Use of thermo‐coagulation as an alternative treatment modality in a ‘screen‐and‐treat’ programme of cervical screening in rural Malawi

Abstract

The incidence of cervical cancer in Malawi is the highest in the world and projected to increase in the absence of interventions. Although government policy supports screening using visual inspection with acetic acid (VIA), screening provision is limited due to lack of infrastructure, trained personnel, and the cost and availability of gas for cryotherapy. Recently, thermo‐coagulation has been acknowledged as a safe and acceptable procedure suitable for low‐resource settings. We introduced thermo‐coagulation for treatment of VIA‐positive lesions as an alternative to cryotherapy within a cervical screening service based on VIA, coupled with appropriate, sustainable pathways of care for women with high‐grade lesions and cancers. Detailed planning was undertaken for VIA clinics, and approvals were obtained from the Ministry of Health, Regional and Village Chiefs. Educational resources were developed. Thermo‐coagulators were introduced into hospital and health centre settings, with theoretical and practical training in safe use and maintenance of equipment. A total of 7,088 previously unscreened women attended VIA clinics between October 2013 and March 2015. Screening clinics were held daily in the hospital and weekly in the health centres. Overall, VIA positivity was 6.1%. Almost 90% received same day treatment in the hospital setting, and 3‐ to 6‐month cure rates of more than 90% are observed. Thermo‐coagulation proved feasible and acceptable in this setting. Effective implementation requires comprehensive training and provider support, ongoing competency assessment, quality assurance and improvement audit. Thermo‐coagulation offers an effective alternative to cryotherapy and encouraged VIA screening of many more women.

Management algorithms for cervical cancer screening and precancer treatment for resource‐limited settings

“…In a rural setting in Malawi, VIA‐positive women were offered thermal coagulation at the screening visit. Out of the 429 VIA‐positive women suitable for ablative treatment, 361 (84.1%) received treatment on the same day, with a very high cure rate (>90%) observed at 3–6 months follow‐up . In a demonstration project in El Salvador, HPV‐positive women were offered either same day treatment or referral for colposcopy and treatment based on histopathological diagnosis.…”

To expand coverage, or increase frequency: Quantifying the tradeoffs between equity and efficiency facing cervical cancer screening programs in low-resource settings

“…8 In the absence of data from actual practice in low-resource settings, the proportion of colposcopies that were accompanied by a biopsy was drawn from START-UP data (95.6% in Uganda). 9 All cancer costs presented include the value of women's time spent pursuing care and transportation to health facilities.…”

“…The laboratory processing time of approximately four hours hinders same‐day results and treatment for HPV‐positive women. Furthermore, cryotherapy is not available at all primary health facilities because of the high cost of equipment and the need for consistent resupply of gas . As a result, a “screen‐and‐treat” approach with HPV testing may be more favorable for women in urban areas, where greater access to laboratory and treatment facilities may lead to more timely follow‐up and management of screen‐positive women.…”

“…Furthermore, cryotherapy is not available at all primary health facilities because of the high cost of equipment and the need for consistent resupply of gas. 9 As a result, a "screen-and-treat" approach with HPV testing may be more favorable for women in urban areas, where greater access to laboratory and treatment facilities may lead to more timely follow-up and management of screen-positive women. However, pilot studies demonstrate that HPV self-collection facilitated by community health workers may increase screening uptake among underserved women, [10][11][12][13] thereby expanding access to care if HPV-positive women can be successfully navigated to a treatment facility.…”

Efficacy, Safety, and Acceptability of Thermal Coagulation to Treat Cervical Intraepithelial Neoplasia: Pooled Data From Bangladesh, Brazil and India

“…This approach has been shown to be acceptable, safe, efficacious and feasible in demonstration projects and large-scale national or regional programs are on-going in countries such as Thailand and Zambia [4,6,7,[17][18][19][20]. Recently a screen-andtreat approach using thermal coagulation has been evaluated in a large screen-and-treat field program in Malawi, in which thermal coagulation for treatment of VIA-positive lesions was introduced as an alternative to cryotherapy [21]. Of the 7,088 women screened with VIA, 429 women (6.1%) were VIApositive; of these 361 (84.1%) were treated on the same day with thermal coagulation and 20 women were treated within 1 month from screening thermal coagulation.…”