The Work and Mission of PINCC

The Work and Mission of PINCC

Cervical cancer is the leading cause of cancer death among women in low- and middle-income countries (LMIC). Cervical cancer is a preventable disease, but these women have little or no access to screening. A mother’s death has many complex repercussions on the children and communities that she leaves behind. Women are central, not only in direct caregiving for their own children, but more broadly in society, playing key roles in the socialization, education and health of children (80,81). Women play “crucial roles in the health care of families and communities as drivers of the wealth and health of nations” (81). Overwhelming evidence suggests that investment in women’s health provides substantial economic returns (85-88). The WHO states that for every dollar spent on cervical cancer prevention, $3.20 will be returned to the economy. This is just women being in the workforce. This number increases to $26.00 if a woman’s impact on their families, communities and society are considered.

PINCC - preventing cervical cancer - globally is a non-profit entity that teaches healthcare workers in LMIC how to recognize and treat cervical dysplasia.  Screening is done with VIAA and VILI and treatment previously with cryotherapy now with thermocoagulation (TC) and loop electrosurgical excision procedure (LEEP). Healthcare workers are trained for a week every 6 months, for 1 year.  After adequate training is achieved, the equipment is donated so that the clinic becomes self-sustaining.  PINCC has trained hundreds of healthcare workers in 12 countries on 4 continents. Thousands of women have been screened and treated.

PINCC was founded in 2006 by Dr. Kay Taylor.  In January 2017, the organization was realigned with Dr. Melissa Miskell becoming the executive director.  This marked the change from the use of cryotherapy to TC.  Cryotherapy is a World Health Organization (WHO) recommended ablative treatment, but one major disadvantage is the need for a refrigerant gas (N2O or CO2 ). The gas containers are bulky and heavy to transport and some areas of low- and middle-income countries (LMICs) may have supply issues. In addition, frequent refilling of freezing gas can be costly (1). TC has been used in many research studies to show that it has the same efficacy as cryotherapy. One such study done in Cameroon stated, “The procedure was associated with minor side effects and is overall feasible in the context of a cervical dysplasia screen-and-treat campaign in sub-Saharan Africa” (2).  A second study showed that “thermal ablation performed by nonphysicians in the public health sector in Kenya proved safe and highly acceptable in treating HPV-positive women living with HIV” 3. The effectiveness of TC is also superior in that it is extremely portable, requires only electricity to charge a rechargeable battery, which performs 30-40 procedures. The TC is low cost device that has a shallow learning curve and a lower chance of injury.

PINCC requires an adequate infrastructure of a site before a commitment to training is made. The site must have staff to train that can commit to 1 week every 6 months for 3 visits.  A designated area for the camp where 3-5 bays can be used for exams (these are sometimes built from donated surgical drapes and gowns). A surrounding area that can support 100 women a day to be screened.  Adequate food, lodging, transportation and safety for the PINCC team and a strong community presence to be able to mobilize the women of the area.

PINCC partnered with Foundation for African Medicine and Education (FAME) in Karatu, Tanzania to establish a cervical cancer screening program at the Reproductive and Child Health Clinic (RCHC) on their campus. Due to inadequate access, cervical cancer has become the number one cause of cancer related death among females at 24% in sub-Sahara Africa5,6. Tanzania ranks 5th highest on the World Life Expectancy chart for cervical cancer 7. These women are what binds a community together. They provide income, education, and stability.  It has been shown that when a young mother dies her children have an increased likelihood of lower educational competency, lower socioeconomic standing and mortality 8,9. The community also suffers because the loss of these women’s economic value (working & spending) destabilizes the village.  The WHO predicts that the global cervical cancer rate will double by 2030, with 90% of these deaths in sub-Saharan Africa.  The number of these deaths will reach 440,000 women, almost a woman every minute.

FAME WAS ABLE TO PROVIDE ALL OF THE CRITERIA FOR A CERVICAL CANCER SCREENING CAMP. 

 Since its introduction in June 2017, FAME has continued a free cervical cancer screening program which has been important to the health of the local women and therefore the entire community.  After the 3rd camp in June of 2018, 1385 VIAA’s had been performed with 112 women being positive (8%).  92 thermocoagulation’s were preformed, 5 LEEP’s and 5 cervical biopsies for suspected cancer. 

 Method:

Community outreach was done in Karatu and surrounding villages.  His outreach was carried out by the FAME social workers. They provided education on cervical cancer and screening. The outreach was conducted in churches, local clinics and markets. The first day of clinc had several hundred women arriving. Priority was given to those who had traveled the furthest. Most women did not know what cervical cancer was but they all knew someone who had died of uncontrollable vaginal bleeding.

The day began with a didactic session for the 5 trainees-1 physician and 4 nurses. Nurses are the primary healthcare providers in Africa. Tanzania has the 7th lowest physician to patient ration in the world 10, therefore it is crucial that nurses are involved in training for detection of cervical dysplasia. During the hour of introductory training, the patients were interviewed by the social workers. Women ages 21 to 60 not having had a hysterectomy and not pregnant were interviewed. They were asked demographic questions pertaining to the village of residence and phone number.  This enabled us to contact them again, if necessary. They were also asked the number of pregnancies, number of miscarriages, if they had been screened before, method of contraception, HIV status and date of last screening, age at 1st sexual experience, and number of sexual partners.  The questionnaire is designed to recognize high risk women as well as give demographic information for statistics. Women who had not been tested for HIV within the last year were sent for free testing before screening. After being interviewed the women were taken to a private bay where the procedure was explained to them. After consent, a bimanual exam was preformed to assess the location of the cervix. The trainees were all experienced with speculum exam. The WHO protocol for VIAA was performed with VILI used for confirmation of a cervical lesion.  The squamous columnar junction (SCJ) was described as fully visualized (FV) or not fully visualized (NFV) and the exam noted as positive or negative depending on the presence of a lesion. If a patient was FV/ negative, she was asked to return for screening in 3 years. If the exam was NFV / negative, she was asked to return in 1 year. If negative at that screening, she would move to a 3-year return. If the patient is FV / positive the lesion was graded as CIN I-III. If CIN I-II the patient was consented for thermocoagulation with the Liger Medical ThermocoagulatorTM set at 1000 Celsius for 20 seconds. If the exam was CIN III or NVV / positive the patient was consented for a LEEP. Lesions suspicious for cancer were biopsied. All procedures were tolerated well with no adverse effects.  After treatment protocols were given for TC and LEEP in Swahili, English or Luo.  All patients were given follow-up cards with their exam results and when to return to the clinic 6 months, 1 year if HIV positive or 3 years. The women who had a procedure were asked to return in 6 months when PINCC would be back, so that treatment could be evaluated.

 Results:

In the 1st camp, 456 women were seen. Of those: 9 low grade lesions (LGSIL) were treated with TC, 3 high grade lesions (HGSIL) were treated with LEEP, and 3 suspicious cancers were biopsied and referred to Ocean Road Cancer Institute in Dar es Salaam.  This was a unusually low percentage of positive cases as the national average is approximately 10%. We were unable to explain this anomaly.

The 5 trainees continued to screen in the 6 month interval period before PINCC’s return.  PINCC supplied them with logbooks to record their exams and findings. When PINCC returned to FAME the women who were previously treated and the women who were reported as positive by the trainees were asked to return and be rescreened. Another screening camp was also undertaken. There was a 100% positive rate in these women that the trainees had screened and all were treated with thermo.  Of the 12 women treated at the 1st camp, 8 were seen as a 6-month follow-up, and 4 were lost to follow-up.  Of the 8 patients that returned 5 had been treated with TC, 4 had a normal exam and 1 was retreated with TC.  All but 1of the LEEP patients were screened negative and this patient received TC for low-grade residual disease. The 2nd camp had 436 patients seen with 36 thermos and 2 biopsies for suspected cancer.  The 5 trainees were all certified in VIAA and use of the TC after the 2nd camp.  The Liger Medical ThermocoagulatorTM was donated to FAME for use by the certified healthcare workers. PINCC returned for a 3rd camp 6 months later.  FAME had instituted a free clinic one day a week for VIAA screening.  During the third camp, there were 255 patients seen with 26 TC’s and 1 LEEP.  Dr.Msuya, the physician who was trained, was certified in LEEP and as a Trainer in PINCC’s Train the Trainer program. This allows him to continue certifying additional healthcare workers in PINCC’s methods. At the end of this training, PINCC donated a Liger Medical battery powered LEEP machine.

In total, over the year of training, The FAME clinic screened 1385 women with 112 positive lesions. 90 TC’s were preformed, 5 LEEP procedures and 8 biopsies all positive for invasive carcinoma of the cervix.

 Conclusion:

There was an 8% positivity rate overall for the yearlong training that was done at FAME. This is similar to the percentage throughout Tanzania at 9.2%12. It is unfortunate that there a major difficulty with follow-up. Even though every effort was made with village name, primary phone number and secondary phone number when possible, we still only had a 67% follow-up rate. However, within that 67% our success rate of treatment was 80%. This is concurrent with other studies using TC for treatment.  

Of our 5 trainees, 4 were nurses. It is highly recommended that nurses, as the stabilizing force in healthcare in Africa, be the choice for training in the see and treat modality. The nurses in a clinic are the ones who know the patients and treat them regularly. They are trusted by the patient and seen as knowledgeable and safe 13. It is our belief that well trained nurses will be the turning point of diagnosis and treatment of cervical dysplasia.

The increase in cervical cancer in Sub-Sahara Africa is directly related to HIV. HIV infection decreases a woman’s ability to rid HPV. These 2 diseases are directly correlated as can be seen by the WHO map relating the 2. HIV is well controlled with free clinics, testing and treatment. But now women are dying of another completely treatable virus because they do not have access to screening.

Tanzania had 9772 cases of cervical cancer in 2018 with 6695 deaths11. This is representative of Sub-Sahara Africa and therefore it is imperative to have a low cost, effective way to diagnosis and treat cervical dysplasia. The see and treat method with VIAA, VILI and TC is the answer to the increasing number of cervical cancer patients. WHO predicts that cervical cancer will kill 700,000 women a year by 2030 if efforts are not put in place to halt the progression., It is by far better to do colposcopy or to have an EVA device, but this is impractical in the majority of LMIC. Therefore, the see and treat method is the answer until HPV self-testing becomes widespread and the vaccine is universal.            

References:

1. The WHO guidelines for the use of thermal ablation for cervical pre-cancer lesions. 2019

2. Feasibility of thermocoagulation in a screen-and-treat approach for the treatment of cervical precancerous lesions in sub-Saharan Africa. Manuela Viviano 1 2, Bruno Kenfack 3, Rosa Catarino 4, Eveline Tincho 3, Liliane Temogne 3, Anne-Caroline Benski 4 5, Pierre-Marie Tebeu 6, Ulrike Meyer-Hamme 4, Pierre Vassilakos 7, Patrick Petignat 4

3. Ablative Therapies for Cervical Intraepithelial Neoplasia in Low-Resource Settings. Miriam L. Cremer, Gabriel Conzuelo-Rodriguez, William Cherniak, and Thomas Randall

4. Safety and Acceptability of Thermal Ablation for Treatment of Human Papillomavirus Among Women Living with HIV in Western Kenya.                                                                                     Chemtai Mungo 1, Cirilus Ogollah Osongo 2, Jeniffer Ambaka 2, Magdalene A Randa 2, Jackton Omoto 3, Craig R Cohen 4, Megan Huchko 5

5. Cervical Cancer Common Amongst African Women. World Health Organization. May 9, 2019

6. The Cancer Atlas. American Cancer Society thecanceraltaa.cncer.org

7. World Life Expectancy https://www.worldlifeexpectancy.com/cause-of-death/cervical-cancer/by-country/female

8.Parents' Death and its Implications for Child Survival

Hani K. Atrash, M.D., M.P.H.1

9.The impact of parental death on school outcomes: longitudinal evidence from South Africa Anne Case 1, Cally Ardington

10. Modeling solutions to Tanzania's physician workforce challenge

Alex J. Goodell,1,* James G. Kahn,2 Sidney S. Ndeki,3 Eliangiringa Kaale,4 Ephata E. Kaaya,5 and Sarah B. J. Macfarlane6

 11. Human Papillomavirus and related diseases report. 2018;(December).

Bruni L, Albero G, Serrano B, Mena M, Gómez D, Muñoz J, de Bosch FX SS.

 12. Cervical cancer in Tanzania: A systematic review of current challenges in six domains

Ava S. Runge,a Megan E. Bernstein,a Alexa N. Lucas,a and Krishnansu S. Tewarib

 13. Nursing’s Potential to Address the Growing Cancer Burden in Low- and Middle-Income Countries

Julia M. Challinor, Annette L. Galassi, Majeda A. Al-Ruzzieh,Jean Bosco Bigirimana, Lori Buswell, Winnie K.W. SoAllison Burg Steinberg, Makeda Williams