Silvana Luciani

Delivering cervical cancer prevention services in low-resource settings

The goals of any cervical cancer prevention program should be threefold: to achieve high coverage of the population at risk, to screen women with an accurate test as part of high‐quality services, and to ensure that women with positive test results are properly managed. This article focuses on the experiences of the Alliance for Cervical Cancer Prevention (ACCP) in delivery of screening and treatment services as part of cervical cancer prevention projects in Africa, Latin America, and Asia. Research and experience show that cervical cancer can be prevented when strategies and services are well planned and well managed and when attention is paid to program monitoring and evaluation. Coordination of program components, reduction of the number of visits, improvement of service quality, and flexibility in how services are delivered are all essential features of an effective service.

A Review of Breast Cancer Care and Outcomes in Latin America

This review presents an overview of breast cancer care, burden, and outcomes in Latin America, as well as the challenges and opportunities for improvement. Information was gleaned through a review of the literature, public databases, and conference presentations, in addition to a survey of clinical experts and patient organizations from the region. Breast cancer annual incidence (114,900 cases) and mortality (37,000 deaths) are the highest of all womens cancers in Latin America, and they are increasing. Twice as many breast cancer deaths are expected by 2030. In Peru, Mexico, Colombia, and Brazil, diagnosis and death at younger ages deprives society of numerous productive years, as does high disease occurrence in Argentina and Uruguay. Approximately 30%-40% of diagnoses are metastatic disease. High mortality-to-incidence ratios (MIRs) in Latin America indicate poor survival, partly because of the late stage at diagnosis and poorer access to treatment. Between 2002 and 2008, MIRs decreased in all countries, albeit unevenly. Costa Ricas change in MIR outpaced incidence growth, indicating impressive progress in breast cancer survival. The situation is similar, although to a lesser extent, in Colombia and Ecuador. The marginal drops of MIRs in Brazil and Mexico mainly reflect incidence growth rather than progress in outcomes. Panamas MIR is still high. Epidemiological data are scattered and of varying quality in Latin America. However, one could ascertain that the burden of breast cancer in the region is considerable and growing due to demographic changes, particularly the aging population, and socioeconomic development. Early diagnosis and population-wide access to evidence-based treatment remain unresolved problems, despite progress achieved by some countries.

Progress and remaining challenges for cancer control in Latin America and the Caribbean

Cancer is one of the leading causes of mortality worldwide, and an increasing threat in low-income and middle-income countries. Our findings in the 2013 Commission in The Lancet Oncology showed several discrepancies between the cancer landscape in Latin America and more developed countries. We reported that funding for health care was a small percentage of national gross domestic product and the percentage of health-care funds diverted to cancer care was even lower. Funds, insurance coverage, doctors, health-care workers, resources, and equipment were also very inequitably distributed between and within countries. We reported that a scarcity of cancer registries hampered the design of credible cancer plans, including initiatives for primary prevention. When we were commissioned by The Lancet Oncology to write an update to our report, we were sceptical that we would uncover much change. To our surprise and gratification much progress has been made in this short time. We are pleased to highlight structural reforms in health-care systems, new programmes for disenfranchised populations, expansion of cancer registries and cancer plans, and implementation of policies to improve primary cancer prevention.

Effectiveness of cryotherapy treatment for cervical intraepithelial neoplasia

To assess the effectiveness of cryotherapy treatment delivered by general practitioners in primary care settings, as part of a screen‐and‐treat approach for cervical cancer prevention.

World Health Organization Guidelines for treatment of cervical intraepithelial neoplasia 2–3 and screen-and-treat strategies to prevent cervical cancer

It is estimated that 1%–2% of women develop cervical intraepithelial neoplasia grade 2–3 (CIN 2–3) annually worldwide. The prevalence among women living with HIV is higher, at 10%. If left untreated, CIN 2–3 can progress to cervical cancer. WHO has previously published guidelines for strategies to screen and treat precancerous cervical lesions and for treatment of histologically confirmed CIN 2–3.

Advocating for cervical cancer prevention.

Cervical cancer is a significant health problem among women in developing countries. Contributing to the cervical cancer health burden in many countries is a lack of understanding and political will to address the problem. Broad‐based advocacy efforts that draw on research and program findings from developing‐country settings are key to gaining program and policy support, as are cost‐effectiveness analyses based on these findings. The Alliance for Cervical Cancer Prevention (ACCP) has undertaken advocacy efforts at the international, regional, national, and local levels to raise awareness and understanding of the problem (and workable solutions), galvanize funders and governments to take action, and engage local stakeholders in ensuring program success. ACCP experience demonstrates the role that evidence‐based advocacy efforts play in the ultimate success of cervical cancer prevention programs, particularly when new screening and treatment approaches—and, ultimately, radically new approaches such as a human papillomavirus vaccine—are available.

Cervical and female breast cancers in the Americas: current situation and opportunities for action

OBJECTIVE To understand better the current regional situation and public health response to cervical cancer and female breast cancer in the Americas. METHODS Data on cervical cancer and female breast cancers in 33 countries, for the period from 2000 to the last year with available data, were extracted from the Pan American Health Organization (PAHO) Regional Mortality Database and analysed. Changes in mortality rates over the study period - in all countries except those with small populations and large fluctuations in time-series mortality data - were calculated using Poisson regression models. Information from the PAHO Country Capacity Survey on noncommunicable diseases was also analysed. FINDINGS The Bahamas, Trinidad and Tobago and Uruguay showed relatively high rates of death from breast cancer, whereas the three highest rates of death from cervical cancer were observed in El Salvador, Nicaragua and Paraguay. Several countries - particularly Paraguay and Venezuela - have high rates of death from both types of cancer. Although mortality from cervical cancer has generally been decreasing in the Americas, decreases in mortality from breast cancer have only been observed in a few countries in the Region of the Americas. All but one of the 25 countries in the Americas included in the PAHO Country Capacity Survey reported having public health services for the screening and treatment of breast and cervical cancers. CONCLUSION Most countries in the Americas have the public health capacity needed to screen for - and treat - breast and cervical cancers and, therefore, the potential to reduce the burden posed by these cancers.

A Pan American Health Organization strategy for cervical cancer prevention and control in Latin America and the Caribbean

Abstract Cervical cancer is the leading cause of cancer deaths among women in Latin America and the Caribbean, and disproportionately affects poorer women. Mortality rates in the region are seven times greater than in North America. In light of the significant public health burden, the Pan American Health Organization has drafted a Regional Strategy for Cervical Cancer Prevention and Control. The Strategy calls for increased action to strengthen programmes through an integrated package of services: health information and education; screening and pre-cancer treatment; invasive cervical cancer treatment and palliative care; and evidence-based policy decisions on whether and how to introduce human papillomavirus (HPV) vaccines. It calls for a seven-point plan of action: conduct a situation analysis; intensify information, education and counselling; scale up screening and link to pre-cancer treatment; strengthen information systems and cancer registries; improve access to and quality of cancer treatment and palliative care; generate evidence to facilitate decision-making regarding HPV vaccine introduction; and advocate for equitable access and affordable HPV vaccines. This proposed strategy, approved by the PAHO Directing Council on 1 October 2008, has the possibility of stimulating and accelerating the introduction of new screening technology and HPV vaccines into programmes throughout Latin America and the Caribbean. Résumé Le cancer du col de l’utérus est la principale cause de mortalité par cancer chez les femmes en Amérique latine et dans les Caraïbes, et il touche de manière disproportionnée les femmes pauvres. Les taux de mortalité dans la région sont sept fois plus élevés qu’en Amérique du Nord. C’est pourquoi l’Organisation panaméricaine de santé (OPS) a formulé une Stratégie régionale pour la prévention et le contrôle du cancer du col de l’utérus. La Stratégie demande une action accrue pour renforcer les programmes par un ensemble intégré de services : éducation en santé ; dépistage et traitement des lésions précancéreuses ; traitement et soins palliatifs des formes invasives ; et décisions de politique à base factuelle sur l’opportunité et les modalités de l’introduction des vaccins contre le papillomavirus humain (PVH). Elle prône un plan d’action en sept points : mener une évaluation de la situation ; intensifier l’éducation, l’information et le conseil ; affermir les programmes de dépistage et de traitement précancéreux ; renforcer les systèmes d’information et les registres du cancer ; améliorer l’accès et la qualité du traitement du cancer et des soins palliatifs ; créer des données probantes pour faciliter la prise de décision concernant l’introduction du vaccin anti-PVH ; et préconiser un accès équitable et abordable aux vaccins anti-PVH. Si elle est approuvée par le Conseil de directeur de l’OPS le 1er octobre 2008, cette stratégie pourrait stimuler et accélérer l’introduction de nouvelles technologies de dépistage et des vaccins anti-PVH en Amérique latine et aux Caraïbes. Resumen El cáncer cervical es la principal causa de muertes por cáncer entre las mujeres de Latinoamérica y el Caribe, y afecta desproporcionadamente a las mujeres más pobres. Las tasas de mortalidad en la región son siete veces mayor que en Norteamérica. En vista de la considerable carga de salud pública, la Organización Panamericana de la Salud elaboró la versión preliminar de una Estrategia Regional para la Prevención y el Control del Cáncer Cervical. La estrategia hace un llamado para aumentar las medidas destinadas a fortalecer los programas mediante una serie integrada de servicios: información y educación en salud; tamizaje y tratamiento pre-cáncer; tratamiento invasivo del cáncer cervical y atención paliativa; y decisiones de políticas basadas en evidencia respecto a si se deben introducir vacunas contra el virus del papiloma humano (VPH) y cómo. Hace un llamado para ejecutar un plan de acción de siete puntos: realizar un análisis de situación; intensificar la información, educación y consejería; ampliar el tamizaje y vincular al tratamiento pre-cáncer; fortalecer los sistemas de información y los registros de cáncer; mejorar el acceso al tratamiento del cáncer y la atención paliativa y la calidad de estos; generar evidencia para facilitar la toma de decisiones respecto al lanzamiento de vacunas contra el VPH; y abogar por igualdad de acceso y vacunas de VPH a precios asequibles. Si es aprobada por el Consejo Directivo de la OPS el 1 de octubre de 2008, esta estrategia tiene la posibilidad de estimular y acelerar el lanzamiento de una nueva tecnología de tamizaje y vacunas contra el VPH en los programas de Latinoamérica y el Caribe.

A participatory assessment to identify strategies for improved cervical cancer prevention and treatment in Bolivia

En este trabajo se evaluan la organizacion y disponibilidad de servicios de prevencion y tratamiento del cancer cervicouterino en cuatro de los nueve departamentos de Bolivia y se identifican estrategias de intervencion. De 2001 a 2002 un equipo multidisciplinario de 15 personas llevo a cabo en Bolivia una evaluacion que comprendio una revision bibliografica sobre el cancer cervicouterino en el pais, entrevistas semiestructuradas con 583 partes interesadas y 56 observaciones de servicios de salud de diversos niveles. En un taller celebrado despues del trabajo de campo se reunieron 60 lideres de todos los departamentos del pais para revisar los resultados y determinar su prioridad, y para elaborar recomendaciones basadas en las pruebas cientificas recaudadas con miras a fortalecer los servicios de prevencion del cancer cervicouterino. Bolivia tiene una de las tasas mas altas de cancer cervicouterino en el mundo. No obstante, no tiene ningun programa organizado ni tampoco ninguna estrategia destinada a lograr que el tamizaje del cancer cervicouterino alcance una cobertura minima de 80%, que es la meta establecida por el Ministerio de Salud y Prevision Social. Una buena parte de la poblacion carece de informacion sobre los servicios para la prevencion y el tratamiento de lesiones precancerosas, o no puede llegar a estos servicios con facilidad. Los proveedores de atencion sanitaria en el sector publico calculan que de 50 a 80% de las mujeres sometidas al tamizaje no regresan a su seguimiento porque no hay ningun sistema que garantice un seguimiento adecuado con fines de diagnostico o tratamiento. Muchos prestadores de atencion de salud desconocen que los frotis de Papanicolaou se usan para detectar lesiones precancerosas. Bolivia tiene una unidad establecida dentro del Ministerio de Salud y Prevision Social cuya funcion es crear, administrar y supervisar programas nacionales para la prevencion y el tratamiento del cancer cervicouterino. Dicha unidad, en coordinacion con las autoridades sanitarias en cada uno de los departamentos del pais, tambien busca fortalecer la imposicion de normas nacionales, actividades de capacitacion, e iniciativas comunitarias de tipo informativo o educativo. No obstante, los servicios de tamizaje no estan debidamente vinculados con los de diagnostico y tratamiento de lesiones precancerosas. Por anadidura, los servicios de diagnostico y tratamiento no siempre abundan o son accesibles. Si se han de mejorar los servicios y la atencion a la comunidad, es necesario llevar a cabo investigaciones, efectuar cambios programaticos y adoptar cambios de politicas a fin de fortalecer la planificacion y el proceso decisorio en conexion con los aspectos administrativos, tecnologicos, socioculturales y economicos del asunto.

World Health Organization Guidelines: Use of cryotherapy for cervical intraepithelial neoplasia

In 2008, cervical cancer was responsible for 275 000 deaths, of which approximately 88% occurred in low‐ and middle‐income countries. In 2009, the World Health Organization (WHO) committed to updating recommendations for use of cryotherapy for cervical intraepithelial neoplasia (CIN).