Periodic Reporting for period 2 - PRESCRIP-TEC (Prevention and Screening Innovation Project Towards Elimination of Cervical Cancer)
Période du rapport: 2022-08-01 au 2024-01-31
The Prevention and Screening Innovation Project towards Elimination of Cervical Cancer (PRESCRIP-TEC), funded by the European Union under H2020, has started in February 2021. The project contributed to effective and innovative cervical cancer screening, including direct treatment and follow-up for women in resource-poor or hard-to-reach settings in the world. PRESCRIP-TEC inverstigated the feasibility of the 2021 World Health Organization strategy to eliminate cervical cancer worldwide as public health problem. Cervical cancer is one of the most prevalent female cancers worldwide, and most cases occur in low- and middle-income countries. Cervical cancer is caused by a chronic infection with the Human Papilloma Virus (HPV). When this infection is detected in an early stage, before cancerous lesions have developed, the disease can be treated, and cancer can be prevented.
PRESCRIP-TEC conducted implementation research into cervical cancer screening in four countries spread over three continents: Bangladesh and India in Asia, Uganda in Africa, and Slovakia in Europe. In this research universities, cancer institutes and non-governmental organisations from these countries collaborated with the University Medical Center in Groningen and the Female Cancer Foundation in the Netherlands, as well as the Connaxis communication company in Spain.
We studied patient- and health services-related facilitators and barriers for uptake of cervical cancer screening in low- and middle-income countries and in vulnerable groups in Eastern Europe. We validated interactive information strategies reaching communities via mobile devices and social media. We studied client-friendly, community-based strategies, with self-collected tests for high risk HPV infection. We validated artificial intelligence decision support systems (AI-DSS) in gynaecological examination, when vaginal inspection with acetic-acid (VIA) was performed.
We performed a cost-effectiveness analysis and produced a business case for the global introduction of hrHPV testing as routine screening for cervical cancer. This research, therefore, aimed at supporting the global WHO strategy for elimination of cervical cancer by providing new evidence.
PRESCRIP-TEC conducted implementation research into cervical cancer screening in four countries spread over three continents: Bangladesh and India in Asia, Uganda in Africa, and Slovakia in Europe. In this research universities, cancer institutes and non-governmental organisations from these countries collaborated with the University Medical Center in Groningen and the Female Cancer Foundation in the Netherlands, as well as the Connaxis communication company in Spain.
We studied patient- and health services-related facilitators and barriers for uptake of cervical cancer screening in low- and middle-income countries and in vulnerable groups in Eastern Europe. We validated interactive information strategies reaching communities via mobile devices and social media. We studied client-friendly, community-based strategies, with self-collected tests for high risk HPV infection. We validated artificial intelligence decision support systems (AI-DSS) in gynaecological examination, when vaginal inspection with acetic-acid (VIA) was performed.
We performed a cost-effectiveness analysis and produced a business case for the global introduction of hrHPV testing as routine screening for cervical cancer. This research, therefore, aimed at supporting the global WHO strategy for elimination of cervical cancer by providing new evidence.
In Uganda and Bangladesh remote rural areas were selected for the intervention, in India both rural as urban poor communities and specific vulnerable groups (women living with HIV, sex workers) and in Slovakia women from Roma minoirty communities and factory workers.
Community sensitisation did take place, by reaching out to local decision makers, health officials, local government organisations, as well as individual women, men and family decision-makers through meetings, personal contacts, and social media. In total nearly one million people were reached via mass-media, and around 50,000 people were seen in person to explain
Eligible women were offered hrHPV self- collected testing at home, or in a health facility (if desirable). In total over 30,000 tests were performed in the four countries. The uptake of the test was high, around 87%. HPV prevalence varied widely, from around 2% in rural areas in India and Bangladesh to around 21% in rural areas in Uganda. In urban areas in India the prevalence rate was around 7%, in Slovakia around 11%. Exceptionally high prevalence rates were found among women living with HIV and sex workers in India, between 35 and 40%.
Women who were HPV-positive were offered follow-up VIA in Bangladesh, Uganda and India. The uptake was around 70%. Women with precancerous lesions (around 20%) were offered cryotherapy or thermal ablation in Bangladesh and India. In Uganda all women who came for VIA received cryotherapy. In Slovakia HPV-positive women were referred to a gynaecologist for Pap-smear. In total 32 women were referred with suspecious cervic al lesions. In 11 women invasive cancers have been diagnosed.
The AI-DSS device was tested under practical conditions in the field. The device proved to be user-friendly. However, attention is required to guarantee quality of the pictures. More training of nurses using the device is therefore necessary. The algoritm was under field conditions less senstive and less specific than under laboratory conditions. This is probably due to the high-resolution camera used in the device. In the follow-up after the project retraining of the algorithm will be performed.
The personal factors of women eligible for cervical cancer screening and of decision-makers in the household (often husbands or mothers in law) in relation to cervical cancer have been measured by applying the AWACAN survey in the four countries. An important finding is that in India, Bangladesh and Uganda, only a minority of women decides on her own concerning participation in cervical cancer screening. In the majority of cases, husbands or family decision-makers (for example mothers-in law) have an important say. Financial issues play a role, even if screening is offered free of charge.
Various client satisfaction survey for women using actual health services were conducted. The fast majority of women did not have any problems of performing the self-collected HPV test, and felt no or slight discomfort when using the swab. Women trusted the services provided, and had a good relation with the health workers. The lower uptake of VIA (70%) compared to self-collected HPV test (87%) is mainly due to fear for potential treatment and related costs.
The service availability and readiness assessment (SARA) was conducted, and analysis is still conducted.
Cost-effectiveness analysis was performed. HPV-testing as primary screening instrument is cost-effective. However, when looking at affordability, HPV tests are still too expensive. Costs of HPV testing should reduce to less than US$ 15 all-in to become within reach of low- and middle income countries. Furthermore, the uptake of the screening should be at least 30% country-wide to reach cost-effectivess levels, which is not the case in most LMICs at this moment. See-triage-treat is cost-effective and leads to less loss of quality of life, if health services can offer a good follow-up service for women who need to undergo new screening within one year of positive hrHPV-test.
Community sensitisation did take place, by reaching out to local decision makers, health officials, local government organisations, as well as individual women, men and family decision-makers through meetings, personal contacts, and social media. In total nearly one million people were reached via mass-media, and around 50,000 people were seen in person to explain
Eligible women were offered hrHPV self- collected testing at home, or in a health facility (if desirable). In total over 30,000 tests were performed in the four countries. The uptake of the test was high, around 87%. HPV prevalence varied widely, from around 2% in rural areas in India and Bangladesh to around 21% in rural areas in Uganda. In urban areas in India the prevalence rate was around 7%, in Slovakia around 11%. Exceptionally high prevalence rates were found among women living with HIV and sex workers in India, between 35 and 40%.
Women who were HPV-positive were offered follow-up VIA in Bangladesh, Uganda and India. The uptake was around 70%. Women with precancerous lesions (around 20%) were offered cryotherapy or thermal ablation in Bangladesh and India. In Uganda all women who came for VIA received cryotherapy. In Slovakia HPV-positive women were referred to a gynaecologist for Pap-smear. In total 32 women were referred with suspecious cervic al lesions. In 11 women invasive cancers have been diagnosed.
The AI-DSS device was tested under practical conditions in the field. The device proved to be user-friendly. However, attention is required to guarantee quality of the pictures. More training of nurses using the device is therefore necessary. The algoritm was under field conditions less senstive and less specific than under laboratory conditions. This is probably due to the high-resolution camera used in the device. In the follow-up after the project retraining of the algorithm will be performed.
The personal factors of women eligible for cervical cancer screening and of decision-makers in the household (often husbands or mothers in law) in relation to cervical cancer have been measured by applying the AWACAN survey in the four countries. An important finding is that in India, Bangladesh and Uganda, only a minority of women decides on her own concerning participation in cervical cancer screening. In the majority of cases, husbands or family decision-makers (for example mothers-in law) have an important say. Financial issues play a role, even if screening is offered free of charge.
Various client satisfaction survey for women using actual health services were conducted. The fast majority of women did not have any problems of performing the self-collected HPV test, and felt no or slight discomfort when using the swab. Women trusted the services provided, and had a good relation with the health workers. The lower uptake of VIA (70%) compared to self-collected HPV test (87%) is mainly due to fear for potential treatment and related costs.
The service availability and readiness assessment (SARA) was conducted, and analysis is still conducted.
Cost-effectiveness analysis was performed. HPV-testing as primary screening instrument is cost-effective. However, when looking at affordability, HPV tests are still too expensive. Costs of HPV testing should reduce to less than US$ 15 all-in to become within reach of low- and middle income countries. Furthermore, the uptake of the screening should be at least 30% country-wide to reach cost-effectivess levels, which is not the case in most LMICs at this moment. See-triage-treat is cost-effective and leads to less loss of quality of life, if health services can offer a good follow-up service for women who need to undergo new screening within one year of positive hrHPV-test.
The project provided evidence about the feasibility of the new WHO strategy for screening of cervical cancer, using hrHPV testing as basis for further action. There is a higher uptake when self-collected hrHPV-tests are offered. The tests are highly acceptable for women. Between 80% and 99% of women does not need a follow-up screening, which saves them time and travel costs. The uptake of VIA after positive HPV test is lower, due to factors of fear and costs. This requires good sensitisation of women and families involved. Around 20% of women undergoing VIA needs a treatment, when a see-triage-treat approach is followed.
The screening component of the WHO strategy toward elimination of cervical cancer is implementable and feasible. However two major points of attention are:
- the hrHPV testing must become cheaper, with a price below US$ 15 to become afordable,
- the health systems must be strengthened to guarantee a high uptake of services and a good continuity of services.
The screening component of the WHO strategy toward elimination of cervical cancer is implementable and feasible. However two major points of attention are:
- the hrHPV testing must become cheaper, with a price below US$ 15 to become afordable,
- the health systems must be strengthened to guarantee a high uptake of services and a good continuity of services.