Shining a spotlight on Cervical Cancer in Developing Countries

The COVID-19 pandemic has shone a spotlight on how critical it is that affordable, accessible, and effective healthcare is to all communities. As vital as it has been for healthcare administrations to allocate budgets to combat COVID-19, it is equally important not to lose sight of many competing healthcare priorities. For example, cancer remains the leading cause of mortality, outstripping COVID-19 deaths in 2020 by over twofold.[1],[2] Cancer continues to overwhelm many countries especially in the developing world, where cancer cases have increased by more than 80 percent since 2008. Nearly 70 percent of these cases result in death.[3] In particular, cervical cancer – which is one of the few types of cancer that can be eliminated with early diagnosis and effective screening – is still prevalent in the developing world, where more than 90 percent of related deaths occur. The most common cause of cervical cancer is persistent infection caused by the sexually transmitted human papilloma virus (HPV), which is much more pervasive in countries that rank low in the human development index (HDI).[4]

Developing countries are not as equipped as their developed counterparts to effectively screen, diagnose, and treat cervical cancer; limited financial resources prevents them from investing in healthcare infrastructure, personnel, and up-to date technologies. Further, the solutions adopted in developing countries can also vary as it greatly depends on each country’s cultural nuances, resource availability, and strategic priorities. Interestingly, the approaches taken to contain cervical cancer have not evolved much over the past two decades, mainly adhering to WHO’s recommended strategies of screening, vaccination, and early diagnosis, as opposed to resource-intensive treatments like radiotherapy and chemotherapy.[5]

Current approaches and challenges

Most approaches to combat cervical cancer in developing countries have focused on vaccination, screening, and early treatment. The most recommended approach for developing countries is to vaccinate as many women as possible against the HPV virus before they experience their first sexual contact. This has shown to reduce the risk of getting cervical cancer by 88% among women before the age of seventeen.[6] In terms of screening, although rapid HPV DNA tests do not directly screen for cervical cancer, they do inform whether one is of high risk of developing it and whether one has contracted HPV, which allows for appropriate monitoring going forward. The Visual Inspection with Acetic Acid (VIA) test is a rather inexpensive and simple screening and diagnostics test that is popular among developing countries. It can determine precancerous and cancerous cervical lesions, and can be administered by personnel with minimal training. Regarding treatment, cryotherapy is one of the most well-known tools available, and is suitable to treat precancerous cervical lesions, or abnormal cells at high risk of becoming cancerous. Many vaccines, training courses, and medical devices are introduced in developing countries through partnerships and deals with multilateral organisations and non-profit organisations. One such organisation is the GAVI Alliance, which secures cervical cancer vaccines at reduced prices for its member countries.

While the above have brought on encouraging progress, many obstacles associated with them remain. Even if developing countries can secure vaccines and HPV tests at affordable prices, the implementation costs and considerations to scale these programmes – such as coordinating logistics, raising awareness, monitoring, and setting-up referral systems – can be unknown and prohibitive to them.[7] Citizens from developing countries continue to lack awareness and understanding of screening programmes, as evidenced by the low participation rates in cervical cancer screening programmes.[8] Finally, cryotherapy devices can be costly and result in side effects such as vaginal bleeding while having restricted portability, which is not suitable for populations residing in rural areas.

There have been several recent and innovative developments tackling some of these challenges, which may serve to inspire developing countries on new possibilities.

1. Creative awareness campaigns

In Colombia, scientists collaborated with healthcare workers to test innovative models to increase awareness on cervical cancer prevention in primary care centres located in low-income settings. One of these initiatives was an awareness campaign named ‘Encanto’, which trained and placed manicurists in hospital waiting rooms to educate customers on cervical cancer prevention methods while they performed their manicure sessions. The experiment proved a success at demystifying false beliefs around cervical cancer, and allowed women to receive updated information about the disease and how to get tested early through Pap smears and HPV tests. This initiative proved effective in encouraging women to get tested, as 12 out of the 15 women who participated underwent testing the following week.[9] Developing countries with low screening participation rates can use similar creative awareness campaigns that use places or contexts where women routinely visit and feel safe, to educate them in comfortable, familiar, and friendly settings.

2. Self-sampled HPV test

A recent innovation in the field of HPV testing has been the self-sampled HPV test that women can conduct on themselves without having to undergo gynaecological examinations. Tests have shown that compared to Pap smear tests, the self-sampled HPV test produces higher sensitivity and specificity, but more importantly encourages those who would otherwise have not gone for Pap smears due to fear of discomfort to get tested. Furthermore, the costs for the self-sampled HPV test are 70 percent lower than Pap smear tests.[10] While countries can further examine the distribution and logistical costs for this form of screening tool, self-testing kits are a promising alternative for developing countries that want to boost their screening participation rates.

3. Crowdfunding to finance healthcare

Funding remains one of the biggest challenges that developing countries face in tackling cervical cancer. Apart from tapping on their own limited reserves, developing nations typically forge partnerships with multilateral organisations and non-profits to access funds, training, technologies, and vaccines at reduced prices. These methods offer a crucial lifeline, but are often not sufficient. Crowdfunding is a promising new alternative for resource-constrained countries to access funds. Donation campaigns can be easily created on digital crowdfunding platforms and social media, to potentially raise funds from millions of donors. For instance in April 2020, the Malaysia Digital Economy Corporation (MDEC) announced a partnership with multiple crowdfunding platforms to solicit donations to support frontline employees defending against COVID-19.[11] Although crowdfunding requires effective digital campaigning to be successful, this presents an interesting addition to existing financing models for cervical cancer treatment.

4. Vaccination planning and partnerships

Cervical cancer is the most common form of cancer amongst women in Rwanda. In 2010 alone, 986 women were diagnosed with cervical cancer, and 678 succumbed to the disease.  That same year, Rwanda partnered with Merck to offer young girls aged 11-12 years old the Gardasil vaccine to protect them from HPV. By 2011, the programme achieved a remarkable 93% coverage after the first three doses of vaccination were administered among girls in grade six.[12] A few key factors around public and private collaboration were responsible for ensuring the successful vaccine roll-out. This included collaboration among multiple ministries and institutions, a nationwide campaign to sensitize and raise awareness about the vaccine, and a partnership with the Ministry of Education to administer the three doses through a school-based strategy. The Government rigorously monitored the situation throughout the implementation phase by collecting data, and individually tracked down students who were not in school on the days of the vaccine administration, to ensure that no girl gets left behind.

Rwanda’s decade-old success story remains among the most successful HPV vaccination roll-out programme across developing nations, and serves as a valuable lesson to countries seeking to embark on similar programmes. It showcases that as important as it was to secure low-cost vaccines, so too is the ability to have an effective implementation plan that efficiently brings together different stakeholders, which is inclusive, extends a far reach, and is consistently-monitored so that progress can be tracked and improvements can be made.

5. Frugal, portable, and effective treatment alternatives

For patients who are not fortunate enough to prevent cervical precancerous lesions through effective screening, cryotherapy is one of the most popular treatment options for developing countries. Recent testing though has shown that thermo-coagulation can also be effective in treating precancerous lesions.[13] In rural Malawi, the results of thermo-coagulation are on par with cryotherapy. Additionally, the device needed for this treatment can be hand-held, lightweight, and portable. This makes it well-suited for developing countries with large rural populations. In addition, thermo-coagulation is cheaper, has a lower treatment duration, fewer side effects, and results in higher patient satisfaction than cryotherapy. As the WHO reviews its recommendations on thermo-coagulation, more governments in low-resource settings can start exploring how this new method can fit with their overall treatment strategy.

Conclusion

These case studies highlight innovative ways that developing countries can raise awareness, increase screening participation rates, raise funds, and offer more affordable and accessible treatment options for their citizens. Costly treatments such as radiotherapy, surgery and chemotherapy are still needed for patients who are experiencing cervical cancer at an advanced stage, and many developing countries lack the infrastructure to offer these treatments at an adequate level. More innovation continues to be necessary to reduce the price of these treatments and to develop more innovative methods for lower-resourced contexts.

[1] Sung, H., Ferlay, J., Siegel, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., & Bray, F. (2021). Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: a cancer journal for clinicians, 71(3), 209–249. Retrieved from https://doi.org/10.3322/caac.21660

[2] The true death toll of COVID-19: estimating global excess mortality. (2021). WHO. Retrieved from https://www.who.int/data/stories/the-true-death-toll-of-covid-19-estimating-global-excess-mortality

[3] Better cancer screening in resource-poor nations. (2020, March 25). Nature. Retrieved from https://www.nature.com/articles/d41586-020-00848-1

[4] Hull, R., Mbele, M., Makhafola, T., Hicks, C., Wang, S. M., Reis, R. M., Mehrotra, R., Mkhize-Kwitshana, Z., Kibiki, G., Bates, D. O., & Dlamini, Z. (2020). Cervical cancer in low and middle-income countries. Oncology letters, 20(3), 2058–2074. Retrieved from https://doi.org/10.3892/ol.2020.11754

[5] World Health Organization. (2020). Global strategy to accelerate the elimination of cervical cancer as a public health problem. Retrieved from https://app s.who.int/iris/bitstream/handle/10665/336583/9789240014107-eng.pdf

[6] Lei, J., Ploner, A., Elfström, K. M., Wang, J., Roth, A., Fang, F., Sundström, K., Dillner, J., & Sparén, P. (2020). HPV Vaccination and the Risk of Invasive Cervical Cancer. New England Journal of Medicine, 383(14), 1340–1348. Retrieved from https://doi.org/10.1056/nejmoa1917338

[7] Graham, J. E., & Mishra, A. (2011). Global challenges of implementing human papillomavirus vaccines. International Journal for Equity in Health, 10(1), 27. Retrieved from https://doi.org/10.1186/1475-9276-10-27

[8] World Health Organization. (‎2020)‎. WHO report on cancer: setting priorities, investing wisely and providing care for all. World Health Organization. Retrieved from https://apps.who.int/iris/handle/10665/330745.

[9] Castro-Sánchez, E. C. S. (2020). Innovative prototypes for cervical cancer prevention in low-income primary care settings: A human-centered design approach. PLoS One. Published. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7446804/

[10] Aarnio, R., Östensson, E., Olovsson, M., Gustavsson, I., & Gyllensten, U. (2020). Cost-effectiveness analysis of repeated self-sampling for HPV testing in primary cervical screening: a randomized study. BMC Cancer, 20(1). Retrieved from https://doi.org/10.1186/s12885-020-07085-9

[11] Malaysia Digital Economy Corporation (MDEC). (2020, April 1). MDEC ANNOUNCES COLLABORATION WITH CROWDFUNDING PLATFORMS TO SUPPORT FRONTLINERS IN DEFENCE AGAINST COVID19 [Press release]. Retrieved from https://mdec.my/wp-content/uploads/Donation-Drive-MDEC.pdf

[12] Wagner, C. M. (2012, May 23). Achieving high coverage in Rwanda’s national human papillomavirus vaccination programme. Retrieved from https://www.who.int/bulletin/volumes/90/8/11-097253/en/

[13] Chigbu, C. O. C., Onwudiwe, E. N. O., & Onyebuchi, A. K. O. (2020). Thermo-coagulation versus cryotherapy for treatment of cervical precancers: A prospective analytical study in a low-resource African setting. Japan Society of Obstetrics and Gynecology. Published. Retrieved from https://doi.org/10.1111/jog.14139