, and to ensuring good performance at all levels in high-development countries.

Role of breastfeeding on maternal and childhood cancers: An umbrella review of meta-analyses

Multiple studies and meta-analyses have claimed that breastfeeding is inversely correlated with maternal and childhood cancers. These results could either be causal or confounded by shared risk factors. By conducting an umbrella review, we aimed to consolidate the relationship between breastfeeding and maternal and childhood cancers. We searched PubMed, Embase, Web of Science, Elsevier ScienceDirect, and Cochrane Library databases from inception to December 2022. Two reviewers independently extracted the data and assessed the quality of the studies using standardised forms. We considered two types of breastfeeding comparisons ("ever" vs "never" breastfeeding; and "longest" vs "shortest" duration). We estimated the pooled risk and 95% confidence interval (CI) for each meta-analysis. We included seventeen meta-analyses with 55 comparisons. There was an inverse correlation between breastfeeding and childhood leukaemia (pooled risk = 0.90, 95% CI = 0.81-0.99), neuroblastoma (pooled risk = 0.81, 95% CI = 0.71-0.93), maternal ovarian cancer (pooled risk = 0.76, CI = 0.71-0.81), breast cancer (pooled risk = 0.85, 95% CI = 0.82-0.88), and oesophageal cancer (pooled risk = 0.67, 95% CI = 0.54-0.81) for "ever" vs "never" breastfeeding; and with childhood leukaemia (pooled risk = 0.94, 95% CI = 0.89-0.98), and maternal ovarian cancer (pooled risk = 0.84, 95% CI = 0.78-0.90) and breast cancer (pooled risk = 0.92, 95% CI = 0.89-0.96) for "longest" vs "shortest" breastfeeding duration. We found evidence that breastfeeding may reduce the risk of maternal breast cancer, ovarian cancers, and childhood leukaemia, suggesting positive implications for influencing women's decision in breastfeeding. PROSPERO (CRD42021255608).

The association of cervical cancer screening and quality of care: A systematic analysis of the Global Burden of Disease Study 2019

Improving the quality of care is vital to enhance outcomes for cervical cancer patients. However, the inequality of cervical cancer care was seldomly assessed. We collected the data of cervical cancer burden from the Global Burden of Disease 2019 database, and constructed the Quality of Care Index (QCI) using principle component analysis. Then the disparity of QCI across regions and populations were evaluated. The association between cervical cancer screening coverage and QCI weas also explored. Quality of cervical cancer care was of disparity across regions with different development levels, with a widening gap between low-income regions and others. Cervical cancer QCI dropped rapidly after the age of 35. Cervical cancer screening coverage was positively associated with QCI, and this association was stronger in countries with low- and middle-development levels. Regions with a low development level and the middle-aged women were vulnerable in QCI improvement. Higher screening coverage was associated with better cervical cancer QCI, implying that expanding cervical cancer screening coverage may be an effective strategy to improve the quality of cervical cancer care.

The road to recovery: an interrupted time series analysis of policy intervention to restore essential health services in Mexico during the COVID-19 pandemic

Recovery of health services disrupted by the COVID-19 pandemic represents a significant challenge in low- and middle-income countries. In April 2021, the Mexican Institute of Social Security (IMSS), which provides health care to 68.5 million people, launched the National Strategy for Health Services Recovery (Recovery policy). The study objective was to evaluate whether the Recovery policy addressed COVID-related declines in maternal, child health, and non-communicable diseases (NCDs) services. We analysed the data of 35 IMSS delegations from January 2019 to November 2021 on contraceptive visits, antenatal care consultations, deliveries, caesarean sections, sick children's consultations, child vaccination, breast and cervical cancer screening, diabetes and hypertension consultations, and control. We focused on the period before (April 2020 - March 2021) and during (April 2021 - November 2021) the Recovery policy and used an interrupted time series design and Poisson Generalized Estimating Equation models to estimate the association of this policy with service use and outcomes and change in their trends. Despite the third wave of the pandemic in 2021, service utilization increased in the Recovery period, reaching (at minimum) 49% of pre-pandemic levels for sick children's consultations and (at maximum) 106% of pre-pandemic levels for breast cancer screenings. Evidence for the Recovery policy role was mixed: the policy was associated with increased facility deliveries (IRR = 1.15, 95%CI = 1.11-1.19) with a growing trend over time (IRR = 1.04, 95%CI = 1.03-1.05); antenatal care and child health services saw strong level effects but decrease over time. Additionally, the Recovery policy was associated with diabetes and hypertension control. Services recovery varied across delegations. Health service utilization and NCDs control demonstrated important gains in 2021, but evidence suggests the policy had inconsistent effects across services and decreasing impact over time. Further efforts to strengthen essential health services and ensure consistent recovery across delegations are warranted.

Overview of thermal ablation devices for treating precancerous cervical lesions in low-resource settings

Epidemiology and risk factors for ovarian cancer incidence in the USA: a multilevel analysis

Ovarian cancer (OC) has the worst prognosis and highest death rate of all gynaecological cancers in the USA. We examined the independent effects of individual-, neighbourhood-, and state-level factors on ovarian cancer incidence using a multilevel analytical framework. In this retrospective cohort study, we analysed de-identified data from the All of Us research database, identifying women ≥18 years without prior ovarian cancer before January 2017. Participants were followed from 1 January 2017 through October 2023 (median follow-up: 6.6 years). Mixed-effects Cox regression models examined data on 85 388 individuals nested within ZIP-code areas and states, analysing individual-level risk factors and neighbourhood-level socioeconomic determinants, while accounting for geographic clustering. We fitted four progressive models: a null (random effects only), individual-level factors, neighbourhood-level factors, and full model with all covariates. Among 85 388 women followed for a total of 569 847 person-years, 419 (0.49%) developed OC. Age demonstrated the strongest associations, with significantly elevated risks of developing OC among women aged 50-59 years (adjusted hazard ratio (aHR) = 1.83; 95% confidence interval (CI) = 1.28-2.61), 60-69 years (aHR = 2.01; 95% CI = 1.39-2.90), and ≥70 years (aHR = 1.67; 95% CI = 1.07-2.59) compared to those <40 years. Retired women had increased risk of OC compared to employed women (aHR = 1.39; 95% CI = 1.04-1.86). Non-Hispanic Black women demonstrated lower risk of OC than non-Hispanic White women (aHR = 0.63; 95% CI = 0.45-0.88). Regional variations showed 53% lower risk in the South vs. Northeast (aHR = 0.47; 95% CI = 0.25-0.86). Hormone replacement therapy was associated with increased risk of OC (aHR = 2.46; 95% CI = 1.07-5.67). Significant geographic clustering of OC was observed at neighbourhood and state levels. Individual-level factors, particularly age and employment status, are the primary determinants of OC risk, while apparent geographic disparities reflect population composition, rather than unmeasured environmental factors. The complete explanation of geographic clustering through measured covariates could provide important insights for targeted prevention strategies and future epidemiological research.

High-resolution disease maps for cancer control in low-resource settings: A spatial analysis of cervical cancer incidence in Kampala, Uganda

The global burden of cervical cancer is concentrated in low-and middle-income countries (LMICs), with the greatest burden in Africa. Targeting limited resources to populations with the greatest need to maximize impact is essential. The objectives of this study were to geocode cervical cancer data from a population-based cancer registry in Kampala, Uganda, to create high-resolution disease maps for cervical cancer prevention and control planning, and to share lessons learned to optimize efforts in other low-resource settings. Kampala Cancer Registry records for cervical cancer diagnoses between 2008 and 2015 were updated to include geographies of residence at diagnosis. Population data by age and sex for 2014 was obtained from the Uganda Bureau of Statistics. Indirectly age-standardized incidence ratios were calculated for sub-counties and estimated continuously across the study area using parish level data. Overall, among 1873 records, 89.6% included a valid sub-county and 89.2% included a valid parish name. Maps revealed specific areas of high cervical cancer incidence in the region, with significant variation within sub-counties, highlighting the importance of high-resolution spatial detail. Population-based cancer registry data and geospatial mapping can be used in low-resource settings to support cancer prevention and control efforts, and to create the potential for research examining geographic factors that influence cancer outcomes. It is essential to support LMIC cancer registries to maximize the benefits from the use of limited cancer control resources.