Moving towards a strategy to accelerate cervical cancer elimination in a high-burden city—Lessons learned from the Amazon city of Manaus, Brazil

Abstract

The World Health Organization Call to Eliminate Cervical Cancer resonates in cities like Manaus, Brazil, where the burden is among the world’s highest. Manaus has offered free cytology-based screening since 1990 and HPV immunization since 2013, but the public system is constrained by many challenges and performance is not well-defined. We obtained cervical cancer prevention activities within Manaus public health records for 2019 to evaluate immunization and screening coverage, screening by region and neighborhood, and the annual Pink October screening campaign. We estimated that among girls and boys age 14–18, 85.9% and 64.9% had 1+ doses of HPV vaccine, higher than rates for age 9–13 (73.4% and 43.3%, respectively). Of the 90,209 cytology tests performed, 24.9% were outside the target age and the remaining 72,230 corresponded to 40.1% of the target population (one-third of women age 25–64). The East zone had highest screening coverage (49.1%), highest high-grade cytology rate (2.5%) and lowest estimated cancers (38.1/100,000) compared with the South zone (32.9%, 1.8% and 48.5/100,000, respectively). Largest neighborhoods had fewer per capita screening locations, resulting in lower coverage. During October, some clinics successfully achieved higher screening volumes and high-grade cytology rates (up to 15.4%). Although we found evidence of some follow-up within 10 months post-screening for 51/70 women (72.9%) with high-grade or worse cytology, only 18 had complete work-up confirmed. Manaus has successfully initiated HPV vaccination, forecasting substantial cervical cancer reductions by 2050. With concerted efforts during campaigns, some clinics improved screening coverage and reached high-risk women. Screening campaigns in community locations in high-risk neighborhoods using self-collected HPV testing can achieve widespread coverage. Simplifying triage and treatment with fewer visits closer to communities would greatly improve follow-up and program effectiveness. Achieving WHO Cervical Cancer Elimination goals in high-burden cities will require major reforms for screening and simpler follow-up and treatment.

Cervical cancer screening, treatment and prophylaxis in Brazil: Current and future perspectives for cervical cancer elimination

“…National pre-pandemic SUS data showed a deficit of 7.3% for colposcopy, 20.4% for biopsies, and 74.8% for type 1 and 2 excision of the transformation zone (ETZ) on an outpatient basis and 67.6% for type 2 ETZ and type 3 ETZ in hospitals ( 46 ). A recent study, carried out in a municipality with a high incidence of cervical cancer in the North of the country, showed 27.1% without evidence of any follow-up and 74.3% without complete work-up 10 months after screening among women with HSIL+ screening results ( 47 ). The entire process is very fragmented, and a woman who needs diagnostic work-up and treatment will generally require nine visits to health services, with an average time between cytology screening and colposcopy of 105 days, 40 days between biopsy and the histopathological report and additional 150 days until a high-grade lesion treatment ( 48 ).…”

Funding of Oncology Benefits by Medical Schemes, South Africa: A Focus on Breast and Cervical Cancer

“…Other variables such as limited access to health care facilities, lack of knowledge and health promotion, and inadequate support and awareness programmes for women, which are more prevalent in less affluent rural areas, influence early detection, diagnosis, and screening uptake [10,11]. Recent research has shown that metropolitan location remains a significant factor related to greater awareness of cervical cancer risk factors, resulting in lower screening rates in rural regions [11][12][13]. In addition, lack of access to facilities in rural locations adds to inadequate screening services, a barrier to an admission that results in delayed seeking behaviour.…”

Current HPV Vaccination Strategies in Brazil

“…9) Title: Moving towards a Strategy to Accelerate Cervical Cancer Elimination in a High-Burden City-Lessons Learned from the Amazon City of Manaus, Brazil. Year of publication: 2021[17].…”