Treatment Options for Cervical Cancer in Low Income

Treatment Options for Cervical Cancer in Low Income Countries Dr. Nelly R. Mugo Obstetrician Gynaecologist/ Research Scientist Kenya Medical Research Institute 2016 WE CAN African Breast and Cervical Cancer Advocacy, Education and Outreach Summit Fairview Hotel 22 nd April 2016

Can we envision a world where women no longer die from cervical cancer ? Cervical cancer is a preventable disease, when diagnosed early We can treat in the outpatient clinic and effectively prevent cancer events

Increased screening has greatly reduced the incidence of cervical cancer in England • Improvements in cervical screening coverage in England have led to a 35% decrease in cervical cancer cases in under a decade Age-standardized incidence of invasive cervical cancer 18 16 10 Year 95 19 90 19 87 19 19 75 19 19 71 0 85 National call-recall introduced 80 12 Invasive cervical cancer 19 14 Covera ge 100 90 80 70 60 50 40 30 20 10 0 Percenta ge Incidence rate per 100, 000 and coverage of screening, England 1971– 1995 Quinn M, et al. Brit Med J 1999; 318: 904– 908.

Why we should invest in preventing cervical cancer • 500, 000 incident cases of cervical cancer each year • 230, 000 deaths each year – 80% of women with cancer and experiencing cervical cancer death reside in sub Saharan Africa – SSA have less than 5% of cancer treatment resources • Risk of Ca cervix for a woman in LIC is approx 24% • Pap smear screening programs have markedly reduced the incidence of ca cervix in Western countries

Kenya situation: - Cancer • Average at presentation for invasive cancer is 42 years • In most cases it is diagnosed late (>90% are stage IIB or worse) • KNH is the only national hospital with radiotherapy – Currently Nairobi city has three private hospitals (AGK, MP Shah, Nairobi Hospital) with radiotherapy units • Several regional hospices offer Palliative care • Situation expected to improve: – Ministry of Health • See and treat approach – VIA/VILLI and cryotherapy • Colposcopy machines • Collaboration with Partners

Treatment options for Pre-Malignant Lesions of the Cervix • • Cryotherapy LEEP Cone Biopsy Hysterectomy

The mouth of the uterus (cervix) provides access normal on naked eye exam

The early lesion is within a small area of the cervix, can be seen clearly with application of acetic acid or lugols iodine, outlining area for treatment Pre-malignant Cervix with acetic acid (VIA) Lugols iodine changes Sqcolumnar junction

SIL = Squamous intraepithelial lesion - CIN : Cervical intraepithelial neoplasia

Treatment: LEEP The wire quickly passed within the borders of the lesion, completely removes the area with early changes- pre cancer Done in the clinic, actual procedure very short

Visual Inspection with Acetic Acid Normal VIA Positive: Aceto White Lesion Instruments for Visual Inspection No power, simple light, can be done in any level of health care Easily followed with cryoyotherapy Suspicious of Cancer

Cryotherapy: freezing technique freezing destroys the abnormal tissue uses gas: nitrogen or carbon dioxide does not require electricity low cost

Appearance after Cryotherapy 2 wks later Iceball-immediate 3 months later One year later

Screen and Treat: is ideal with no repeat visits reduces both direct (facility) and indirect costs (to clients-transport and time) In Zambia: >15 service points, screened 20, 000 women over a 2 year period Utilize nurses, with a screen and treat approach Referral for none cryotherapy eligible lesions

In Kenya, there over 10. 3 million women at risk for cervical cancer over the age of 15 years, with risk of cervical cancer we have the knowledge and tools to effectively prevent the advent of cancer in their lives 15

A Team Approach To Cervical Cancer Prevention And Control • Cervical cancer control requires a multi- sectoral and multidisciplinary effort. • It also requires strong linkages and team work between providers at all levels of health care system – Target high risk women with a once or twice lifetime use of a highly sensitive test – Emphasis on high coverage (80%) • Effective screening programme low resource settings require – adequate financial resources – adequate infrastructure – Trained manpower – Surveillance mechanisms for screening, treating, and follow up