A single-visit approach for cervical cancer prevention.

The recent demonstration of the safety and acceptability of a single-visit approach for cervical cancer prevention in rural Thailand emphasizes the importance of having appropriate resources and infrastructure to implement research findings.

Nearly half a million women develop cervical cancer each year worldwide, and it is the leading cause of death due to cancer among women in developing countries. Several countries, including Thailand, have traditional cervical cancer prevention programs based on the Pap smear, a cytology-based screening tool. But Pap smears require special training, laboratory equipment, and repeat visits for clients. (Screening can be performed in one visit, but results can take quite a while to obtain, diagnoses can only be confirmed later, and women must return to the clinic if treatment is necessary.) The infrastructure in many resource-poor settings cannot sustain such programs, and screening rates remain low. In Thailand,only about 5 percent of women have been screened. (1)

An alternative to Pap smears is visual inspection of the cervix with acetic acid and a light source, followed by provision of cryotherapy (freezing) of suspected precancerous cervical lesions--all in a single visit.

Researchers from U.S.-based JHPIEGO'S Cervical Cancer Prevention Program and the Royal Thai College of Obstetricians and Gynaecologists (RTCOG), with support from the Ministry of Public Health in Thailand, conducted a demonstration study of this single-visit approach in Roi-et Province in 2000. (2) Twelve nurses were trained to use the approach and then used it to screen nearly 6,000 women in village centers and district hospitals. Both lowcost (3) and effective at detecting most precancerous lesions, (4) the single-visit approach also proved safe and very acceptable to women.

"Now it is time for the local Ministry of Health to decide whether it wants to adopt this approach on a larger, if not a national, scale," says Dr. Paul Blumenthal, director of JHPIEGO's Cervical Cancer Prevention Program.

For now, the Ministry of Public Health has decided not to officially change any national service delivery policies to include the new approach. But it is supporting implementation in more provinces, as long as the provinces have sufficient resources.

The most difficult step for the provinces is going to be program start-up, says Dr. Blumenthal. This will require extensive training, purchases of equipment, and development of infrastructures to deliver the new services. Once these factors are in place and the programs are running well, they should be sustainable, he says.

The chief provincial health officer of Roi-et Province at the time of the initial study has since moved to Nong Kai Province, where he and the Ministry of Public Health are spearheading an effort to expand the single-visit approach. The team from JHPIEGO and RTCOG has provided training and supervision of nurse providers for the program,which screened its first patient earlier in 2003.

"We are also helping in training and preparation for another four provinces in northeast Thailand to implement this single-visit approach,"says Dr. Khunying Kobchitt Limpaphayom, project director of JHPIEGO's Cervical Cancer Prevention Program in Thailand. "Northeast Thailand is considered the area with the fewest resources, so implementation will require a lot of leadership and commitment from the chief provincial health officers there. The results remain to be seen."

References

(1.) Royal Thai College of Obstetricians and Gynaecologists (RTCOG) and the JHPIEGO Corporation Cervical Cancer Group. Safety, acceptability, and feasibility of a single-visit approach to cervical-cancer prevention in rural Thailand: a demonstration project. Lancet 2003;361(9360):814-20.

(2.) Royal Thai College of Obstetricians and Gynaecologists (RTCOG).

(3.) Mandelblatt JS, Lawrence WF, Gaffikin L, et al. Costs and benefits of different strategies to screen for cervical cancer in less-developed countries. J Natl Cancer lnst 2002;94(19):146983; Goldie SJ, Kuhn L, Denny L, et al. Policy analysis of cervical cancer screening strategies in low-resource settings: clinical benefits and cost-effectiveness. JAMA 2001;285(24):3107-15.

(4.) University of Zimbabwe and JHPIEGO Cervical Cancer Project. Visual inspection with acetic acid for cervical-cancer screening: test qualities in a primary-care setting. Lancet 1999;353(9360): 869-73.