research project on cervical cancer

Cervical Cancer Research

For some people with early-stage cervical cancer, a surgical procedure called a simple hysterectomy may be a safe and effective alternative to treatment with a radical hysterectomy, results from the SHAPE trial show.

It may be worthwhile for some individuals between ages 65 and 69 to get tested for HPV, findings from a Danish study suggest. Specifically, the testing may help prevent cervical cancer among those who haven’t had cervical cancer screening for at least 5 years.

One dose of the HPV vaccine was highly effective in protecting young women against infection from high-risk HPV types, a study in Kenya found. A single dose would make HPV vaccines more accessible worldwide, reducing cervical cancer’s global burden.

The rates of timely cervical cancer screening fell between 2005 and 2019, researchers found, and disparities existed among groups of women. The most common reason for not receiving timely screening was lack of knowledge about screening or not knowing they needed screening.

Fewer women with early-stage cervical cancer are having minimally invasive surgery, including robotic, as part of their treatment, a new study shows. The shift toward more open surgeries follows the release of results from the LACC trial in 2018.

Widespread HPV vaccine use dramatically reduces the number of women who will develop cervical cancer, according to a study of nearly 1.7 million women. Among girls vaccinated before age 17, the vaccine reduced cervical cancer incidence by 90%.

Updated cervical cancer screening guidelines from the American Cancer Society recommend HPV testing as the preferred approach. NCI’s Dr. Nicolas Wentzensen explains the changes and how they compare with other cervical cancer screening recommendations.

In a new study, an automated dual-stain method using artificial intelligence improved the accuracy and efficiency of cervical cancer screening compared with the current standard for follow-up of women who test positive with primary HPV screening.

More than a decade after vaccination, women who had received a single dose of the HPV vaccine continued to be protected against infection with the two cancer-causing HPV types targeted by the vaccine, an NCI-funded clinical trial shows.

Women with cervical or uterine cancer who received radiation to the pelvic region reported side effects much more often using an online reporting system called PRO-CTCAE than they did during conversations with their clinicians, a new study shows.

A research team from NIH and Global Good has developed a computer algorithm that can analyze digital images of the cervix and identify precancerous changes that require medical attention. The AI approach could be valuable in low-resource settings.

A new test can help to improve the clinical management of women who screen positive for HPV infection during routine cervical cancer screening, an NCI-led study has shown.

FDA has approved pembrolizumab (Keytruda) for some women with advanced cervical cancer and some patients with primary mediastinal large B-cell lymphoma (PMBCL), a rare type of non-Hodgkin lymphoma.

By comparing the genomes of women infected with a high-risk type of human papillomavirus (HPV), researchers have found that a precise DNA sequence of a viral gene is associated with cervical cancer.

Investigators with The Cancer Genome Atlas (TCGA) Research Network have identified novel genomic and molecular characteristics of cervical cancer that will aid in subclassification of the disease and may help target therapies that are most appropriate for each patient.

Project overview

 project overview.

Cervical cancer is a major public health problem, with annually more than 500.000 women worldwide diagnosed with this disease. The Prevention and Screening Innovation Project toward Elimination of Cervical Cancer (PRESCRIP-TEC) contributes to effective and innovative cervical cancer screening, including direct treatment for women in resource-poor or hard-to-reach settings in the world. PRESCRIP-TEC conducts implementation research in four countries over three continents: Bangladesh and India in Asia, Uganda in Africa, and Slovakia in Europe. We are improving existing screening protocols in the four countries.

Better communication

We are improving interactive information with communities via traditional media, mobile devices and social media. We are approaching women of hard-to-reach regions and populations through posters, radio, flyers, awareness talks in the communities, theatrical performances, door-to-door visits, promoted posts on social media, etc.

All over the world, the use of mobile devices, social media, and modern communication technology is spreading quickly. Also women with limited health literacy or limited internet access, are using the technology more and more. PRESCRIP-TEC is investigating to which extent the range of awareness raising and community mobilisation options can be expanded for prevention and screening of cervical cancer.

Better testing for HPV

Nearly all cervical cancers are caused by infection with the Human Papilloma Virus (HPV). The Word Health Organisation recommends HPV testing as the primary screening intervention .

We are offering client-friendly HPV self-tests at home. Women do not have to travel to a clinic for gynaecological examination, to know if they have a HPV infection. After the beneficiary women have performed an easy and convenient self-test, only those who are HPV positive will be invited for further investigation.

Artificial Intelligence

In India, Bangladesh and Uganda HPV positive women undergo a Visual Inspection of the cervix with Acetic acid (VIA) in mobile clinics or primary healthcare facilities, to diagnose any precancerous lesions, which need treatment.

We are using an artificial intelligence decision support system (AI-DSS) in gynaecological examination. The use of artificial intelligence built into mobile devices offers high quality diagnosis in resource-poor settings. Inter-observer variation in VIA will be reduced.

Immediate treatment

We offer to women who need treatment for precancerous lesions direct treatment in the location where the VIA is performed. This reduces travel time and therefore drop-out of women in the process.

We are analysing the uptake of cervical cancer screening offered.

Will improved communication lead to higher attendance? Will convenient HPV testing at home lead to higher acceptance? Will AI-DSS lead to better diagnosis?

We will perform a cost-effectiveness analysis and a produce a business case for the global introduction of hrHPV testing as routine screening for cervical cancer. We will show the advantage of point-of-delivery testing and the benefits of self-testing for cancer in the post-COVID era, which reduces pressure on the health system. This research, therefore will be a major contribution in supporting the global WHO strategy for elimination of cervical cancer.

Cancer of the cervix of the uterus is a global health challenge: worldwide numbers are increasing, although cervical cancer is largely preventable through vaccination and screening programmes. In 2018 approximately 570,000 women were diagnosed with cervical cancer worldwide, and 311,000 died of the disease, of whom 90% in low- and middle-income countries (LMICs). This number is higher than the registered number of deaths due to Corona Virus Infectious Disease (COVID 19) in the period January – May 2020. In high-income countries (HICs) the infection rate is lower, but women from vulnerable communities are mostly affected.

Primary prevention : Primary prevention of cervical cancer consists of vaccination for high risk Human Papilloma Virus (hrHPV). This virus is responsible for over 90% of cervical cancers and vaccination significantly reduces the incidence of HPV infection and premalignant lesions. Over the last ten years, most high income countries have started vaccination programmes but coverage is not optimal. The HPV vaccination is slowly being introduced in low- and middle-income countries. This project will provide information to at least 450,000 people about vaccination, but will not engage in vaccination programmes.

Screening and secondary prevention : The occurrence of premalignant lesions and invasive cervical cancer is almost exclusively dependent on a persistent hrHPV infection. Tests determining presence of hrHPV have become the first line screening tool for cervical cancer in the Netherlands and few other Western countries, even before Pap-smear or VIA test. hrHPV infection often does not lead to cervical cancer. Depending on the age of the woman and other risk factors like HIV-co-infection, around 80% women with HPV-infection will clear the virus and not develop precancerous changes. When women are HPV-positive, additional testing (Pap-smear or VIA) is needed to detect precancerous lesions and select women for treatment. 

Secondary prevention programmes were initiated decades ago in high-income countries, even before the relation between HPV infection and cervical cancer was known, and have led to a dramatic decrease in the incidence of cervical cancer. Secondary prevention for cervical cancer without hrHPV testing includes several strategies. In settings where pathology laboratory facilities are available, screening with Pap smear, collected through gynaecological examination, is recommended. Presence of dysplasia (precancerous cells) is an indication for a colposcopy, where the cervix is examined visually with a magnifying lens and biopsies can be taken for histological analysis. If indicated, lesions are treated with local electrosurgical excision.  

In LMICs laboratory facilities are limited and screening is performed using visual inspection with acetic acid (VIA). During gynaecological examination, acetic acid is applied to the cervix and under direct visual inspection the cervix is screened for aceto-white lesions, indicating presence of precancerous cells. In the same visit (one stop-shop) women are treated with cryotherapy or thermal ablation, techniques that destroy the precancerous cells of the cervix through respectively freezing or heating. 

The diagnostic accuracy of both colposcopy and VIA are dependent on the skills of the health care worker, especially for VIA sensitivity and specificity reported varies across studies. Manipal Academy of Higher Education in India has proven that adding artificial intelligence to VIA improves diagnostic accuracy (an accuracy of 97.94%, a sensitivity of 99.05% and specificity of 97.16%. ). Artificial intelligence is a Decision Support System and can support the individual judgement of observers, reduce the interobserver variability and provides highly sensitive results. This means that screening can be done by nurses or midwives without extensive training in VIA. 

Bottlenecks for increasing coverage of cervical cancer screening programmes

Several publications analysed factors for success of cervical cancer screening programmes. The factors can be distinguished in client-related factors and health systems factors.

Factors related to clients can be categorised as in the table below. In general, the factors mentioned below are more prevalent in people with lower levels of education, low health literacy and lower socio-economic status. 

Table 1 Client-related factors influencing uptake (modified and adapted from SAGE)

From literature, the following health system factors can be identified as in the table below.

Table 2 Health system factors for cervical cancer screening

The project will address both health systems- and client-related factors in order to improve the coverage (Availability Accessibility Acceptability Quality) of cervical cancer screening. 

Overall objective    

The overall objective of PRESCRIP-TEC is to build on and upscale existing screening programmes with women-friendly and cost-effective tools and test whether and why they are effective in increasing participation in cervical cancer screening in Europe and in Low- and Middle-Income Countries in accessible, affordable and equitable ways.

Purpose    

The purpose of this project is to study and to address the barriers and facilitators of providing state-of-the-art community-based screening, treatment and follow-up programme for cervical cancer in selected settings in Bangladesh, India, Uganda and Slovak Republic. The research project measures coverage and uptake in relation to availability, accessibility, acceptability, quality and cost-effectiveness, and options for scaling up. The implementation research will focus on best ways to increase participation and compliance in cervical cancer screening (on the beneficiaries’ side) and improve implementation fidelity (on the providers’ side).

National screening programmes and country-specific information

In all high income countries and in many low and middle income countries national screening programmes have been introduced, however coverage of screening by eligible women is low. In the Netherlands, for example, 61% of eligible women participate in the screening programme.  When opportunistic screening (offered when gynaecological examination is performed for another reason) is included, the total of 72% of women is reached. In Central and Eastern Europe coverage is less than 50% and  below 10% in LMICs.  

Table  National programmes for cervical cancer screening

NA= not applicable

Most LMICs have not yet integrated the cervical cancer screening in the standard package of health care services, because of different health system challenges, e.g. lack of human resources (gynaecologists, pathologists, nurses and midwives), lack of equipment (colposcopes, cryo-therapeutic equipment), lack of suitable examination rooms in primary healthcare facilities. Often, screening activities are opportunistic (when a woman comes for another reason to a health facility) and direct treatment for women with precancerous lesions is not available in a single visit.

Client-related factors, such as complacency concerning threats of cancer, lack of understanding due to low health literacy, lack of financial resources to travel and lack of time are contributing factors. Moreover, because of the gynaecological examination involved, there are religious and cultural barriers that prevent women to come to clinics for examination. 

In HIC, screening does not cover all at-risk populations. Especially women at high risk, for example migrants, asylum seekers, women from minority groups and commercial sex workers, have low participation in national screening programmes, halting national coverage at 60-70%. Sometimes, it is because they are not registered and not invited, but also client-related factors (health literacy, culture, religion) play a role, especially when coming from other cultural backgrounds.

The countries selected for this implementation project – Bangladesh, India, Uganda and Slovakia – differ not only in geographical location, but also in terms of population size and density, health worker force, cervical cancer burden and implementation of a national strategy for the prevention of cervical cancer. The table below illustrates the estimated incidence and mortality per 100,000 women for each country participating in this research. Uganda has a much higher hrHPV infection rate than other countries, also caused by higher incidence of the HIV co-infection.

Table  Mortality due to cervical cancer

The table below illustrates the differences in terms of total population and current coverage of the cervical cancer screening programmes. Women above the age of 15 years are considered to be at risk to develop cervical cancer. The WHO recommends targeting women between the age of 30 and 49 years old to be screened for cervical cancer, in order to have a significant impact. The different target groups shown below are derived from the national strategies of each country.

Table  Screening for cervical cancer in target countries

Community mobilisation through communication activities

The project consortium will conceptualise, design and implement per country a communication plan, focusing on community mobilisation. Those country plans will build on existing community mobilisation activities and communication platforms, like for example Friendship in Bangladesh or URDT in Uganda. Previous experiences for UNICEF and other organisations will be used in the design.

Our model for community mobilisation will be consisting of four elements: situation analysis, information provision, engagement and advocacy and support to community groups.

Situation analysis

At the beginning of the project, we will start in collaboration with the local teams in Bangladesh, India, Uganda and Slovakia to identify the key needs, social religious and cultural factors influencing uptake of cervical cancer screening, available information resources, etc. Objectives, key results, strategies and performance indicators will be set. This will result in a community mobilisation plan and manual.

Information provision

To reach the target audiences, we apply a branded content approach that will help us to transmit values, emotions and behaviours: graphics, data visualisation diagrams, infographics GIFs, designs, blog posts, press releases, human interest stories, etc. 

We will produce one informative video for each country. The videos will be adapted for the web, Instagram, Facebook, YouTube and Twitter. These videos can also be used in the presentations that the local implementers perform in the target countries.

We create a website that will have a specific section for each target country, that can be linked to the existing websites of organisation.

Table 11 Internet in four project countries

* wikipedia and Statcounter

Internet penetration varies for the 4 countries. In Uganda and Bangladesh it is around 20%, in India it is about 50% and in Slovakia it reaches 80%. Even if in Uganda and Bangladesh the penetration seems low, in nearly each family there is a simple phone. Those phones are quickly being replaced with smartphones.  People who have access to the internet, use mostly the smartphone to access, therefore the PRESCRIP-TEC website will be designed from a mobile first approach.

The project will use social media to mobilise women to come for screening, offered close to their homes. We will select the type of social media to be used based on the situation analysis. Social media will also be used to influence other social actors around target women.

We will design, configure and optimise advertising campaigns in Facebook ads, Twitter ads and Google ads to be sure we reach a massive and targeted audience within the target groups. Considering the current social media advertising fares and average interaction of the users in Uganda, Bangladesh, India and Slovakia, we can estimate that, on average, with each 100 € invested on digital advertising, we can reach a targeted audience of approximately 90.000 people.

Besides social media, to reach the people who have mobile phones but not smartphones, we will also use SMS technology to raise awareness and encourage the women to participate in the screening sessions. The project aims to reach at least 90,000 women in eligible age groups.

Engagement and advocacy

In collaboration with local partners we create lobby and advocacy activities with local civil society, (e.g. religious leaders, women organisations, teachers, community leaders) to increase awareness and commitment to screening programmes, which will reinforce present mobilisation mechanisms. We will produce tailored advocacy plans and activities for community mobilisation for each specific context in each of the four countries. 

Table 12 engagement in community mobilisation

Support to community groups

During the three years of the project, we will offer technical assistance and support to local teams. We will also ensure that the necessary knowledge transfer takes place so that local teams have the know-how and tools to continue mobilising the community to encourage women to come for screening.

We will perform the following activities to support community groups:

• Training: The communication experts in the consortium will provide specific trainings in community management and social marketing to the local teams to reach the target audiences efficiently. 
• Content curation: Support to the local teams in edition, curation, optimisation and dissemination of the contents generated by them.
• Support on community management: We will support the local implementers in updating and managing social media profiles.
• Promoted content: We will run advertising campaigns to promote the contents shared on social media to make sure they reach a massive and targeted audience.
• Printed materials: Design and implementation of printed materials in compliance with the communication plan: posters, flyers, roll up, POP material, brochures, etc.
• Events and presentations: Strategic expert advice and technical assistance in events organisation and layout and design of reports and presentations. We will create diagrams, infographics and other data visualisation tools to make the presentations. We will also support the local teams in events organisation.
• Monitoring and reporting: We will provide technical assistance to make sure all the countries are able to effectively measure the impact of their communication activities (e.g. by using Google analytics, questions in exit interviews after screening) and have time based goals and evaluation mechanisms.

See all the community mobilisation activities

The figures below provide the protocol applied in the implementation research project. The figures show two alternatives for use with VIA and AI-DSS or use with PAP smear. These protocols show how steps in the screening process are taken in a logical sequence. The two alternative approaches are applied in their proper context. In low-resource settings where pathologists are only available in university laboratories, as explained in the introduction, VIA is the standard. In European settings PAP smear is the standard. In both protocols these tests will be preceded by a hrHPV test.

The project will work with governmental and non-governmental organisations within the local context of financing, clinical guidelines and regulations, and where necessary assist the responsible authorities to draft them. The project will apply– and, if necessary, further develop – the necessary procedures for protection of vulnerable women, for avoidance of stigmatisation (see inventory above),

The dotted lines in the figures below show where the project interacts with the existing systems for referral. In the Slovak Republic Pap smear and further steps are done by the primary healthcare gynaecologist and reimbursed by the health insurance.

Figure 2 Protocol for screening in LMICs

Figure 3 Protocol for screening in Slovak Republic

The AI-DSS for cervical cancer screening is a low-risk type of artificial intelligence . The images of cervix before and after application of acetic acid will be saved into the device storage. A diagnosis report is generated with these two images, random generated number and the final assessment. 

In case of doubt, a second opinion can be sought – since this device provides images of cervix, it eliminates the need of the expert on site. (Calling the senior on the spot is not needed). The senior can be in remote location, while images is sent to him/her. This kind of remote evaluation is possible. 

Research questions

The project will apply a Comparative Effectiveness (CE) approach, in order to facilitate better informed and more evidence-based decisions by clinicians, clients, third-party payers, and policy makers. 

We compare the effectiveness of cervical cancer screening and treatment of precancerous lesions under different circumstances and settings. In each country, we will work in at least two settings. This approach makes it possible to identify generalisable factors that work under all conditions. It reduces the risk of giving too much weight to specific local conditions, which may hamper or stimulate success of screening programmes. This is relevant for scaling up approaches. The CE provides essential information to improve outcomes in everyday clinical practice. 

For this research we will work with an interdisciplinary faculty capable of designing and executing multimodal implementation and evaluation research. We will work with ready-to-roll field testing sites. Thus the project will create a research network across continents. At the project level, we will aggregate results to see the overall effects, and compare countries and sites, to assess specific success or fail factors.

The methodology of researching the comparative effectiveness and efficacy of the new processes is based on comparing the baseline to data collected after the introduction of the protocol.

Measuring conditions for scaling-up 

Through applying the RE-AIM framework for assessment of scaling up interventions, the project will show its impact and feasibility. The indicators mentioned under the first five research questions (above) can be fitted into the RE-AIM framework, of 

• % of eligible women aware of cervical cancer and screening
• % of eligible women screened
• Scores on trust and cancer awareness 
• % of hrHPV women coming for VIA or Pap smear
• % of women receiving early treatment
• % of women referred for advanced care
• % of health professionals implementing standard procedures
• Involvement of authorities in implementation of screening programme
• Scores in the SARA surveys 
• Adoption of improved national screening guidelines

PRESCRIP-TEC will show how conditions for scaling up can be met, and will deliver a concrete implementation plan for integrating cervical cancer screening in a package of Universal Health Coverage. This will be developed for broad dissemination across countries, contributing to the WHO strategy for elimination of cervical cancer.

See scientific papers related to cervical cancer

Learn all the details about how PRESCRIP-TEC contributes to the elimination of cervical cancer in the following video.

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Improving cervical cancer screening rates: a scoping review of resources and interventions

• Review article
• Published: 18 August 2022
• Volume 33 , pages 1325–1333, ( 2022 )

Cite this article

• Madyson L. Popalis 1 ,
• Sarah I. Ramirez 1 ,
• Kelsey M. Leach 1 ,
• Marni E. Granzow 1 ,
• Kelsey C. Stoltzfus 1 &
• Jennifer L. Moss   ORCID: orcid.org/0000-0002-3794-1344 1  

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Introduction

Cervical cancer mortality can be prevented through early detection with screening methods such as Pap and high-risk human papillomavirus (hrHPV) tests; however, only 81% of women aged 21–65 are up-to-date on screening. Many interventions to increase cervical cancer screening have been implemented, but there is limited understanding about which intervention components are most successful.

We conducted a scoping review of existing literature and available resources for cervical cancer screening interventions to identify gaps in the research. We used t tests and correlations to identify associations among intervention components and effect sizes.

Out of nine studies, the mean overall effect size for interventions was 11.3% increase in Pap testing for cervical cancer screening (range =  − 4–24%). Interventions that included community health workers or one-on-one interaction had the biggest effect size ( p  < 0.05). No associations with effect size were noted for literacy level, number of intervention components, or targeting by race/ethnicity.

Conclusions

Future interventions may include educational sessions with community health workers or one-on-one patient interaction to improve cervical cancer screening. Further research is needed to establish effect sizes for large-scale interventions and hrHPV screening interventions.

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Data availability.

Enquiries about data availability should be directed to the authors.

American Cancer Society (2020) Key statistics for cervical cancer. Accessed 7 July 2020

National Cancer Institute (2020) Cancer stat facts: cervical cancer. Available from: https://seer.cancer.gov/statfacts/html/cervix.html . Accessed 7 July 2020

Centers for Disease Control and Prevention (2019) What can I do to reduce my risk of cervical cancer? [updated August 7, 2019]. Available from: https://www.cdc.gov/cancer/cervical/basic_info/prevention.html . Accessed 7 July 2020

National Cancer Institute (2020) Cervical cancer screening. Available from: https://progressreport.cancer.gov/detection/cervical_cancer . Accessed 7 July 2020

Office of Disease Prevention and Health Promotion (2018) Cervical cancer: screening. Available from: https://health.gov/healthypeople/tools-action/browse-evidence-based-resources/cervical-cancer-screening . Accessed 7 July 2020

Armstrong R, Hall BJ, Doyle J, Waters E (2011) Cochrane update. ‘Scoping the scope’ of a cochrane review. J Public Health (Oxf) 33(1):147–150

Article   Google Scholar  

Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG (2009) Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42(2):377–381

Walsh TM, Volsko TA (2008) Readability assessment of internet-based consumer health information. Respir Care 53(10):1310–1315

PubMed   Google Scholar  

Blumenthal DS, Fort JG, Ahmed NU, Semenya KA, Schreiber GB, Perry S et al (2005) Impact of a two-city community cancer prevention intervention on African Americans. J Natl Med Assoc 97(11):1479–1488

PubMed   PubMed Central   Google Scholar  

Braun KL, Thomas WL Jr, Domingo JL, Allison AL, Ponce A, HaunaniKamakana P et al (2015) Reducing cancer screening disparities in medicare beneficiaries through cancer patient navigation. J Am Geriatr Soc 63(2):365–370

Fernández ME, Gonzales A, Tortolero-Luna G, Williams J, Saavedra-Embesi M, Chan W et al (2009) Effectiveness of Cultivando la Salud: a breast and cervical cancer screening promotion program for low-income Hispanic women. Am J Public Health 99(5):936–943

Maxwell AE, Bastani R, Vida P, Warda US (2003) Results of a randomized trial to increase breast and cervical cancer screening among Filipino American women. Prev Med 37(2):102–109

Paskett ED, Tatum CM, D’Agostino R Jr, Rushing J, Velez R, Michielutte R et al (1999) Community-based interventions to improve breast and cervical cancer screening: results of the Forsyth County Cancer Screening (FoCaS) Project. Cancer Epidemiol Biomark Prev 8(5):453–459

CAS   Google Scholar  

Studts CR, Tarasenko YN, Schoenberg NE, Shelton BJ, Hatcher-Keller J, Dignan MB (2012) A community-based randomized trial of a faith-placed intervention to reduce cervical cancer burden in Appalachia. Prev Med 54(6):408–414

Taylor VM, Hislop TG, Jackson JC, Tu SP, Yasui Y, Schwartz SM et al (2002) A randomized controlled trial of interventions to promote cervical cancer screening among Chinese women in North America. J Natl Cancer Inst 94(9):670–677

Taylor VM, Jackson JC, Yasui Y, Nguyen TT, Woodall E, Acorda E et al (2010) Evaluation of a cervical cancer control intervention using lay health workers for Vietnamese American women. Am J Public Health 100(10):1924–1929

Thompson B, Carosso EA, Jhingan E, Wang L, Holte SE, Byrd TL et al (2017) Results of a randomized controlled trial to increase cervical cancer screening among rural Latinas. Cancer 123(4):666–674

Wells KJ, Luque JS, Miladinovic B, Vargas N, Asvat Y, Roetzheim RG et al (2011) Do community health worker interventions improve rates of screening mammography in the United States? A systematic review. Cancer Epidemiol Biomark Prev 20(8):1580–1598

Frieden TR (2010) A framework for public health action: the health impact pyramid. Am J Public Health 100(4):590–595

Buskwofie A, David-West G, Clare CA (2020) A review of cervical cancer: incidence and disparities. J Natl Med Assoc 112(2):229–232

Schapira MM, Swartz S, Ganschow PS, Jacobs EA, Neuner JM, Walker CM et al (2017) Tailoring educational and behavioral interventions to level of health literacy: a systematic review. MDM Policy Pract 2(1):2381468317714474

Davidson EM, Liu JJ, Bhopal R, White M, Johnson MR, Netto G et al (2013) Behavior change interventions to improve the health of racial and ethnic minority populations: a tool kit of adaptation approaches. Milbank Q 91(4):811–851

Joober R, Schmitz N, Annable L, Boksa P (2012) Publication bias: what are the challenges and can they be overcome? J Psychiatry Neurosci 37:149–152

Yeh PT, Kennedy CE, de Vuyst H, Narasimhan M (2019) Self-sampling for human papillomavirus (HPV) testing: a systematic review and meta-analysis. BMJ Glob Health 4:e001351

Miller KD, Goding Sauer A, Ortiz AP, Fedewa SA, Pinheiro PS, Tortolero-Luna G et al (2018) Cancer statistics for Hispanics/Latinos, 2018. CA Cancer J Clin 68(6):425–445

American Society of Clinical Oncology (2020) Cervical cancer: statistics. Available from: https://www.cancer.net/cancer-types/cervical-cancer/statistics . Accessed 7 July 2020

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Acknowledgments

Funding for this project came from K22 CA225705 (PI: Moss) and an Institutional Research Grant, IRG-17-175-04, from the American Cancer Society (PI: Moss). In addition, the project described was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through UL1 TR002014 and UL1 TR00045. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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Popalis, M.L., Ramirez, S.I., Leach, K.M. et al. Improving cervical cancer screening rates: a scoping review of resources and interventions. Cancer Causes Control 33 , 1325–1333 (2022). https://doi.org/10.1007/s10552-022-01618-2

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DOI : https://doi.org/10.1007/s10552-022-01618-2

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HPV vaccine: the key to eliminating cervical cancer inequities

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Effect of the HPV vaccination programme on incidence of cervical cancer and grade 3 cervical intraepithelial neoplasia by socioeconomic deprivation in England

• Related content
• Peer review
• Trisha L Amboree , postdoctoral fellow 1 ,
• Joslyn Paguio , advocate for patients with cervical cancer 2 ,
• Kalyani Sonawane , associate professor 3
• 1 The University of Texas MD Anderson Cancer Center, Houston, TX, USA
• 2 Patient author, The Cervivor Advocacy Group, CA, USA
• 3 MUSC Hollings Cancer Center, Charleston, SC 29464, USA
• Correspondence to: K Sonawane sonawane{at}musc.edu

Programmes must ensure equitable access for all eligible groups

The human papillomavirus (HPV) vaccine protects individuals from HPV strains that cause cancer. Evidence of its effectiveness in eliminating invasive cervical cancers is growing. 1 2 3 4 In a linked paper, Falcaro and colleagues (doi: 10.1136/bmj-2023-077341 ) provide further evidence for the impact of HPV vaccination in eliminating invasive cancers. 5 They also answered the vexed question of whether national HPV vaccination programmes magnify or narrow cervical cancer inequities.

Women from lower socioeconomic backgrounds share a disproportionately greater burden of cervical cancer incidence and mortality. 6 Notably, socioeconomic inequities in cervical cancer are reported across high, middle, and low income countries. 7 8 9 Falcaro and colleagues’ findings underscore the importance of the HPV vaccine as an effective tool for reducing inequalities in cervical cancer, making a clear case for equitable access to the vaccine.

In their nationwide study, Falcaro and colleagues found that HPV vaccination reduced cervical cancer risk and grade 3 cervical intraepithelial neoplasia by 83.9% (95% confidence interval 63.8% to 92.8%) and 94.3% (92.6% to 95.7%), respectively, in the contemporary birth cohort of women offered vaccination routinely at age 12-13 years in England. Invasive cervical cancers decreased by more than 80% in all socioeconomic groups among vaccinated girls and women, preventing an estimated 687 cervical cancers by mid-2020. Interestingly, vaccine effectiveness (the proportion of cervical cancers averted) was consistent regardless of socioeconomic status. This finding suggests that marginalized groups may benefit from the HPV vaccine despite poor social determinants of health or higher prevalence of risk factors such as smoking, alcohol consumption, and reduced uptake of cancer screening. 10 11 12 13 14

Vaccine equity

Foundational to the success of England’s universal HPV immunization programme was the consideration of equitable access. More than 100 countries have introduced HPV vaccination programmes, and inequities in vaccine access and availability are documented. 15 To successfully eliminate cervical cancers, policy makers must develop, implement, or redesign programmes to ensure equal access to the HPV vaccine for all individuals, regardless of their income. For example, the Vaccines for Children programme in the US provides free HPV vaccination to children from a low income household, as a result of which vaccine coverage in teenagers from such households is comparable to (and exceeds) coverage among teenagers from high income households. 16 Similarly, the national immunization programme in Australia, introduced in 2007 and providing free HPV vaccination to schoolchildren aged 12-13 years, led to rapid uptake and attainment of 80% vaccine coverage. 17 The human and monetary consequences of cervical cancer and treatment averted through HPV vaccination outweigh the costs of making it accessible to all age eligible individuals. 18

Another notable finding from Falcaro and colleagues’ study is the incremental effect of building up HPV vaccine coverage in successive birth cohorts. Typically, the effect of a public health programme is often not fully evident during the early phases due to lag time in population uptake. In England, for instance, HPV vaccine coverage (a proxy for herd protection from HPV) increased from 38.9% to 48.1% in individuals born between September 1990 and August 1993 to 70.8-75.7% in those born between September 1993 and August 1995 and to 80.9-88.0% in those born between September 1995 and August 2000. The reduction in cervical cancer risk in these three cohorts was incremental—35.5%, 71.3%, and 86.0%, respectively.

Inherently, these data also emphasize the importance of attaining the 90% coverage target recommended by the World Health Organization. 19 Currently, HPV vaccine coverage is below target in many countries despite being offered for several years. 20 Inequities in vaccine access, hesitancy, and variation in the extent to which healthcare providers recommend vaccination create a major challenge to target attainment in countries with existing HPV vaccine programmes. 21 22 23 24 Additionally, upstream factors (finances, health system capacity, supply, and vaccine prioritization) can deter introduction and scale-up in countries with no programmes. 25 To overcome the challenges of reaching target coverage and to maximize population herd immunity, collective efforts of government, community stakeholders, and healthcare professionals in these countries will be necessary.

In conclusion, the HPV vaccine is the key to eliminating cervical cancer inequalities. An equity driven approach is critical for the success of HPV vaccination programmes.

Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: Dr. Sonawane has consulted Value Analytics Labs on unrelated projects.

Further details of The BMJ policy on financial interests is here: https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf .

Provenance and peer review: Commissioned; not externally peer reviewed.

• Elfström KM ,
• Palmer TJ ,
• Kavanagh K ,
• Cuschieri K ,
• Falcaro M ,
• Castañon A ,
• Skorstengaard M ,
• Thamsborg LH ,
• Lorenzoni V ,
• Amboree TL ,
• Damgacioglu H ,
• Sonawane K ,
• Montealegre JR ,
• Deshmukh AA
• Vaccarella S ,
• Lortet-Tieulent J ,
• Saracci R ,
• De Vries E ,
• Sierra MS ,
• Georges D ,
• Pappas-Gogos G ,
• Douglas E ,
• Currin LG ,
• Linklater KM ,
• NCD Global Health Research Group ,
• Association of Pacific Rim Universities (APRU)
• Khanduri A ,
• Pingali C ,
• Elam-Evans LD ,
• Brotherton J ,
• Macartney K ,
• Rosettie KL ,
• Sparks GW ,
• ↵ World Health Organization. Human papillomavirus vaccines: WHO position paper, December 2022. Weekly Epidemiological Record, WER No 50, 2022, 97, 645-72.
• ↵ World Health Organization. HPV immunization coverage estimates among primary target cohort (9-14 years old girls) (%). Retrieved from The Global Health Advisory. WHO, March 31 2023. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/girls-aged-15-years-old-that-received-the-recommended-doses-of-hpv-vaccine
• Sabeena S ,
• Arunkumar G
• Watson-Jones D
• Guillaume D ,
• Waheed DE ,
• Schleiff M ,
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• Vorsters A ,

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Cervical cancer

Introduction

News & events, epidemiology of hpv-associated cancers past, present and future: towards prevention and elimination, cancer screening metrics: effective evaluation to balance benefits and harms, cancer screening in five continents (canscreen5): a global data repository for breast, cervical, and colorectal cancer screening programmes, why is brazil changing its hpv vaccine recommendations, infographics, world immunization week 2024: vaccination against hpv and hepatitis viruses.

Kathmandu, Nepal

Cervical Cancer Awareness Month 2021 Questions and Answers (Q&A)

Every few years, IARC publishes the latest global data on cancer incidence and mortality. What do these figure show about cervical cancer? Which geographical areas are most affected, and why?

What are the main solutions to address this problem globally?

What is the WHO Cervical Cancer Elimination Initiative?

• Open access
• Published: 13 April 2023

Cervical cancer survival prediction by machine learning algorithms: a systematic review

• Milad Rahimi   ORCID: orcid.org/0000-0002-2750-3826 1 ,
• Atieh Akbari   ORCID: orcid.org/0000-0001-5628-0409 2 ,
• Farkhondeh Asadi   ORCID: orcid.org/0000-0003-0939-7983 3 &
• Hassan Emami   ORCID: orcid.org/0000-0003-4309-5049 4  

BMC Cancer volume  23 , Article number:  341 ( 2023 ) Cite this article

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Cervical cancer is a common malignant tumor of the female reproductive system and is considered a leading cause of mortality in women worldwide. The analysis of time to event, which is crucial for any clinical research, can be well done with the method of survival prediction. This study aims to systematically investigate the use of machine learning to predict survival in patients with cervical cancer.

An electronic search of the PubMed, Scopus, and Web of Science databases was performed on October 1, 2022. All articles extracted from the databases were collected in an Excel file and duplicate articles were removed. The articles were screened twice based on the title and the abstract and checked again with the inclusion and exclusion criteria. The main inclusion criterion was machine learning algorithms for predicting cervical cancer survival. The information extracted from the articles included authors, publication year, dataset details, survival type, evaluation criteria, machine learning models, and the algorithm execution method.

A total of 13 articles were included in this study, most of which were published from 2018 onwards. The most common machine learning models were random forest (6 articles, 46%), logistic regression (4 articles, 30%), support vector machines (3 articles, 23%), ensemble and hybrid learning (3 articles, 23%), and Deep Learning (3 articles, 23%). The number of sample datasets in the study varied between 85 and 14946 patients, and the models were internally validated except for two articles. The area under the curve (AUC) range for overall survival (0.40 to 0.99), disease-free survival (0.56 to 0.88), and progression-free survival (0.67 to 0.81), respectively from (lowest to highest) received. Finally, 15 variables with an effective role in predicting cervical cancer survival were identified.

Combining heterogeneous multidimensional data with machine learning techniques can play a very influential role in predicting cervical cancer survival. Despite the benefits of machine learning, the problem of interpretability, explainability, and imbalanced datasets is still one of the biggest challenges. Providing machine learning algorithms for survival prediction as a standard requires further studies.

Peer Review reports

Introduction

Cervical cancer is the fourth most common cancer in the female reproductive system and the seventh most common cancer worldwide. There is a higher likelihood of cancer tumors growing in areas where endocervix cells become exocervix cells or near the Squamocolumnar Junction (SCJ). Cervical cancer is one of the main factors related to the death of females worldwide [ 1 ]. According to the World Health Organization (WHO) cervical cancer report in 2020, there were about 604,127 diagnosed cases and 341,831 deaths worldwide, of which 1,056 diagnosed cases and 644 deaths occurred in Iran [ 2 ]. Sexually transmitted diseases, multiple partners, smoking, weak nutrition, and the immune system play a role in the growth and development of cervical cancer [ 3 ]. An important risk factor for cervical cancer is the persistence of human papillomavirus (HPV), especially genotypes 16 and 18 [ 4 ]. Although about 90% of human papillomavirus infections heal by themselves within two years, some may also lead to the growth of cancerous masses in the cervix [ 5 , 6 ]. Diagnosing a cancerous mass in the early stages increases the patient’s chance of survival and treatment. In late diagnosis, the possibility of complete recovery of the patient decreases [ 7 ]. Cervical cancer is entirely preventable and treatable if pre-cancer symptoms are identified at an early stage. The pap smear is frequently used for cervix medical diagnosis to track cervical cancer. A few cervical cell samples are taken, a cell smear is made, the cells are examined under a microscope for abnormalities, and the result is a diagnosis of the cervical condition [ 8 ]. Physicians consider the patient's chance of survival to guide their treatment plan.

Survival prediction is a set of statistical methods for data analysis, where the outcome variable is the time to an event. In other words, survival prediction is calculated by considering the time between exposure to the event and the occurrence of the event [ 9 ]. According to the American Society of Clinical Oncology (ASCO), the average 5-year overall survival rate for cervical cancer is 66%, i.e., about 66% of people diagnosed with cervical cancer today will survive for at least the next five years. The best treatment method for each patient can be adopted by evaluating the patient’s clinical and treatment data to accurately predict the patient’s survival. Researchers have often used classical statistical methods such as non-parametric, parametric, and semi-parametric (COX) tests to predict survival [ 10 ]. In recent years, artificial intelligence algorithms, with their impressive capabilities, have been in fierce competition with statistical tests and have grown significantly in survival prediction.

Big data are being generated and stored with the rapid growth of digital technologies in healthcare and the evolution of electronic health records (EHR) [ 11 ]. Classical statistical methods often focus on the relationship between dependent variables to achieve the final result, but machine learning algorithms can learn hidden patterns in data. Machine learning algorithms do not require implicit assumptions and can manage non-linear relationships between variables [ 12 ]. Machine learning makes computers intelligent without directly teaching them how to make decisions and solve problems [ 13 ]. Today, machine learning algorithms have been studied and developed in the diagnosis, prognosis, and prediction of the occurrence of many diseases [ 14 ], which performed very well in dealing with Big data [ 15 ].

This study aimed to evaluate published studies on machine learning algorithms in predicting the survival of patients with cervical cancer, considering overall, disease-free, and progression-free survival.

Materials and methods

This systematic review examined original articles that used machine learning algorithms to predict the survival of patients with cervical cancer and discovered knowledge.

Study selection

The article selection method was based on the Preferred Protocol for Systematic Reviews and Meta-Analysis (PRISMA) and the retrieved articles were imported into Excel software. The first search returned 229 articles, then 45 review articles and 85 duplicate articles were removed. A total of 99 items remained for screening based on the eligibility criteria. During the screening process, 70 articles were excluded by title and abstract verification, and 16 articles were excluded based on method, results, or study design nature. The screening process was performed twice to reduce errors. Any discrepancies were resolved through discussions with the second and third authors. Finally, 13 articles were thoroughly examined and included in the study (Fig.  1 ).

Description: Flow diagram of the study identification and selection process, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines

Search strategy

Articles published until October 1, 2022, were collected from three electronic databases, PubMed, Scopus, and Web of Science, and the search query consisted of three basic parts. The first part was about cervical cancer, which included two keywords of "cervical cancer" and "Uterine Cervical Neoplasms". The second part was about predicting survival with one keyword named "Survival", and the third part was about artificial intelligence with three keywords, including "Machine learning", "Deep learning", and "Artificial Intelligence." Details are available in Table 1 .

Inclusion and exclusion criteria

This study included original articles and full English text, which used machine learning algorithms as predictive models for cervical cancer survival.

Books, review articles, meta-analyses, case reports, posters and case studies were filtered. In addition, articles that did not sufficiently focus on the implementation of machine learning algorithms, cervical cancer, and model outputs were excluded in the screening section. All entry and exit criteria are listed in Table 2 .

From the initial search results, 229 articles were found, of which only 13 articles met the study criteria and were included in the study for further investigation. All included articles were retrospective and used machine learning algorithms as modeling to predict cervical cancer survival.

Characteristics of studies

Most of the imported articles were published from 2018 onwards, and the last was from 2022 (Table 3 ). Table 4 provides additional information and a general view of the included studies. A total of eight articles were performed in Asia [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ], four in Europe [ 24 , 25 , 26 , 27 ], and one in the United States [ 28 ]. Generally, eight articles on overall survival (OS) [ 17 , 19 , 20 , 21 , 23 , 26 , 27 , 28 ], six articles on disease-free survival (DFS) [ 16 , 18 , 21 , 22 , 23 , 24 ], and three articles on survival progression-free (PFS) [ 19 , 25 , 28 ] were used to predict the survival of patients with cervical cancer. Moreover, two articles were excluded from the study due to the use of machine learning algorithms only as a tool for feature selection [ 29 , 30 ].

Database information

Ten articles used hospital and clinic datasets [ 16 , 19 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ], and three articles each used the cancer genome atlas [ 20 ], SEER [ 17 ], and Geo [ 18 ]. The datasets used in the three articles were more detailed and open to public access [ 17 , 18 , 20 ], but private datasets were used in the other ten articles. The maximum and minimum sizes of the datasets used for modeling were 14,946 and 85 records, respectively, and the datasets had more than 1000 records only in three articles [ 17 , 19 , 21 ].

Data preprocessing

A total of 11 articles used data preprocessing techniques [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 ], and three mentioned missing data [ 18 , 19 , 25 ]. Selected approaches to handle missing data included record deletion, multiple imputations, and the nearest neighbor algorithm. The feature selection approach was used in all the articles except article [ 27 ], but only eight articles specified the details [ 16 , 18 , 20 , 21 , 23 , 24 , 25 , 26 ]. Logistic regression [ 24 ], Naive Bayes [ 24 ], Random Forest [ 24 ], Genetic algorithm [ 26 ], lasso [ 17 , 18 , 25 , 27 ], k-means [ 19 , 20 ], Support vector machine [ 18 , 19 , 26 , 28 ], AdaBoost [ 18 ], Elastic-net [ 23 ], recurrent feature elimination (RFE) [ 16 , 25 ], and deep learning [ 22 , 23 , 28 ] were among the algorithms used for feature selection and extraction. Two articles mentioned the management of outlier data [ 16 , 20 ], but only one provided more details [ 16 ].

Imbalanced data in the dataset causes a lack of generalizability in the model and is considered a serious challenge [ 31 ]. The challenge of unbalanced data in the dataset was discussed in two articles [ 25 , 26 ], and the RF cost-sensitive method was used to overcome this challenge in one article [ 25 ].

Data modeling

The model was calibrated in three articles [ 16 , 18 , 25 ], but the work details were not provided. Hyperparameter tuning was used in model training in six articles, but only four shared the work details [ 18 , 24 , 25 , 28 ].

Six articles used only one machine learning algorithm to build the model [ 16 , 17 , 20 , 22 , 23 , 26 ]. Further, two or more machine learning algorithms were used in seven articles, and their output was compared with each other [ 18 , 19 , 21 , 24 , 25 , 27 , 28 ]. The most frequent machine learning algorithms were random forest, logistic regression, support vector machine, deep learning, and ensemble and hybrid learning.

Model validation

The selected articles were based on internal validation in 11 articles and external validation in two articles [ 18 , 24 ]. Most of the studies related to internal validation used the cross-validation method.

The most common criteria for evaluating the algorithm performance in the articles were the model AUC from 0.40 to 0.99 in seven articles, regardless of the type of survival. C-index was 0.39 to 0.94 in 5 articles, and the accuracy was 0.61 to 0.92 in 4 articles. In three articles, sensitivity and F1-score were 0.20 to 0.97 and 0.22 to 0.92, respectively. More details were shown in Table 5 .

Regarding articles with more than one model, ensemble and hybrid models in 3 articles [ 18 , 19 , 21 ], random forest in 3 articles [ 24 , 25 , 26 ], logistic regression [ 17 ], and deep learning [ 28 ] in 1 article had the best performance.

Important variables

Clinical tabular data were used as model inputs in 11 articles [ 16 , 17 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 27 , 28 ], which were the only model inputs in five articles [ 17 , 19 , 21 , 27 , 28 ]. Image-based data was used [ 16 , 22 , 23 , 24 , 25 , 26 ] in six articles, one of which applied the machine learning model trained only with images [ 26 ]. In two articles, molecular data were used to predict survival [ 18 , 20 ]. According to the output of all survival prediction models, cancer stage variables, histology, treatment method, and tumor-related information have significantly affected cervical cancer survival prediction. The important variables extracted from the included articles are shown in Table 6 .

A systematic review of 229 articles resulted in the inclusion of 13 articles. The selected articles contained qualitative and quantitative information about predicting and analyzing the survival of cervical cancer patients using machine learning algorithms. The number of articles using machine learning algorithms to predict cervical cancer survival was few. Studies related to all three types (overall survival, disease-free survival, and progression-free survival) were inevitably included in the study due to the variation in survival and the small number of studies specific to each type of survival.

The three included studies that used open-access databases were more transparent and competitive in preprocessing and model building. Multiple researchers can analyze open-access databases to discover the most valuable features and the best machine-learning model for that particular dataset. Another essential thing even mentioned in the article [ 32 ] was the correlation of the model output with the data of a specific geographical environment and the change of medical prescriptions over time. Generalizability and the time interval between data collection and modeling can be evaluated in the applicability of the model output. Databases with open access were more suitable and valuable for studying and predicting survival.

The included articles used datasets with different sizes and types for modeling. The largest dataset included in the study was related to the article [ 17 ], with 14,946 clinical tabular data and C-index (0.86). The smallest dataset included in the study is related to the article [ 26 ] with 85 image data records (PET/CT) and C-index (0.77). Image datasets had fewer records than other datasets among the imported articles. According to the reports of (Illia Horenko) [ 33 ], small datasets used in model training often cause overfitting of the model and reduce the model’s capacity for generalization. Image datasets sometimes make the model more accurate than tabular data, which can be caused by the power of image processing algorithms [ 34 ]. Feature extraction, feature selection, transfer learning, fine-tuning, augmentation, object segmentation, and object detection were the most critical advantages of image processing algorithms [ 34 , 35 , 36 ]. In addition to the cases mentioned, convolutional neural networks obtained valuable results on 3D images [ 37 ]. Recently, medical image datasets have been used to predict the survival of patients. However, larger image datasets and more optimal convolutional neural network structures should reach a robust model.

Only two of the articles included in this study had external validation. Article [ 18 ] with molecular data and the other article [ 24 ] with the combination of clinical tabular data and images (PET/CT) obtained precision of 0.82 and 0.42 respectively. The model’s generalizability is more reliable in external validation due to the use of different data. Most included articles used the five-fold cross-validation method for internal validation. Cross-validation is a resampling method for evaluating a model with limited data [ 38 ]. The advent of open-access datasets and standard databases of medical data has made it more feasible to evaluate models using external validation methods.

Data wrangling and preprocessing play an essential role in modeling and model output. Medical datasets often include noise, redundant data, outliers, missing data, and irrelevant variables [ 39 ]. Hoeren mentioned that the actual value of data lies in its usability [ 40 ], and data quality is the most critical concern in model training. Data cleaning is one of the essential solutions in the data preprocessing stage for reducing errors, preventing model bias caused by dirty data, and obtaining the best results [ 41 ]. Therefore, data preprocessing such as cleaning, transformation, reduction, and integration, should be conducted properly, which includes 70–80% of the training and model workload [ 42 ]. All the included studies paid attention to this principle.

Among all the included articles, six used hyperparameter tuning and feature selection methods in their study [ 18 , 21 , 24 , 25 , 26 , 28 ]. Studies often used hyperparameter tuning and feature selection to avoid overfitting or to achieve high-accuracy models [ 24 , 25 ]. According to articles [ 25 , 32 ], selecting appropriate modeling variables directly affected the model’s output. Therefore, feature selection, extraction, reduction, and engineering are necessary to reach an ideal model. Hyperparameter tuning is one of the essential steps in the model-building pipeline, which can produce a model with high accuracy by finding the most optimal input parameters. Most of the entered studies used the Grid search method for this operation. Considering that feature selection in convolutional neural networks is done automatically, having background knowledge can enhance the model’s reliability. Approaches such as Bayesian Optimization and Evolutionary algorithms like Genetic Algorithms [ 26 ] and Artificial Fish Swarm [ 18 ] can be more suitable approaches for hyperparameter tuning and feature selection.

Recently, the use of Hybrid and Ensemble models has increased in the medical field, especially in predicting survival. Three of the included studies that used the abovementioned methods to predict survival have obtained acceptable accuracy and precision [ 18 , 19 , 21 ]. Random forest (RF) and Extreme Gradient Boosting (XGBoost) models are also among Ensemble learning (EL) algorithms [ 26 ]. Developing and optimizing machine learning models using hybrid and ensemble techniques continuously improve computational aspects, performance, generalizability, and accuracy [ 43 ]. Ensemble models, like deep learning algorithms, have spontaneous feature selection ability. In these two Ensemble and Hybrid learning methods, several models with weak learners are trained to solve a specific problem and combined to achieve better results [ 44 ].

Most studies have used a combination of clinical, imaging, and molecular data to predict survival to achieve greater accuracy in training machine learning models. Articles [ 22 , 23 , 24 , 25 ] used a combination of clinical data types with more accuracy and reliability. Most articles that used composite data to predict cervical cancer survival occurred from 2021 onwards. Random forest and deep learning were the most used in mixed data modeling. All types of patient data, with the help of artificial intelligence, can play a significant role in Precision Medicine.

With recent advances in artificial intelligence, deep learning algorithms have undeniably gained power as well. Deep learning algorithms are able to recognize patterns from large, extensive and heterogenous data. They have also provided an admirable ability to process image, video, text, audio and signals [ 45 ]. According to comparative studies, it has been determined that artificial intelligence has a better performance than classical statistics [ 45 ]. With the daily advancement of technologies and the rapid expansion of artificial intelligence science, we will see the use of transformers [ 46 ], meta learning [ 47 ] and quantum machine learning [ 48 ] in medical data processing in the near future. Nevertheless, solutions to the questions of interpretability and explainability should be considered together with the immense potential of AI in health research [ 49 ].

Conclusions

Recording and storing patient information has become easy and is overgrowing due to the growth and improvement of hospital information systems (HIS) and electronic health record systems (EHRs). Classical statistical models such as Cox are used in many survival studies but are no longer compatible with many medical data. Today, machine learning algorithms have become a focal point in research and development because of their unique abilities in pattern recognition in data, feature selection and extraction, and great power in medical image processing.

Most of the survival articles of the last few years have used machine learning algorithms to predict the survival of cervical cancer patients. Combining heterogeneous multidimensional data with machine learning techniques could affect the prediction of cervical cancer survival. The low or lack of explainability in machine learning algorithms has prevented the official use of artificial intelligence models in health. Machine learning is more accurate than other statistical methods in predicting the survival of cervical cancer patients, but more studies are needed to become a standard.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

Overall Survival

Progression-free Survival

Disease-free Survival

Concordance Index

Probabilistic Neural Network

Artificial Neural Network

Multilayer Perceptron Network

Gene Expression Programming

Support Vector Machines

Radial Basis Function Neural Network

Random Forest

Logistic Regression

Naïve Bayes

• Machine Learning
• Deep Learning

K-nearest Neighbors

Dose-volume Histogram

Whole Slide Image, EL: Ensemble Learning

Hybrid Learning

The Cancer Genome Atlas

Gene Expression Omnibus

Surveillance, Epidemiology, and End Results

Hybrid and Ensemble learning

Mean Absolute Error

Positive Predictive Value

Negative Predictive Value

Area Under the Curve

Hospital Information Systems

Electronic Health Record

Positron Emission Tomography

Computed Tomography

Body Mass Index

Human Papillomavirus

Terasawa T, Hosono S, Sasaki S, Hoshi K, Hamashima Y, Katayama T, et al. Comparative accuracy of cervical cancer screening strategies in healthy asymptomatic women: a systematic review and network meta-analysis. Sci Rep. 2022;12(1):94.

Article   PubMed   PubMed Central   Google Scholar  

Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209–49.

Article   PubMed   Google Scholar  

Cohen PA, Jhingran A, Oaknin A, Denny L. Cervical cancer. Lancet. 2019;393(10167):169–82.

Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189(1):12–9.

Article   CAS   PubMed   Google Scholar  

Gates A, Pillay J, Reynolds D, Stirling R, Traversy G, Korownyk C, et al. Screening for the prevention and early detection of cervical cancer: protocol for systematic reviews to inform Canadian recommendations. Syst Rev. 2021;10(1):2.

Okunade KS. Human papillomavirus and cervical cancer. J Obstet Gynaecol. 2020;40(5):602–8.

Waggoner SE. Cervical cancer. Lancet. 2003;361(9376):2217–25.

Wang C-W, Liou Y-A, Lin Y-J, Chang C-C, Chu P-H, Lee Y-C, et al. Artificial intelligence-assisted fast screening cervical high grade squamous intraepithelial lesion and squamous cell carcinoma diagnosis and treatment planning. Sci Rep. 2021;11(1):16244.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Clark TG, Bradburn MJ, Love SB, Altman DG. Survival analysis part I: basic concepts and first analyses. Br J Cancer. 2003;89(2):232–8.

Wang P, Li Y, Reddy CK. Machine learning for survival analysis: A survey. ACM Computing Surveys (CSUR). 2019;51(6):1–36.

Article   Google Scholar  

Paydar S, Emami H, Asadi F, Moghaddasi H, Hosseini A. Functions and outcomes of personal health records for patients with chronic diseases: a systematic review. Perspect Health Inf Manag. 2021;18(Spring):1l.

PubMed   PubMed Central   Google Scholar  

Obermeyer Z, Emanuel EJ. Predicting the future—big data, machine learning, and clinical medicine. N Engl J Med. 2016;375(13):1216.

Samuel AL. Some studies in machine learning using the game of checkers. IBM J Res Dev. 2000;44(1.2):206–26.

Xu Y, Ju L, Tong J, Zhou C-M, Yang J-J. Machine learning algorithms for predicting the recurrence of stage IV colorectal cancer after tumor resection. Sci Rep. 2020;10(1):2519.

Sheidaei A, Foroushani AR, Gohari K, Zeraati H. A novel dynamic Bayesian network approach for data mining and survival data analysis. BMC Med Inform Decis Mak. 2022;22(1):251.

Takada A, Yokota H, Watanabe Nemoto M, Horikoshi T, Matsushima J, Uno T. A multi-scanner study of MRI radiomics in uterine cervical cancer: prediction of in-field tumor control after definitive radiotherapy based on a machine learning method including peritumoral regions. Jpn J Radiol. 2020;38(3):265–73.

Liang J, He T, Li H, Guo X, Zhang Z. Improve individual treatment by comparing treatment benefits: Cancer artificial intelligence survival analysis system for cervical carcinoma. J Transl Med. 2022;20(1):1–15.

Senthilkumar G, Ramakrishnan J, Frnda J, Ramachandran M, Gupta D, Tiwari P, et al. Incorporating artificial fish swarm in ensemble classification framework for recurrence prediction of cervical cancer. IEEE Access. 2021;9:83876–86.

Kim SI, Lee S, Choi CH, Lee M, Suh DH, Kim HS, et al. Machine learning models to predict survival outcomes according to the surgical approach of primary radical hysterectomy in patients with early cervical cancer. Cancers. 2021;13(15):3709.

Ding D, Lang T, Zou D, Tan J, Chen J, Zhou L, et al. Machine learning-based prediction of survival prognosis in cervical cancer. BMC Bioinformatics. 2021;22(1):1–17.

Guo C, Wang J, Wang Y, Qu X, Shi Z, Meng Y, et al. Novel artificial intelligence machine learning approaches to precisely predict survival and site-specific recurrence in cervical cancer: a multi-institutional study. Translat Oncol. 2021;14(5):101032.

Article   CAS   Google Scholar  

Shen W-C, Chen S-W, Wu K-C, Hsieh T-C, Liang J-A, Hung Y-C, et al. Prediction of local relapse and distant metastasis in patients with definitive chemoradiotherapy-treated cervical cancer by deep learning from [18F]-fluorodeoxyglucose positron emission tomography/computed tomography. Eur Radiol. 2019;29(12):6741–9.

Chen C, Cao Y, Li W, Liu Z, Liu P, Tian X, et al. The pathological risk score: a new deep learning-based signature for predicting survival in cervical cancer. Cancer Med. 2023;12(2):1051–63.

Ferreira M, Lovinfosse P, Hermesse J, Decuypere M, Rousseau C, Lucia F, et al. [(18)F]FDG PET radiomics to predict disease-free survival in cervical cancer: a multi-scanner/center study with external validation. Eur J Nucl Med Mol Imaging. 2021;48(11):3432–43.

Arezzo F, La Forgia D, Venerito V, Moschetta M, Tagliafico AS, Lombardi C, et al. A machine learning tool to predict the response to neoadjuvant chemotherapy in patients with locally advanced cervical cancer. Appl Sci. 2021;11(2):823.

Carlini G, Curti N, Strolin S, Giampieri E, Sala C, Dall’Olio D, et al. Prediction of Overall Survival in Cervical Cancer Patients Using PET/CT Radiomic Features. Appl Sci. 2022;12(12):5946.

Obrzut B, Kusy M, Semczuk A, Obrzut M, Kluska J. Prediction of 5-year overall survival in cervical cancer patients treated with radical hysterectomy using computational intelligence methods. BMC Cancer. 2017;17(1):840.

Matsuo K, Purushotham S, Jiang B, Mandelbaum RS, Takiuchi T, Liu Y, et al. Survival outcome prediction in cervical cancer: Cox models vs deep-learning model. Am J Obstet Gynecol. 2019;220(4):381. e1-e14.

Han Q, Kim SI, Yoon SH, Kim TM, Kang HC, Kim HJ, et al. Impact of computed tomography-based, artificial intelligence-driven volumetric sarcopenia on survival outcomes in early cervical cancer. Front Oncol. 2021:3810.

Wallbillich JJ, Tran PM, Bai S, Tran LK, Sharma AK, Ghamande SA, et al. Identification of a transcriptomic signature with excellent survival prediction for squamous cell carcinoma of the cervix. Am J Cancer Res. 2020;10(5):1534.

CAS   PubMed   PubMed Central   Google Scholar  

Lin WJ, Chen JJ. Class-imbalanced classifiers for high-dimensional data. Brief Bioinform. 2013;14(1):13–26.

Li J, Zhou Z, Dong J, Fu Y, Li Y, Luan Z, et al. Predicting breast cancer 5-year survival using machine learning: A systematic review. PLoS ONE. 2021;16(4):e0250370.

Horenko I. On a scalable entropic breaching of the overfitting barrier for small data problems in machine learning. Neural Comput. 2020;32(8):1563–79.

Zhang A, Xing L, Zou J, Wu JC. Shifting machine learning for healthcare from development to deployment and from models to data. Nat Biomed Eng. 2022:1–6.

Frid-Adar M, Diamant I, Klang E, Amitai M, Goldberger J, Greenspan H. GAN-based synthetic medical image augmentation for increased CNN performance in liver lesion classification. Neurocomputing. 2018;321:321–31.

Hajiabadi M, AlizadehSavareh B, Emami H, Bashiri A. Comparison of wavelet transformations to enhance convolutional neural network performance in brain tumor segmentation. BMC Med Inform Decis Mak. 2021;21(1):327.

Savareh BA, Emami H, Hajiabadi M, Ghafoori M, Azimi SM. Emergence of convolutional neural network in future medicine: why and how. A review on brain tumor segmentation. Polish J Medi Phys Eng. 2018;24(1):43–53.

Ramspek CL, Jager KJ, Dekker FW, Zoccali C, van Diepen M. External validation of prognostic models: what, why, how, when and where? Clin Kidney J. 2021;14(1):49–58.

Razzaghi T, Roderick O, Safro I, Marko N. Multilevel weighted support vector machine for classification on healthcare data with missing values. PLoS One. 2016;11(5):e0155119.

Hoeren T. Big Data and Data Quality. In: Hoeren T, Kolany-Raiser B, editors. Big Data in Context: Legal, Social and Technological Insights. Cham: Springer International Publishing; 2018. p. 1–12.

Chapter   Google Scholar  

Stöger K, Schneeberger D, Kieseberg P, Holzinger A. Legal aspects of data cleansing in medical AI. Comput Law Secur Rev. 2021;42:105587.

Han J, Kamber M. Data mining: concepts and techniques, 2nd. University of Illinois at Urbana Champaign: Morgan Kaufmann; 2006.

Google Scholar  

Ardabili S, Mosavi A, Várkonyi-Kóczy AR, editors. Advances in Machine Learning Modeling Reviewing Hybrid and Ensemble Methods. Engineering for Sustainable Future; 2020 2020//; Cham: Springer International Publishing.

Kazienko P, Lughofer E, Trawinski B. Editorial on the special issue “Hybrid and ensemble techniques in soft computing: recent advances and emerging trends.” Soft Comput. 2015;19(12):3353–5.

Rajula HSR, Verlato G, Manchia M, Antonucci N, Fanos V. Comparison of conventional statistical methods with machine learning in medicine: diagnosis, drug development, and treatment. Medicina. 2020;56(9):455.

Vaswani A, Shazeer N, Parmar N, Uszkoreit J, Jones L, Gomez AN, et al. Attention is all you need. Adv Neural Inf Process Syst. 2017;30.

Vilalta R, Drissi Y. A perspective view and survey of meta-learning. Artif Intell Rev. 2002;18:77–95.

Biamonte J, Wittek P, Pancotti N, Rebentrost P, Wiebe N, Lloyd S. Quantum machine learning. Nature. 2017;549(7671):195–202.

Kourou K, Exarchos KP, Papaloukas C, Sakaloglou P, Exarchos T, Fotiadis DI. Applied machine learning in cancer research: a systematic review for patient diagnosis, classification and prognosis. Comput Struct Biotechnol J. 2021;19:5546–55.

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Milad Rahimi

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Rahimi, M., Akbari, A., Asadi, F. et al. Cervical cancer survival prediction by machine learning algorithms: a systematic review. BMC Cancer 23 , 341 (2023). https://doi.org/10.1186/s12885-023-10808-3

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Correlates of intention to screen for cervical cancer among adult women in Kyotera District, Central Uganda: a community based cross-sectional study

• Richard Kabanda 1 ,
• Arthur Kiconco 2 , 3 ,
• Anguzu Ronald 1 ,
• Kirsten M. M. Beyer 1 &
• Steven A. John 4  

BMC Women's Health volume  24 , Article number:  296 ( 2024 ) Cite this article

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Introduction

Cervical cancer continues to pose a major public health challenge in low-income countries. Cervical cancer screening programs enable early detection and effectively reduce the incidence of cervical cancer as well as late-stage diagnosis and mortality. However, screening uptake remains suboptimal in Uganda. This study assessed correlates of intention to screen for cervical cancer among women in the Kyotera district of Central Uganda.

We analyzed cross-sectional data collected to determine the effectiveness of community audio towers (CATs) as a modality of health communication to support cervical cancer prevention. Women ( n  = 430) aged 21–60 years without a prior history of cervical cancer screening were surveyed about demographics, sources of health information and cervical cancer screening intentions in 2020. We used generalized linear modelling with modified Poisson regression and backwards variable elimination to identify adjusted prevalence ratios and 95% confidence intervals (CI) to determine factors associated with intention to screen for cervical cancer.

Half (50.2%) of the participants had intentions to screen for cervical cancer within twelve months and 26.5% had moderate knowledge about cervical cancer. Nearly half (46.0%) considered themselves at risk of cervical cancer. Compared to residents who primarily received their health information from social media and radio, participants who received health information primarily from CATs (aPR:0.64, 95% CI:0.52–0.80, p  < 0.001) and TV (aPR:0.52, 95% CI:0.34–0.82, p  = 0.005) had a lower prevalence of intention to screen for cervical cancer. The prevalence of intentions to screen for cervical cancer in twelve months was higher among those resided in town councils (aPR:1.44, 95% CI:1.12–1.86, p  = 0.004) compared to rural areas, and higher among those who considered themselves to be at risk of cervical cancer (aPR:1.74, 95% CI:1.28–2.36, p  < 0.001) compared to those who did not.

Conclusions

We found suboptimal prevalence of intentions to screen for cervical cancer among women in central Uganda. Additional research and implementation projects are needed to increase cervical cancer screening. Targeting risk perceptions and behavioral approaches to increase intentions could be effective in future intervention work. Based on urban-rural differences, additional work is needed to support equitable sharing of information to support cancer prevention messaging; CATs and TV may best help reach those with lower intentions to screen based on our research.

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Cervical cancer continues to pose a major global public health burden, with over 340,000 deaths annually [ 1 ]; projections estimate this number increasing to 400,000 annual deaths by 2030 [ 2 ]. Cervical cancer is the fourth most common cancer among women globally [ 3 ], with an estimated 604,127 new cases of cervical cancer in 2020 [ 1 ] and an anticipated increase to 700,000 by 2030 [ 4 ]. Cervical cancer is among the common human papillomavirus (HPV)-related diseases, with nearly all cases of cervical cancer attributable to HPV infection; specifically, HPV types 16 and 18 are known to cause 70% of cervical cancers and precancerous cervical lesions [ 5 , 6 , 7 ].

There are significant socioeconomic disparities in cervical cancer incidence rates, with national rates increasing as the Human Development Index (HDI) decreases; the poor, especially in low- and middle-income countries (LMICs), shoulder the largest disease burden [ 1 ]. The highest cervical cancer incidence occurs in Africa, followed by Latin America, Asia, and Melanesia. Within sub-Saharan Africa, the 2020 age-adjusted incidence rate for cervical cancer was highest in eastern Africa, estimated at 40 cases per 100,000 women-years [ 1 ]. The 2023 age-adjusted incidence and mortality rates for Uganda were 56.2 and 41.4 respectively [ 8 ]. In the same year, the annual estimates indicated that 6,959 women were diagnosed with cervical cancer and 4,607 died from the disease—making it the first most frequent cancer among women in Uganda [ 8 ].

Despite disparities in cervical cancer incidence rates, resources for prevention, diagnosis and treatment are limited in most LMICs [ 9 , 10 ]. Although preventable and curable if identified at an early stage, cervical cancer remains a top cancer killer of women in low-resource settings [ 11 ]. The HIV/AIDS epidemic is also believed to exasperate high rates of cervical cancer incidence and mortality, as the risk of development, progression, and recurrence of HPV-induced cervical precursor lesions and cervical cancer are higher among women living with HIV (WLHIV) [ 12 , 13 , 14 , 15 , 16 ]. Despite reductions in HIV new infections in Uganda, the HIV prevalence remains high at 7.2% among women compared to 4.3% among men [ 17 ].

The World Health Organization (WHO) Global Cervical Cancer Elimination Initiative (GCCEI) aims to reduce incidence below a threshold of 4 cases per 100,000 women-years in every country [ 2 ]. Cervical cancer is the number one cause of cancer-related deaths among women in Uganda [ 18 ], and the WHO estimates approximately 3,915 Ugandan women were diagnosed with cervical cancer and 2,160 died from the disease in 2014 [ 19 ]. In Uganda, cervical cancer screening guidelines recommend visual inspection of the cervix with acetic acid (VIA) annually for women living with HIV and every 3 years for those HIV-negative [ 20 ].

Cervical cancer screening programs enable the detection of cervical lesions before they become cancerous, which can effectively reduce the incidence of cervical cancer by 75–90% [ 21 , 22 ]. Screening also results in earlier detection of cancer, improving prognosis among those diagnosed and treated. As such, population-based cervical cancer screening programs are effective in reducing cervical cancer mortality [ 23 , 24 ]. Despite these statistics, only a small percentage (estimated at 19%) of women have been screened for cervical cancer in LMICs, compared to 63% in high-income countries [ 25 ]. In Uganda, it is estimated that the percentage of women who had ever screened for cervical cancer ranged from 9 to 10% and only about 7.5% had screened in the last 5 years in 2023 [ 8 ].

Further, researchers have previously attributed low cervical cancer screening uptake to a number of key factors, including limited resources required for successful screening programs [ 25 , 26 ], cervical cancer knowledge gaps [ 27 , 28 , 29 , 30 ], fear of positive diagnosis [ 31 ], and lower risk perception and negative attitudes [ 32 ]. The SARS-CoV-2 (i.e., COVID-19) pandemic is also believed to have led to delays in diagnosis and treatment due closures of health facilities, disruptions in access due to loss of insurance as people were laid off from work, and fear of COVID-19 exposure by those eligible for screening and care [ 33 ]. Most cervical cancer prevention programs aimed at increasing screening uptake usually focus on modifiable contextual factors such as knowledge, women’s intentions, and service availability, among others. However, few studies have assessed correlates of intention to screen for cervical cancer. As such, we assessed correlates of intention to screen for cervical cancer among adult women in Kyotera District, Central Uganda.

Study design

This was a cross-sectional analytical study based on secondary analysis of data collected at baseline for a study to determine the efficacy of community audio towers (CATs) as a health communication channel used in the prevention of cervical cancer in rural communities in Uganda [ 34 ]. The primary study was carried out between March and June 2020. It compared the use of CATs to disseminate messages on cervical cancer versus other health communication channels and cervical cancer screening among women aged 21 to 60 years. This analysis focused on data collected at baseline, prior to the use of the CATs for dissemination of cervical cancer-prevention messaging.

Study setting

This study was carried out in Kyotera district, located in the south-central region, southwest of Kampala Capital City in Uganda. Kyotera District headquarters are approximately 182 km from Kampala and forty-seven kilometers from Masaka City. Kyotera District was created from Rakai District in the year 2015 by an Act of Parliament but started operating as an independent district and local government on July 1, 2017, with two counties of Kakuuto and Kyotera. The district is primarily rural and borders with Kalangala, Masaka, Rakai, and Lwengo districts in Uganda and the Missenyi district in the south, which is in the Kagera region of Republic of Tanzania.

Kyotera District was part of Rakai where the first case of HIV/AIDS in Uganda was discovered at the Uganda-Tanzania border of Mutukula [ 35 ]. The district is known for its high HIV prevalence, currently standing at 11.1% [ 36 ]. There is a known link between HIV/AIDS and cancers, including cancer of the cervix, which shares similar risk factors. Although there are no disaggregated data showing the district prevalence of cervical cancer, the prevalence of cancer of the cervix is likely high in Kyotera.

Inclusion and exclusion criteria

The study population consisted of women aged 21–60 years living in Kyotera district. To be eligible, participants were required to: (1) be aged 21–60 years; (2) have lived in Kyotera for at least 3 months; and (3) have direct access to information as narrow-casted from CATs. Participants were excluded if (1) they had previously screened for cervical cancer in the past three years or one year for those LHIV; and (2) intended to relocate in the proceeding 16 weeks at the time of the survey. All participants consented to participate in this study.

Sample size and sampling

Sample size.

The sample size for the parent study was 480 participants. Each cluster (village) had sixty participants, and eight clusters were included. Fifty (50) of the participants had screened in the previous three years and were excluded from this sample; thus, the final sample for analysis was 430 participants.

Sampling and recruitment procedures

The initial process of sampling was based on the composition of Kyotera district in terms of counties. Kyotera has two counties, and each of these forms a health subdistrict. Recruitment of participants from clustered villages was done by systematic sampling from a list of households registered by community health workers to have the targeted age group. Where households had more than one eligible participant, only one was sampled and the lottery method was used to select one.

Study variables

Dependent variable.

The dependent variable for this study was intention to screen for cervical cancer. This was measured using three questions: (i) If never screened for cervical cancer, would you like to be screened? With responses: ‘Yes,’ ‘No’ or ‘I do not know.’ ‘No’ and ‘I do not know’ were merged as No; (ii) If yes above, when do you intend to have the screening done? With responses: in three months, six months, one year, not sure and never; (iii) Where would you like to go for the screening? With responses: nearby government hospital, private health facility, regional referral hospital, or any other. A previous study in an area closer to the study area measured intention using two questions of whether one intended to go for screening and when [ 32 ], but we added a third question of where they intended to go for the screening. Those who responded ‘yes’ in the first question, intention to go in either three or six months or one year and indicated where they intended to go for screening were considered to have intentions to screen.

Independent variables

We measured cervical cancer knowledge using a 20-item scale consisting of four constructs: risk factors (six items); signs and symptoms (eight items); eligibility for screening (5 items); and routine cervical cancer screening recommendations (one item). A previous study in Eastern Uganda considered all women who scored above the average for 20-point possible answers to be more knowledgeable, while those who scored below the average were considered to have less knowledge [ 37 ]. For this study, we considered those who scored in the 75th percentile to be knowledgeable and those whose scores fell below the 75th percentile to be less knowledgeable. The other independent variables considered were age (categorized into 20–29, 30–39, 40–49 and 50–59); marital status (single, cohabiting/married, commercial Sex Worker/divorced/widowed); work status (employed, student/not-working); regular income (yes and no); highest level of education (A-level+, O-level, PLE, none); residence (rural area, town board, town council); family cancer history (don’t know, no, and yes); common source of health information (social media/FM radio, TV, CATs, health worker, and any other); perceived self-risk for cervical cancer (yes, no, I do not know); fear of getting diagnosed with cancer (yes, no, I do not know, refused to answer); and fear of the cervical cancer screening procedure (yes, no, I do not know, refused to answer).

Statistical analysis

Descriptive statistics were reported using frequency distributions of the participant characteristics at individual level. Bivariate and multivariable analyses were conducted using generalized linear modelling with modified Poisson regression; prevalence ratios (PR) instead of odds ratios were used because of the high prevalence of intention to screen for cervical cancer [ 38 , 39 ]. We built our final analytic model using backwards elimination, where only variables with a p -value ≤ 0.2 were considered for the adjustment stage to determine the factors independently associated with intention to screen for cervical cancer. Collinearity between independent variables was assessed using pairwise correlation analysis. Data were analysed using Stata/SE 17, and statistical significance was considered at p  < 0.05; 95% confidence intervals are reported.

Baseline characteristics of the participants

Half of the participants had intentions to be screened for cervical cancer. In addition, half the participants were aged 20–29 years, and nearly three-quarters (73%) were married or cohabiting, as shown in Table  1 below. There was almost an equal distribution in residence for rural, town board and town council. Three-quarters (76%) of the participants reported no family history of cervical cancer, and 46% considered themselves at risk of cervical cancer. Half (52.5%) of the participants had full-time jobs, 62% had a regular source of income, and only 12.8% had more than A-level (high school equivalent) education.

CATs were mentioned as the main source of health information for nearly half (49.8%); more than half (64%) also feared being diagnosed with cervical cancer, while 40.9% feared the screening procedure. Approximately one-quarter (26.5%) had moderate knowledge about cervical cancer.

Correlates of intention to screen for cervical cancer among adult women

At the bivariate level, knowledge of cervical cancer, residence, common source of health information and perceived risk of getting cervical cancer were associated with intention to screen for cervical cancer. After adjusting for potential confounders, only participants’ residence, common source of health information and perceived risk of getting cervical cancer were independently associated with intention to screen for cervical cancer. Participants who resided in the town council were 44% more likely to have intentions to screen for cervical cancer compared to those who lived in the rural areas (see Table  2 ).

Compared to participants who mentioned FM radio or social media as their main source of health information, those who mentioned television were 48% less likely to have intentions to screen for cervical cancer, while those who mentioned CATs/health workers were 36% less likely to have intentions to screen for cervical cancer. Participants who perceived themselves to be at risk of cervical cancer were 74% more likely to have intentions to screen compared to those who did not. The full results are presented in Table  2 .

This study assessed the correlates of intention to screen for cervical cancer in Kyotera district, Central Uganda. We found 50.2% of the participants had intentions of being screened for cervical cancer. This prevalence was slightly lower than the 63% reported in a neighbouring district of Masaka in 2013 [ 32 ] and the 61% reported in rural Indonesia in 2016 [ 40 ]. However, it is higher than the prevalence of 45.3% in Ethiopia in 2017 [ 41 ]. Given the length of time since these prior estimates, we classify the prevalence of intention to screen in our study as suboptimal; we would anticipate increasing rates of screening over time and that there is a gap in cervical cancer related health promotion. As such, additional efforts are needed to promote cervical cancer screening in this area.

Participants who resided in the town council were 44% more likely to have intentions to screen for cervical cancer compared to those who lived in rural areas. This could be attributed to geographic proximity to health services located in urban areas, as well as the potential differences in income between urban and rural areas. Women who lived in urban and semiurban areas in Eastern Uganda were four times and two times more likely to have high knowledge about cervical cancer than their rural counterparts, respectively [ 37 ]. Our findings and others indicate there is a disparity in intentions to screen, which likely translates to differences in screening uptake. More equitable approaches to service delivery are warranted, including increased funding to support health education and cervical cancer screening promotion.

CATs were mentioned as the main source of health information for 49.8% of participants, compared to only 8.4% reported health workers as their main source of health information. The proportion that reported health workers was lower than the 15.1% reported from health facilities in Eastern Uganda [ 37 ]. Another study conducted in a neighbouring district had found that women who had discussions on cervical cancer with health care providers reported more intentions to screen for cervical cancer [ 32 ]. Even among women in Thailand, having received a recommendation from health care providers was associated with decisions to attend cervical cancer screening [ 42 ]. As such, integrating cervical cancer screening into health workers education packages and disseminating information via CATs may be effective health communication delivery mechanisms, where available. This may be feasible in Kyotera since a previous study found that the majority of the health workers believed CATs were accessible and easier to communicate on health issues; however, fewer than 20% used them [ 43 ].

We found only 46% of the sample considered themselves at risk of cervical cancer compared to 76.0% who perceived themselves to be at risk of cervical cancer in another study in Eastern Uganda, as reported in 2017 [ 44 ]. Risk perceptions were identified to be particularly important since those who perceived themselves to be at risk of cervical cancer were 74% more likely to have intentions to screen compared to those who did not; these findings align with prior reports in a neighbouring district [ 32 ]. Relatedly, a family history of cervical cancer was not associated with higher intentions of screening in this study, but it was reported to be associated among women in rural areas of Indonesia [ 40 ]; further research is needed to identify potential differences between family history and the impact on cancer screening. Multiple approaches for conducting effective Health education should be strengthened including use of print and interpersonal communication, as this could to help increase risk perception, increase intentions for screening, and ultimately aid in increasing uptake of cervical cancer screening.

Although being knowledgeable about cervical cancer was not associated with intentions to screen for cervical cancer after adjustment, it is important to note that only 26.5% of the participants had moderate knowledge (> 75th percentile) about cervical cancer. Increasing knowledge about cervical cancer is a critical area for further intervention given its importance in decision-making; yet it is likely this factor significant at the bivariate level was no longer significant after adjustment because of potential correlation with other social determinants of health (e.g., rurality). Knowledge has been reported to be associated with intention to undergo Pap smear testing in rural areas of Indonesia [ 40 ]. Therefore, improving knowledge about cervical cancer literacy could improve screening uptake.

Over half of the participants feared being diagnosed with cervical cancer, while 40.9% feared the screening procedure. Although these fears were not associated with intentions to screen for cervical cancer after adjustment, they could remain potential barriers to screening. These findings are inconsistent with previous studies conducting in neighbouring districts, Thailand, and Ethiopia [ 32 , 42 , 45 ]. Additional qualitative research could help identify nuance in these reports and is recommended; decreasing barriers to screening and managing a diagnosis are important to support patients in cancer prevention.

Strengths and limitations

We applied approaches to maximize the validity of the findings of this study. First, we assessed the outcome variable with more than a single question to only consider those who indicated the intention as well as when and where they would go for screening as those with intention to minimize social desirability bias. The district-wide sampling and the rich distribution of participants by age are other strengths of this study and are key to representativeness and thus generalizability of the study findings across the district and similar contexts. Despite these, some limitations are acknowledged. First, there could have been some people who still indicated intentions without actual intentions. In addition, the inherent limitations of cross-sectional study design including recall and difficulties with self-reporting on other variables other than intention cannot miss acknowledgement.

In this study, we found only half of adult women sampled in the Kyotera district, Central Uganda, had intentions for cervical cancer screening, and only 46% considered themselves at risk of cervical cancer. Urban residence, risk perception, and CATs as a source of health information were associated with higher intentions to screen for cervical cancer. The urban-rural difference calls for equity in cervical cancer health education and service delivery. In addition to other communication channels, targeting health information sharing via CATS and interactive TV educational messages may help reach those with lower intentions to screen.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Singh D, et al. Global estimates of incidence and mortality of cervical cancer in 2020: a baseline analysis of the WHO Global Cervical Cancer Elimination Initiative. Lancet Global Health. 2023;11(2):e197–206.

Article   CAS   PubMed   Google Scholar  

World Health Organization. Accelerating the elimination of cervical cancer as a global public health problem. World Health Organization. Regional Office for South-East Asia; 2019.

WCRFI. Cervical cancer statistics. 2023 2022 [cited 2023 3/6/2023]; https://www.wcrf.org/cancer-trends/cervical-cancer-statistics/ .

Arbyn M, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. Lancet Global Health. 2020;8(2):e191–203.

Article   PubMed   Google Scholar  

WHO. Human papilloma virus (HPV) and cervical Cancer: fact sheet. World Health Organization; 2016.

Markowitz LE, et al. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63(RR–05):1–30.

PubMed   Google Scholar  

de Sanjose S, et al. Human papillomavirus genotype attribution in invasive cervical cancer: a retrospective cross-sectional worldwide study. Lancet Oncol. 2010;11(11):1048–56.

ICO/IARC, Uganda Human Papillomavirus and related cancers, fact sheet 2023 (2023-03-10) . 2023, the Catalan Institute of Oncology (ICO) and the International Agency for Research on Cancer (IARC): Barcelona, Spain.

Ferlay J et al. GLOBOCAN 2012: Cancer incidence and mortality worldwide: IARC CancerBase no. 11. Lyon, France: International Agency for Research on Cancer . 2013.

Boyle P, Levin B. World cancer report 2008. IARC Press, International Agency for Research on Cancer; 2008.

Denny L, et al. Cervical cancer. Disease Control priorities, (volume 3): Cancer. World Bank; 2015. H. Gelband, Jha, P., Sankaranarayanan, R. and Horton, S., Editor.

Tate DR, Anderson RJ. Recrudescence of cervical dysplasia among women who are infected with the human immunodeficiency virus: a case-control analysis. Am J Obstet Gynecol. 2002;186(5):880–2.

Ghebre RG, et al. Cervical cancer control in HIV-infected women: past, present and future. Gynecologic Oncol Rep. 2017;21:101–8.

Article   Google Scholar  

Ginindza TG, Sartorius B. Projected cervical cancer incidence in Swaziland using three methods and local survey estimates. BMC Cancer. 2018;18:1–10.

Chibwesha C, et al. Estimating the burden of cervical disease among HIV-infected women accessing screening services in South Africa: a model-based analysis. South Afr Med J. 2018;108(3):235–9.

Article   CAS   Google Scholar  

Simonds HM, et al. Completion of and early response to chemoradiation among human immunodeficiency virus (HIV)-positive and HIV‐negative patients with locally advanced cervical carcinoma in South Africa. Cancer. 2012;118(11):2971–9.

MOH. The Uganda Population-based HIV Impact Assessment (UPHIA 2020–2021). Uganda: Kamapala, Uganda: Ministry of Health (MOH); 2022.

Google Scholar  

Nakisige C, Schwartz M, Ndira AO. Cervical cancer screening and treatment in Uganda. Gynecologic Oncol Rep. 2017;20:37–40.

Bruni L et al. ICO Information Centre on HPV and Cancer (HPV Information Centre) Human papillomavirus and related diseases in India. Summary Report, 2015: pp. 12–23.

Nakisige C, Schwartz M, Ndira AO. Cervical cancer screening and treatment in Uganda. Gynecol Oncol Rep. 2017;20:37–40.

Article   PubMed   PubMed Central   Google Scholar  

Saslow D, et al. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin. 2002;52(6):342–62.

May DS, et al. The national breast and cervical Cancer Early Detection Program: report on the first 4 years of mammography provided to medically underserved women. AJR Am J Roentgenol. 1998;170(1):97–104.

Peirson L, et al. Screening for cervical cancer: a systematic review and meta-analysis. Syst Reviews. 2013;2:35–35.

Landy R, et al. Impact of cervical screening on cervical cancer mortality: estimation using stage-specific results from a nested case–control study. Br J Cancer. 2016;115(9):1140–6.

Gakidou E, Nordhagen S, Obermeyer Z. Coverage of cervical cancer screening in 57 countries: low average levels and large inequalities. PLoS Med. 2008;5(6):e132.

Holowaty P, et al. Natural history of dysplasia of the uterine cervix. J Natl Cancer Inst. 1999;91(3):252–8.

Aweke YH, Ayanto SY, Ersado TL. Knowledge, attitude and practice for cervical cancer prevention and control among women of childbearing age in Hossana Town, Hadiya Zone, Southern Ethiopia: community-based cross-sectional study. PLoS ONE. 2017;12(7):e0181415.

Nwankwo KC, et al. Knowledge attitudes and practices of cervical cancer screening among urban and rural Nigerian women: a call for education and mass screening. Eur J Cancer Care. 2011;20(3):362–7.

Sudenga SL, et al. Knowledge, attitudes, practices, and perceived risk of cervical cancer among Kenyan women: brief report. Int J Gynecol Cancer. 2013;23(5):895–9.

Ndejjo R, et al. Uptake of Cervical Cancer Screening and Associated Factors among women in rural Uganda: A Cross Sectional Study. PLoS ONE. 2016;11(2):e0149696.

Mupepi SC, Sampselle CM, Johnson TR. Knowledge, attitudes, and demographic factors influencing cervical cancer screening behavior of Zimbabwean women. J Womens Health (Larchmt). 2011;20(6):943–52.

Twinomujuni C, Nuwaha F, Babirye JN. Understanding the low level of Cervical Cancer Screening in Masaka Uganda using the ASE Model: A Community-based survey. PLoS ONE. 2015;10(6):e0128498.

Siegel RL et al. Cancer statistics, 2023 CA: A Cancer Journal for Clinicians, 2023. 73(1): pp. 17–48.

Kabanda R. Availability, use and efficacy of community audio towers in health communication for prevention of cervical cancer in the communities of Kyotera District, Uganda [Unpublished doctoral dissertation] . 2021, Uganda Martyrs University.

Serwadda D, et al. Slim disease: a new disease in Uganda and its association with HTLV-III infection. Lancet. 1985;2(8460):849–52.

UAC, Factsheet - facts on HIV and AIDS in Uganda 2021 (based on data ending 31st December 2020) . 2021, Uganda AIDS Commission Secretariat: Kampala, Uganda.

Mukama T, et al. Women’s knowledge and attitudes towards cervical cancer prevention: a cross sectional study in Eastern Uganda. BMC Womens Health. 2017;17(1):9–9.

Thompson ML, Myers JE, Kriebel D. Prevalence odds ratio or prevalence ratio in the analysis of cross sectional data: what is to be done? Occup Environ Med. 1998;55(4):272.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Tamhane AR, et al. Prevalence odds ratio versus prevalence ratio: choice comes with consequences. Stat Med. 2016;35(30):5730–5.

Sumarmi S, et al. Factors associated with the intention to undergo pap smear testing in the rural areas of Indonesia: a health belief model. Reproductive Health. 2021;18(1):138.

Getahun T, Kaba M, T Derseh B. Intention to screen for cervical Cancer in Debre Berhan Town, Amhara Regional State, Ethiopia: application of theory of Planned Behavior. J Cancer Epidemiol. 2020;2020:3024578.

Budkaew J, Chumworathayi B. Factors associated with decisions to attend cervical cancer screening among women aged 30–60 years in Chatapadung Contracting Medical Unit, Thailand. Asian Pac J Cancer Prev. 2014;15(12):4903–7.

Kabanda R, et al. Utilisation of Community Audio Towers in Health Education for Prevention of Cervical Cancer by Health Workers in Kyotera District, Uganda: a cross-sectional study. Risk Manag Healthc Policy. 2021;14:3667–73.

Mukama T, et al. Women’s knowledge and attitudes towards cervical cancer prevention: a cross sectional study in Eastern Uganda. BMC Womens Health. 2017;17(1):1–8.

Getahun T, Kaba M, Derseh BT. Intention to Screen for Cervical Cancer in Debre Berhan Town, Amhara Regional State, Ethiopia: Application of Theory of Planned Behavior Journal of cancer epidemiology, 2020. 2020: pp. 3024578–3024578.

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Kabanda, R., Kiconco, A., Ronald, A. et al. Correlates of intention to screen for cervical cancer among adult women in Kyotera District, Central Uganda: a community based cross-sectional study. BMC Women's Health 24 , 296 (2024). https://doi.org/10.1186/s12905-024-03129-5

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Improving cervical cancer screening rates: a scoping review of resources and interventions

Madyson l. popalis.

1 Department of Family and Community Medicine, Penn State College of Medicine, Hershey, PA, USA

Sarah I. Ramirez

Kelsey m. leach, marni e. granzow, kelsey c. stoltzfus, jennifer l. moss, associated data.

Enquiries about data availability should be directed to the authors.

Introduction

Cervical cancer mortality can be prevented through early detection with screening methods such as Pap and high-risk human papillomavirus (hrHPV) tests; however, only 81% of women aged 21–65 are up-to-date on screening. Many interventions to increase cervical cancer screening have been implemented, but there is limited understanding about which intervention components are most successful.

We conducted a scoping review of existing literature and available resources for cervical cancer screening interventions to identify gaps in the research. We used t tests and correlations to identify associations among intervention components and effect sizes.

Out of nine studies, the mean overall effect size for interventions was 11.3% increase in Pap testing for cervical cancer screening (range = − 4–24%). Interventions that included community health workers or one-on-one interaction had the biggest effect size ( p < 0.05). No associations with effect size were noted for literacy level, number of intervention components, or targeting by race/ethnicity.

Conclusions

Future interventions may include educational sessions with community health workers or one-on-one patient interaction to improve cervical cancer screening. Further research is needed to establish effect sizes for large-scale interventions and hrHPV screening interventions.

In 2020, an estimated 13,800 women in the United States will be newly diagnosed with cervical cancer, and approximately, 4,300 women will die from the disease [ 1 ]. Overall, five-year relative survival is 66.1% [ 2 ]; however, five-year relative survival for cervical cancers diagnosed at a localized stage is 91.8%, emphasizing the promise of early detection for minimizing cervical cancer mortality [ 2 ]. The cornerstone of early detection of cervical cancer is routine screening with the Pap test and/or high-risk human papillomavirus (hrHPV) DNA testing [ 3 ]. However, national screening rates for women ages 21 to 65 have been falling since 2000, landing at 81% in 2018 [ 4 ]. This rate, while high, remains consistently lower in certain population subgroups, and is lower than the Healthy People 2030 goal of 84.3% [ 5 ]. Interventions are needed to ensure timely and consistent access to screening.

Many interventions focused on increasing cervical cancer screening (CCS) have been developed, implemented, and tested in various populations. These interventions vary in study design, target population, and intervention components, rendering them difficult to compare. There is a paucity of understanding regarding which intervention components are most effective for increasing CCS in future interventions. In particular, community organizations interested in participating in CCS promotion efforts may be hard-pressed to identify existing programs and their resources that would be most appropriate and effective.

The goal of this study is to identify which of these interventions are most effective in increasing CCS by analyzing and comparing effect sizes from published program evaluations with publicly available program resources. Additionally, we aim to identify which components of these interventions are associated with greatest effect sizes, to generate evidence about crucial components to include in future interventions. These findings can be used to select and design the best intervention (or intervention components) for a target population with a goal of increasing CCS and reducing cervical cancer incidence and mortality.

Resources and methods

We conducted a scoping review to recapitulate existing research while identifying gaps in evidence-based interventions promoting CCS [ 6 ]. The literature was collected by searching Google Scholar, PubMed, and reviewing the websites for American Cancer Society and the National Cancer Institute, without a restriction on the date of publication. An example search term is “Cervical cancer AND screen AND intervention.” We reviewed the citation lists for included studies to identify additional papers for review. We reviewed papers in English that described interventions to increase cervical cancer screening, included self-reported or EHR-verified screening as an outcome. Importantly, we limited the review to interventions that had program resources available for review. These final inclusion criteria were necessary to evaluate resource-specific details, such as resource type, literacy level, and language, which could influence intervention outcomes. Details regarding program resources were not readily available in the overall program evaluation manuscripts, making it necessary to review the materials themselves. Thus, this was a non-exhaustive list of interventions and was limited to studies for which we could access intervention resources.

When assessing each project, we gathered the peer-reviewed journal article along with the associated intervention resources used to encourage CCS. These resources included pamphlets, flyers, implementation manuals, discussion guides, and videos. Many of the projects’ resources were found either among the supplemental information of the journal article or online (e.g., on the senior author’s website). If the resources could not be located, we emailed the first and/or senior author of the manuscript to request a copy of all resources. Collectively, we gathered nine manuscripts along with their respective resources for CCS promotion projects.

A data abstraction form was created in REDCap ( https://www.project-redcap.org/ ) to document intervention details (e.g., sample size, target population, location), participant demographics (including age, race/ethnicity, etc., targeted by the intervention), characteristics of the CCS resources (e.g., type, literacy level, languages), the theoretical framework for the project design, and CCS outcomes [ 7 ]. We determined literacy level using the Flesch-Kincaid grade level calculation [ 8 ]. Theoretical framework elements were determined explicitly through text in the manuscript or by the study team’s judgment of the ideas expressed in the manuscript. Following a training on the abstraction form, at least two of four study team members (MP, JM, KL, KS) evaluated each project before meeting to review and reconcile findings for a unanimous consensus on all projects.

We utilized the collected data to construct a narrative that summarizes relevant features of the CCS promotion projects. The effects of the interventions were calculated as the absolute percent difference in screening outcomes across different time points. The variation in reporting these effects, however, did not allow us to control for characteristics related to patient population, context, or intervention type. Where applicable, t tests or Pearson’s correlation coefficients were calculated to evaluate the relationship between project characteristics and intervention effect sizes for dichotomous and continuous features, respectively. All analyses were performed in SAS version 9.4 (Cary, NC) using a two-sided p value of 0.05 for significance.

A total of nine CCS promotional resources with associated manuscripts were included ( Table 1 ) [ 9 – 17 ].

Study characteristics for peer-reviewed papers on increasing cervical cancer screening

Study design and participant characteristics

Five projects compared CCS outcomes for one intervention group versus one control group [ 10 , 11 , 13 , 14 , 16 ]. The remaining four projects used additional comparison groups [ 9 , 12 , 15 , 17 ]. All nine projects utilized an educational component in an attempt to increase CCS. Additional strategies utilized throughout the projects included patient navigation or community health workers (CHWs) [ 11 , 13 – 17 ], phone calls [ 16 ], counseling [ 13 ], and systems-level interventions [ 13 ]. The reviewed projects used, on average, 2.3 strategies with a range of 1–3. All projects took place in the USA, with one project that had a second intervention location in Canada [ 15 ] ( Table 1 ). The projects enrolled participants of various ages with an overall range of 18–65+ and targeted various racial and ethnic backgrounds including Asian [ 10 , 12 , 15 , 16 ], African American [ 9 , 13 ], Native Hawaiian/Pacific Islander [ 10 ], and Hispanic [ 11 , 17 ].

Characteristics of CCS promotional resources

All projects utilized printed resources to promote CCS [ 9 –17], and one project also used audio and video components [ 17 ]. All nine projects were available in English [ 9 – 17 ]; two were also available in Spanish [ 13 , 17 ] and three in other languages (Tagalog, Cantonese, Mandarin, and Vietnamese) [ 12 , 15 , 16 ]. These resources, on average, had a 6.9-grade reading level with a range of 3.4–10.3.

CCS outcomes and interventions effects

Project outcomes differed in length of follow-up, data source, and analytic approach. All nine studies assessed group-level differences in CCS with a Pap test [ 9 – 17 ]; none of the papers assessed changes in CCS by hrHPV testing, which is a relatively new screening option. Across the nine papers, we collected 12 reported effect sizes (including comparisons across multiple arms within a single study).

Blumenthal et al. [ 9 ] reported change in pre-/post-intervention CCS by Pap testing over 18 months for participants in two intervention cities versus their comparison cities which received no intervention. The intervention cities received educational sessions, mass media campaigning with local partners, and community events promoting cancer screening. In one intervention city, the post-intervention CCS rate was higher (+ 2.5%, p < 0.01) than its paired comparison city. However, in the second intervention city, the post-intervention CCS rate was lower (– 3.7%, p = not significant) than its paired comparison city. Braun et al. [ 10 ] reported CCS over 24 months, where the control arm received nutrition education and relevant cancer education resources, while the intervention arm received patient navigation assistance. In the final assessment, CCS was higher in the intervention group than the control group by + 20.6% ( p < 0.01). Fernandez et al. [ 11 ] reported CCS in the intervention compared to control group over 6 months, where the intervention group received in-home visits with CHWs, information about local providers, and a 2-week follow-up from CHWs; the control arm received no intervention (+ 15.9%, p < 0.01). Maxwell et al. [ 12 ] reported higher CCS testing over 3 months in the intervention group compared to the control group, where the intervention group received a cancer screening education module and a list of local facilities that offered free/low cost Pap testing, and the control group received a physical activity education module (+ 4%, p = 0.2).

Paskett et al. [ 13 ] reported an increase in CCS over 30 months in an intervention group compared to a control group. The intervention group received community-level and clinic-level interventions including, but not limited to media campaigns, educational sessions, and one-on-one counseling (+ 21.0%, p < 0.01). Studts et al. [ 14 ] reported higher CCS over 8 months in the intervention group, which received educational sessions and patient navigation, compared to the control group, which received no intervention (+ 7.0%, p = 0.04). Taylor et al. [ 15 ] reported greater CCS over 6 months in two intervention groups compared to a control group. Compared to the control group, a direct mail intervention had a smaller improvement in CCS rates than a CHW intervention (+ 10.0%, p = 0.03 and + 24.0%, p < 0.01, respectively). Taylor et al. [ 16 ] reported higher CCS over the 6 month follow-up in the intervention group compared to the control group, where the intervention group attended educational sessions led by CHWs and the control group received information and resources on physical activity (+ 10.0%, p = 0.07). Finally, Thompson et al. [ 17 ] reported higher CCS rates in two intervention groups compared to the usual-care control group over a 7-month follow-up period. The low-intensity intervention arm included an educational video (+ 4.7%, p = 0.4), and the high-intensity intervention arm included an educational video and home visit by a healthcare worker (+ 19.4%, p < 0.01).

The mean effect size for CCS was + 11.3%, and the median effect size was + 10% (range − 4–24%). Effect sizes were greater for interventions that included CHWs (16.2% versus 6.4%, t = − 2.29, p = 0.045) or one-on-one patient interaction (16.1% versus 3.5%, t = – 3.96, p < 0.01). No other project characteristics were associated with intervention effect sizes.

We conducted a scoping review of nine interventions that focused on increasing CCS through Pap testing. We found that interventions with CHWs or one-on-one patient interaction were associated with the greatest effect size for improving CCS. Interventions did not appear to be more effective based on literacy level of educational resources, follow-up duration, number of intervention components, or targeting by race/ethnicity.

CCS promotion intervention characteristics

CHWs are public health advocates that work directly with a group of people serving as liaisons between community, health care systems, and social service systems. CHWs are often members of the community that they serve and are able to impact change in health behaviors in ways that public health practitioners alone cannot [ 18 ]. Our review showed that interventions with CHWs or similar one-on-one patient interactions had the greatest effect sizes in increasing CCS. This success may be due to the fact that these interventions are intensive, targeting people who may face the most barriers and are known to not receive routine screening. However, interventions focused on CHWs or patient navigation require high effort and reach a small number of people [ 19 ]. Therefore, these intervention strategies may not be disseminable or sustainable on a large scale [ 19 ].

The Health Impact Pyramid proposes that interventions that take into account social determinants of health will be more effective and sustainable at a population level [ 19 ]. It is therefore important to focus on interventions and program designs that address disparities in social determinants of health affecting the target communities. The interventions reviewed through this scoping review were high intensity with small sample sizes. Future interventions should be designed to address social determinants of health, such as education and other relevant socioeconomic status factors, in an attempt to reduce healthcare burden in target populations. Interventions of this design may allow a larger number of patients to benefit from public health programming and from greater access to cancer prevention services. Focusing on social determinants of health is important because of the observable disparities that exist in cervical cancer burden, particularly for individuals of racial/ethnic minority groups, with low socioeconomic status, and residing in rural areas [ 20 ].

We expected effect sizes to vary by literacy level, follow-up duration, number of intervention components, and race/ethnicity of participants. We found that none of these factors were significantly associated with effect size. We anticipated that interventions utilizing lower literacy levels for printed resources would promote higher screening rates for cervical cancer because the resources would be able to reach a wider audience [ 21 ]. This was not the case across the included studies. This pattern of results may have emerged because of the strong positive association between CCS effect sizes and use of CHWs; that is, the literacy level of resources in interventions using CHWs may have been less important because another person was available to help participants read and comprehend the resources.

Additionally, we hypothesized that interventions with a longer follow-up duration would increase the likelihood of getting screened. Longer follow-up periods allow more time for the participants to interact with intervention resources/activities, think about how to get screened, and complete the screening. However, we found no evidence for an association between follow-up duration and screening rates. We also predicted that interventions with more components would increase the likelihood of screening for participants. Higher number of intervention components would increase the intervention dose by maximizing the interaction that a participant has with intervention resources. This was not the case, as the number of intervention components was not associated with effect size. It is possible that both follow-up duration and number of intervention components have threshold effects on CCS effect sizes such that, after a certain duration or a certain number of components, adding more (time or components) to the intervention does not meaningfully impact participants’ behavior.

Finally, we hypothesized that designing an intervention for a specific racial/ethnic group would help target the intervention for that group and increase relevance to the target population [ 22 ], thereby increasing the screening rates. In this review, 8 out of the 9 interventions were targeted by race/ethnicity, but we did not find difference in effect size according to this variable. However, we did find that intervention design varied based on the targeted race/ethnicity. Studies focused on the African American women leveraged community engagement for their interventions as compared to those focused on Hispanic women, where the focus was on one-on-one interaction in the home of the participant by a CHW [ 9 , 11 , 13 , 17 ]. Future research studies should continue to evaluate the effects of literacy level, follow-up duration, number of intervention components, and focus on race/ethnicity on interventions aiming to increase CCS.

Strengths and limitations

A strength of this scoping review is that we were able to review existing literature on CCS interventions that have peer-reviewed results and available promotional resources. Using the resources, we were able to analyze more specific components of the intervention (i.e., the participant-facing resources) than with the research literature alone. This allowed us to analyze effect sizes for the intervention itself, as well as how the effect sizes might be related to characteristics of the promotional resources. The interventions we reviewed were diverse in target race, ethnicity, and location, which increases the generalizability of the results.

The study has limitations; first, the studies we evaluated varied greatly in sample size, ranging from 234 to 3,914. This large variation makes it difficult to accurately compare effect sizes and make overall conclusions about CCS interventions. Next, only nine studies met the inclusion criteria for the present study, which was largely due to the lack of available intervention resources to accompany the peer-reviewed manuscripts. Only four of the included studies looked at underrepresented populations, including African American and Latinx women, who are most affected by cervical cancer morbidity and mortality. Publication bias may also play a role in the lack of literature surrounding CCS interventions, as results with positive findings are more likely to be published [ 23 ]. This means we were not able to identify intervention characteristics that may be detrimental to (or have no effect on) CCS. Finally, all of the interventions took place in the USA which indicates that the review lacks international application.

Gaps in the literature

As previously mentioned, the most impactful interventions included in this review require high intensity, one-on-one patient interaction. These approaches are likely insufficient to create large-scale behavior change [ 19 ]. There is a lack of literature on interventions that use a population health approach and address social determinants of health to increase CCS. Additionally, none of the studies utilized hrHPV testing (either in a clinical setting or through self-sampling) as a method to increase CCS, which could also increase the scale of behavior change. Self-sampling for hrHPV tests involves a patient collecting a cell sample from her own cervix with a small stick or brush, then delivering the sample to a lab to be tested for the presence of hrHPV DNA [ 24 ]. These tests offer autonomy and convenience to patients because they do not have to visit a healthcare provider to complete CCS. Current research on hrHPV self-sampling show promising results for increasing CCS, particularly among underserved and under-screened populations [ 24 ].

In this review, we found that most interventions focused on one particular race or ethnic group. Of greater concern, only four of the included studies focused on underrepresented populations, particularly African American and Latinx women. This is relevant because while the burden of disease from cervical cancer has decreased in recent years, it remains a significantly disparate issue for minority groups in the USA [ 25 ]. For example, when compared to white women, the five-year survival rate for African American women diagnosed with cervical cancer is 13% lower [ 26 ]. In light of such disparities, significant emphasis needs to be placed on research aimed at developing population-based interventions for these communities so screening can be increased at a large scale. It is also notable that none of the papers reported conducting a needs assessment of their respective community to help inform the design of their intervention. It is possible that such an assessment would have resulted in improved effect size especially when addressing excess burden of disease in minority populations. Future interventions focusing on both minority populations and social determinants of health could lead to wide-spread increases in CCS.

The findings from this review can help guide organizations aiming to increase CCS in their community. Through our analysis, we found that the most successful interventions included a CHW or one-on-one patient interaction with a healthcare employee. Organizations can use educational interventions with CHWs to help increase CCS rates in a small target population or at a particular clinic. However, this type of intervention may not be sustainable on a large scale due to resource constraints. Therefore, it is imperative that future research is conducted on interventions focusing on large-scale change using population health theory.

Acknowledgments

Funding for this project came from K22 CA225705 (PI: Moss) and an Institutional Research Grant, IRG-17-175-04, from the American Cancer Society (PI: Moss). In addition, the project described was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through UL1 TR002014 and UL1 TR00045. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Conflict of interest The authors have no potential conflicts of interest to disclose.

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Cervical cancer kills 300,000 people a year — here’s how to speed up its elimination

• Lynette Denny 0 ,
• Ishu Kataria 1 ,
• Lisa Huang 2 &
• Kathleen M. Schmeler 3

Lynette Denny is a professor of special projects in the Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.

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Ishu Kataria is a senior public-health researcher at the Center for Global Noncommunicable Diseases at RTI International, New Delhi, India.

Lisa Huang is director of the SUCCESS project at Expertise France, Abidjan, Côte d’Ivoire.

Kathleen M. Schmeler is a professor of gynaecological oncology and associate vice-president of the Global Oncology Program, MD Anderson Cancer Center, Houston, Texas.

You have full access to this article via your institution.

Cervical cancer can be prevented through vaccination and be cured if diagnosed early. Yet it still kills more than 300,000 people worldwide each year. Globally, only around 21% of women have had a vaccine against the human papillomaviruses (HPVs) that cause the disease.

Cervical cancer could be eliminated: here’s how

That number needs to rise to 90% by 2030, if cervical cancer is to be eliminated in the next century — as the World Health Organization (WHO) plans . Screening and treatment should also become routine worldwide, with 70% of people with a cervix checked by the age of 35 and again at 45, and 90% of those with signs of cervical cancer treated.

The world is not on track to meet any of these targets. A step change is urgently needed. The tools to vaccinate, screen and treat people are available, and effective. But a lack of funding, staffing and infrastructure — coupled with vaccine hesitancy — are major obstacles. Here, four specialists highlight pockets of good practice that can help to buck the trend.

LYNETTE DENNY: Target schools for vaccination programmes

Oncologist Lynette Denny has spent 29 years working in the field of cervical cancer prevention. Credit: Lynette Denny

Schools are the most effective place to roll out national HPV vaccination programmes. As long as enrolment levels in education are high, it’s easier to reach young people at school than in health-care settings. Political will is crucial, as is collaboration between a government’s health and education departments — and close communication with schools.

I’ve seen the benefits of school-based vaccination at first hand. In 2013, I helped to run a pilot project targeting girls in 31 primary schools in South Africa, in regions where poverty and lack of health-care provision are typically obstacles to high vaccination rates. Our pilot provided 97.8% of eligible girls with what was then the full course of three vaccines 1 . (In December 2022, the WHO advised that a single dose is sufficient to protect against cervical cancer.) Similar results were seen in other pilots, including in Bolivia, Uganda and Vietnam.

Scaling these up to country-wide programmes requires determination. But lessons can be learnt from countries around the world. Take Rwanda. In 2011, it became the first low-income country to implement a national HPV immunization programme for girls in the sixth grade (mostly aged 11–12 years). By 2018, more than one million girls had received a vaccination — 98% of the target population 2 .

Women’s health research lacks funding — these charts show how

To do this, Rwanda had to overcome a lack of resources — a common problem in low- and middle-income countries (LMICs) — and put cervical cancer at the apex of its health agenda. Merck provided free vaccines for three years and helped to prepare for the national roll-out. Later funding came from GAVI, the Vaccine Alliance — an international organization focused on providing vaccines for children in LMICs. Multiple government departments 3 collaborated to set up committees that would oversee all aspects of the programme. Together, these partners organized and delivered school-based vaccinations, rigorously monitored vaccination coverage and ran awareness campaigns 4 . Girls not enrolled in schools, or absent on vaccination days, were tracked by community health workers and vaccinated at health-care facilities instead.

As Rwanda shows, strong, trustworthy and reliable collaboration between all stakeholders is key. We’ve found the same ingredients to be essential in South Africa, where we invested more than six months in regular meetings between health-care workers, education providers, technology specialists and the government to ensure that the roll-out was well coordinated.

High-income countries, which typically have more resources and fewer barriers to introducing vaccination programmes, would do well to learn from Sweden. In 2012, the country rolled out a free, school-based HPV vaccination programme for girls as young as 10 — alongside a successful screening and treatment programme. Here again, planning and stakeholder cooperation was essential. By 2021, 90% of girls in the country had received one vaccine dose by age 15, and 84% had received two.

Going forward, governments around the world must place prevention of cervical cancer high on the health agenda. Health and education departments must cooperate, and must allocate funding to all aspects of HPV vaccination — from vaccine procurement to infrastructure, awareness campaigns to human resources. Without this focus, roll-out will fail.

ISHU KATARIA: Bust myths through communication campaigns

Ishu Kataria surveyed physicians in India to understand their hesitancy around the HPV vaccine. Credit: Ishu Kataria

People in India are generally not hesitant about vaccines, especially for children. Yet, the Indian government has not included the HPV vaccine in its national immunization programme — even though one person dies from cervical cancer every eight minutes here.

In 2019, I interviewed 32 physicians in Kolkata, to try and understand the hesitancy surrounding HPV vaccination 5 . The physicians’ foremost reason was that many parents associate HPV vaccination with promiscuity. Because HPV is transmitted through sexual intercourse, parents often assume that giving a young child the vaccine will be viewed in the community as a sign that they are sexually active.

Physicians were also unclear about the benefits of recommending the HPV vaccine before a child becomes sexually active, and they did not want to risk their reputation by making a recommendation that could be controversial. Similar concerns and misunderstandings are common elsewhere, including in Eastern Mediterranean countries 6 .

Cancer will cost the world $25 trillion over next 30 years

A campaign run by national health departments is needed to instil confidence in the vaccine among physicians. It should make clear that vaccination is most effective between the ages of 9 and 14, because that is when it produces the most robust immune response. The campaign should highlight that the vaccine is extremely safe. It should provide guidance on communicating the benefits to parents in a culturally sensitive way — as a vaccine to prevent cancer, rather than against a sexually transmitted infection.

Raising general awareness — among schoolteachers, parents, children and adolescents — is also crucial.

The campaign run by the health department for the northeastern state of Sikkim when it first rolled out the HPV vaccine in 2018 provides a blueprint for others to follow. Sikkim’s six-month-long campaign educated physicians, community leaders, government officials, the media and the public through workshops, written materials and television and radio broadcasts. It resulted in 97% HPV vaccine uptake among eligible girls 7 .

Indian states cannot afford to roll out the vaccine unless it is part of the national immunization programme (in which case the government covers the cost of the vaccine). The launch of an affordable, cost-effective, India-manufactured vaccine by the Serum Institute in September 2022 has put pressure on the Indian government to fund the HPV vaccine, with a decision expected after this year’s election. States should now lay the groundwork for roll-out, following Sikkim’s lead. Key first steps include communication with physicians and parents, along with logistical planning.

LISA HUANG: Integrate screening into health-care systems

Public-health expert Lisa Huang. Credit: Expertise France

There is no one-size-fits-all approach to rolling out cervical cancer screening programmes. For LMICs, the best strategies focus on maximizing efficiency — and thereby reducing costs — for resource-poor countries.

This can be achieved by integrating screening and treatment programmes into existing health-care systems and facilities. The SUCCESS project, of which I am a director, is trialling such an approach in Burkina Faso, Côte d’Ivoire, Guatemala and the Philippines.

Performing screens in existing health-care settings minimizes the need for extra medical workers, who are scarce in LMICs. Screening programmes can be run in primary health-care settings, gynaecology clinics, family-planning services and — importantly — HIV clinics. The last is essential because the 20 million women living with HIV are six times more likely than other women to develop cervical cancer.

African scientists call for research equity as a cancer crisis looms

Local contexts need to be considered. In many countries, staff members will need to be trained in screening, and supply chains and inventory management systems will need to be set up. Digital health-information systems are crucial, allowing patient information to be passed between departments and between health workers to aid follow-up.

In the SUCCESS project, we’ve seen the benefits of such digital solutions. In Burkina Faso and Côte d’Ivoire we’ve made use of the DHIS2 Tracker, an app available as part of DHIS2 — an open-source health-information management platform widely used in LMICs. Using a tablet, a health-care worker can input patient information into the tracker along with information about any follow-up needed, which the patient can be told of either by instant messaging or when visiting another health centre.

Although it is challenging to collect digital data in LMICs, I am confident that tracking screening will save lives. Governments should aim to implement tracking technologies as soon as possible. People often resist complex changes, so engagement with health-care workers is an essential first step in a move towards digitization, to gain support for the switch. Investment from local and international funders is key, and time must be taken to understand each country’s health-care ecosystem and ensure that new digital solutions are interoperable with those already in use.

KATHLEEN M. SCHMELER: Use international mentors to train doctors

Kathleen Schmeler helps to train medical graduates in Mozambique. Credit: Sarah Berger

LMICs face a shortage of medical providers. Just 4% of the global medical workforce is in Africa, for instance — yet the continent shoulders one-quarter of the global disease burden 8 . Most LMICs have no formal training programmes for cancer specialists, particularly surgeons. In these countries, more specialized nurses and physicians are urgently needed to diagnose and treat cervical cancer.

Global collaboration can help to meet the need for training, as demonstrated by two international projects in which I’ve been involved. Both focused on Mozambique, a country that has no organized screening programme and few trained medical providers. In Mozambique, 39 of every 100,000 women die from cervical cancer, compared with the global average of 7.2.

First, I co-lead a collaboration between the Mozambique Ministry of Health, the MD Anderson Cancer Center in Houston, Texas, and five institutes in Brazil. The collaboration — which was initiated in 2014 at the request of the First Lady of Mozambique — aims to build capacity in Mozambique by teaching the nation’s medical providers to treat ‘pre-cancerous’ cells. Specialists from Texas and Brazil travel to Mozambique three or four times a year to provide lectures, hands-on training and mentoring to trainee doctors and nurses. We train 30–40 participants each time. Ongoing support is provided through monthly video conferences.

Second, I co-chair a global gynaecological oncology fellowship run by the International Society of Gynecologic Cancer (see go.nature.com/4b6edzk ) for institutions in LMICs that lack formal training in cancer care. The fellowship site is paired with a partner institute in a high-income country. Fellows — recently, graduates in obstetrics and gynaecology — spend two years undertaking a comprehensive education and training programme, mainly in their home country, but with a few months at the mentor institution. Maputo Central Hospital in Mozambique was a pilot site when the programme first began in 2017. There are now fellowship sites in 22 countries.

Each of these projects initially required a handful of very motivated international mentors. But training and mentoring is now being performed, at least in part, by programme graduates living in Mozambique.

To scale up these efforts, institutes in high-income countries must coordinate with one another, and enhance collaborations with health ministries and training institutions in LMICs. Funding for our work has come from small grants, philanthropic, institution and foundation budgets, and often from the volunteers themselves. These types of donation can fund individual projects, but investment from governments, United Nations agencies and industry partners is needed to make the approach work on a global scale.

Nature 626 , 30-32 (2024)

doi: https://doi.org/10.1038/d41586-024-00241-2

Moodley, I., Tathiah, N., Mubaiwa, V. & Denny, L. S. Afr. Med. J. 103 , 318–321 (2013).

Article   Google Scholar  

Sayinzoga, F. et al. Vaccine 38 , 4001–4005 (2020).

Article   PubMed   Google Scholar  

Binagwaho, A. et al. Bull. World Health Org. 90 , 623–628 (2012).

Kabakama, S. et al. BMC Public Health 16 , 834 (2016).

Kataria, I. et al. Vaccine X 12 , 100228 (2022).

Hakimi, S., Lami, F., Allahqoli, L., Alkatout, I. J. Turk. Ger. Gynecol. Assoc. 24 , 48–56 (2023).

Sankaranarayanan, R. et al. Lancet Oncol. 20 , e637–e644 (2019).

Boniol, M. et al. BMJ Glob. Health. 7 , e009316 (2022).

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THE GLOBAL CERVICAL CANCER PREVENTION PROJECT

OUR MISSION IS TO PROMOTE THE MORAL IMPERATIVE OF SAVING AS MANY LIVES AS QUICKLY AS POSSIBLE WHILE FIGHTING CORRUPTION IN THE MEDICAL PROFESSION

Pap screening in lower-income countries is a moral imperative because saving as many lives as quickly as possible is a moral imperative.

CERVICAL CANCER  is a leading cause of death in lower-income countries. Today, approximately 90% of the world's cervical cancer deaths occur among women in lower-income countries.

Pap screening prevents cervical cancer by detecting and eradicating pre-cancerous cervical lesions before they progress to life-threatening cervical cancers. The US Preventive Services Task Force has determined that Pap screening reduces cervical cancer rates by 60% to 90% within 3 years of implementation, and that these reductions in suffering and premature death are " consistent and dramatic​ across populations ."

The Head of Cancer Screening at the World Health Organization has emphasized that "good-quality Pap screening can be implemented  even in a rural setting  of a lower-income country with reasonable investment."

Pap screening in lower-income countries is a moral imperative because saving as many lives as quickly as possible is a moral imperative.  However, moral imperatives lack relevance if they are not supported by sufficient political will. ​  

                                                                           **********​  

FOUR TECHNOLOGIES  prevent cervical cancer: Pap screening, visual screening, human papillomavirus (HPV) screening, and HPV vaccination.

Chronic infection of the cervix by HPV, which is sexually acquired, causes cervical cancer.  Nearly everyone will get HPV at some point in their lives.  HPV vaccination is recommended for girls because it does not prevent cervical cancer among women who have previously gotten HPV. Therefore, HPV vaccination does not offer protection against cervical cancer for most women in lower-income countries. Pap screening can offer protection for all women in lower-income countries.

HPV vaccination, if implemented without cervical screening, will require decades  to reduce cervical cancer rates by 50%. In contrast, the US Preventive Services Task Force has determined that Pap screening reduces cervical cancer rates by 60% to 90% within 3 years.  HPV vaccine expert Diane Harper observes “Combining cervical screening with HPV vaccination does not significantly lower the number of women getting cervical cancer every year, but does decrease the number of women with abnormal screening tests.”

HPV tests cannot be used to screen women under the age of 30, due to unacceptably high false-positive rates of HPV tests among younger women.  Visual screening tests cannot be used to screen older women, due to anatomical changes that occur in the cervix as a woman approaches menopause. ​ Pap screening protects women of all ages from developing cervical cancer.

Even in expert hands, quality control for visual screening has  failed  catastrophically.  HPV screening, which remains  too expensive  for routine implementation in lower-income countries, requires a pre-existing Pap screening infrastructure and can readily be phased in to pre-existing Pap screening programs should prices for HPV tests fall into an affordable range.

If our objective is to honor the moral imperative of saving as many lives as quickly as possible, then  Pap smear screening  is the appropriate technology to promote for cervical cancer prevention in lower-income countries. Competing imperatives -- such as corporate profit-making, non-profit corporate fundraising, and academic advancement -- involve promoting technologies other than Pap screening for lower-income countries.

                                                                         **********

WE LEARNED in 1994 that the burden of cervical cancer in Vietnam was a legacy of the Vietnam War. That knowledge generated sufficient political will to honor the moral imperative of saving as many lives as quickly as possible. Working as unpaid volunteers, we subsequently participated in the  establishment  of Pap screening in southern Vietnam, which led to 50% reductions in cervical cancer rates between 1998 and 2003. We delayed publication of data linking war to disease  until 2004 in an attempt to ease the process of reconciliation by presenting what most would acknowledge to be a remedy in advance of what some would perceive to be an accusation.

At the start of the 21st Century, Vietnam had provided a model for  successful cervical cancer prevention  in lower-income countries. Vietnamese and American colleagues were preparing to replicate Vietnam's success by, together, implementing Pap screening in other lower-income countries.

UNFORTUNATELY , since the start of the 21st Century, two developments have decimated political will for the moral imperative of Pap screening in lower-income countries:

1. In 1997, the US National Institutes of Health (NIH) launched an  experiment  in Mumbai that contributed to the preventable cervical cancer deaths of  at least 500,000  Indian women. As part of the cover-up of that catastrophe, NIH-funded physicians have broadcast the unfortunate falsehood that Pap screening is not feasible in lower-income countries. 

2. In 1999, the Bill & Melinda Gates Foundation established the Alliance for Cervical Cancer Prevention. The non-transparent and incorrect founding  assumption  of the Alliance was that novel technology, instead of Pap screening, was the most likely solution for cervical cancer in lower-income countries. That unfortunate assumption has corrupted medical science and decimated political will for Pap screening in lower-income countries. In 2002, the Alliance formally  dismissed  our suggestion that Pap screening be implemented in lower-income countries.

Because of NIH and the Gates Foundation, one of the world's big, fixable problems is being fixed far too slowly -- with catastrophic, lethal consequences .

THE GOAL  of this website is to avert further human catastrophe by encouraging NIH leaders to start telling the truth.  

Eric J Suba MD President and Executive Director

The Global Cervical Cancer Prevention Project

(formerly named The Viet/American Cervical Cancer Prevention Project)

The New England Journal of Medicine: The Mumbai Experiment Contributed To  At Least 500,000 Preventable Cervical Cancer Deaths

CERVICAL SCREENING  prevents cervical cancer by detecting and eradicating pre-cancerous cervical lesions before they progress to life-threatening cervical cancers.

From 1997 until 2015, the US National Institutes of Health (NIH) funded an  experiment  in Mumbai that used premeditated, preventable death as the yardstick to compare the effects of a  discredited cervical screening test  to the effects of no screening at all.

The Mumbai experiment has been  condemned  because physicians deliberately withheld cervical screening from women who subsequently died from cervical cancer. As documented in the video clip above, the Mumbai experiment displayed frightening  similarities  to the Tuskegee Syphilis Study, which President Bill Clinton condemned as being " clearly racist ."

In 2021, the Journal of the National Cancer Institute formally confirmed  that the Mumbai experiment evaluated the effects of a cervical screening test that had been discredited before the experiment began.

The reasons for NIH funding such a pointless, deadly evaluation – and renewing that funding continually for 18 years – remain important unsolved mysteries. In an effort to solve them, we submitted a US Freedom of Information Act (FOIA) request for the initial NIH grant application for the Mumbai experiment. 

NIH responded  that “all documents related to this grant number were destroyed in accordance with applicable records retention policies.” Other documents  obtained through FOIA show that scientific data may have been falsified to create an appearance that the discredited cervical screening test had saved lives.

THE ABSURD SCIENTIFIC DESIGN  of the Mumbai experiment required that a pre-determined number of women would die from cervical cancer without ever having been screened for pre-cancerous cervical lesions. To guarantee they would obtain that pre-determined number of preventable cervical cancer deaths, physicians had to persuade 151,538 low-income women of color to risk dying from cervical cancer without ever having been screening for pre-cancerous cervical lesions.  

Predictably, the US Office for Human Research Protections (OHRP) – the bioethical oversight agency of the US Government – discovered duplicity  in the methods used to convince women to join the experiment.

Low-income women in Mumbai understand Marathi, but not English. OHRP discovered critical differences between English-language and Marathi-language versions of the informed-consent form used for the Mumbai experiment. The English-language version, which was submitted with NIH funding applications, included life-saving information about cervical screening that was missing from the Marathi-language version used to recruit experimental participants.

Without such duplicity, NIH could not have launched the Mumbai experiment.

US Government-funded p hysicians who conducted the Mumbai experiment “applied the  principle  that whenever a new intervention is evaluated, it is compared to the standard care existing in the country and only subsequently should it be implemented as a public health policy.” That unfortunate principle delayed the implementation of Pap screening throughout India for the duration of the experiment. During that 18-year delay, at least one million women died from cervical cancer in India .

The US Preventive Services Task Force has determined that Pap screening reduces cervical cancer rates by 60% to 90% within 3 years of implementation, and that these reductions in suffering and death are " consistent and dramatic​ across populations ."  

As we reported in 2022 in the New England Journal of Medicine , the Mumbai experiment thereby contributed to the preventable cervical cancer deaths of at least 500,000 Indian women. In their published response, NIH and WHO colleagues did not dispute the number.  

                                                                         ********** ​

DOCUMENTS  we obtained through the US Freedom of Information Act show that NIH physicians Edward Trimble and Clifford Lane participated in a  cover-up  of the catastrophe in India. Dr Trimble reported to Nobel Laureate Harold Varmus. Dr Lane reported to Dr Anthony Fauci. During the course of the cover-up, false statements were made to Congressional staffers  Anne Morris Reid , who reported to Representative Henry Waxman,  and  Wendell Primus,  who reported to Representative Nancy Pelosi.  Those false statements left the staffers “gratified to learn that the Mumbai experiment has had such positive impacts.” Subsequently, Dr Trimble announced to the global public "We looked at the ethics [of the Mumbai experiment] very carefully and felt them to be sound."

It is legal for physicians to lie to the global public. However, making false statements to Congress, even when not under oath, is a  criminal  offense punishable by fine and/or imprisonment.

NIH leadiers  should put an end to the cover-up conducted by NIH physicians by telling the truth about the Mumbai experiment.

NIH leaders should formally acknowledge that OHRP determinations were accurate, and that the Mumbai experiment was unscientific and unethical. Because NIH funded the Mumbai experiment for 18 years, NIH leaders should apologize for the needless suffering and death it caused.

Until NIH physicians admit the Mumbai experiment was a mistake, they will be unable to conduct the root cause analysis needed to prevent catastrophes like the Mumbai experiment from happening again.

The Mumbai Experiment and Its Cover-Up Have Corrupted Global Health Policy

"Our results clearly show that good-quality Pap screening can be implemented even in a rural setting of a developing country with reasonable investment, while HPV screening does not give any better detection of pre-cancerous cervical lesions, despite the higher investments."     Rengaswamy Sankaranarayanan MD       Head of Cancer Screening at the World Health Organization (WHO)

          and

    Surendra Shastri MD     Principal Investigator of the Mumbai Experiment              [writing in 2005 in the International Journal of Cancer ]

THE MUMBAI EXPERIMENT  contributed to the preventable cervical cancer deaths of at least 500,000 Indian women because it delayed the implementation of Pap screening throughout India from 1997 until 2015.

​However, if the moral imperative of Pap screening in lower-income countries is discredited, then the number of preventable cervical cancer deaths attributable to the Mumbai experiment drops to zero.  

THE COVER-UP  of the Mumbai experiment has required publicizing the politically expedient falsehood that Pap screening is not feasible in lower-income countries.

As documented in the video clip above, the principal investigator of the Mumbai experiment, Dr Surendra Shastri, has promoted that falsehood to the United Nations and to other influential groups. As noted at the top of this page, Dr Shastri himself, together with the Head of Cancer Screening at WHO, have both convincingly refuted that falsehood.  

Nevertheless, that falsehood has been incorporated into  WHO policy guidelines , which falsely state "In low- and middle-income countries, because of the high cost of setting up screening programmes based on Pap screening, coverage of screening is very low and alternative screening methods are needed.”   

THE US NATIONAL INSTITUTES OF HEALTH  (NIH) funded the Mumbai experiment for 18 years. Perhaps by coincidence, NIH physicians refuse to endorse Pap screening for lower-income countries.

NIH physician Mark Schiffman has  acknowledged the success  of Pap screening in Vietnam, yet  persistently  refuses  to endorse Pap screening for other lower-income countries. Instead, since at least  2009 , Dr Schiffman has  promoted  HPV screening for lower-income countries. Simultaneously, Dr Schiffman  concedes  that HPV screening is too expensive for routine implementation in lower-income countries. 

NIH physicians also  promote  HPV vaccination for lower-income countries. As explained on the first page of this website, HPV vaccination does not prevent cervical cancer among most women in lower-income countries, and   HPV vaccine expert Diane Harper observes “Combining cervical screening with HPV vaccination does not significantly lower the number of women getting cervical cancer every year.”  

PERHAPS BY COINCIDENCE , NIH  shares profits  from HPV vaccine sales with HPV vaccine manufacturers  Merck   and  GlaxoSmithKline , both of which have pled guilty to criminal marketing policies and brushed off billions of dollars in fines. Merck has attempted to  inappropriately influence  US HPV vaccination policies. The clear conflicts of interest between NIH and HPV vaccine manufacturers are entirely legal, yet are difficult to manage, because terms of the profit-sharing arrangements among NIH, Merck, and GlaxoSmithKline are  exempt from disclosure  under the US Freedom of Information Act.

It is correspondingly difficult to estimate how much income NIH stands to earn from global, perennial HPV vaccination.

NIH scientist Phil Castle has  acknowledged  the success of Pap screening in Vietnam, yet  warns  that reports of successful Pap screening in lower-income countries “raise an important ethical concern” because such reports may reduce demand for HPV-based technologies.

Because of the NIH-funded Mumbai experiment and its cover-up, one of the world's big, fixable problems is being fixed far too slowly -- with catastrophic, lethal consequences -- while income is transferred from lower-income countries to NIH and to corporations that market HPV vaccines and HPV tests.

                                                                       **********  

FURTHER HUMAN CATASTROPHE  may be averted if Dr Schiffman tells the truth and formally acknowledges the 2005 determination by WHO that “ good-quality Pap screening can be implemented even in a rural setting of a developing country with reasonable investment, while HPV screening does not give any better detection of pre-cancerous cervical lesions, despite the higher investments .”

That acknowledgement will be an important step toward encouraging WHO and other organizations to change course and to promote the moral imperative of Pap screening for lower-income countries.

The Bill & Melinda Gates Foundation: "Implicitly Dangerous"

WORLD HEALTH ORGANIZATION  (WHO) malaria expert Arata Kochi MD has  warned  that the Bill & Melinda Gates Foundation "was stifling debate on the best ways to treat and combat malaria, prioritizing only those methods that relied on new technology." Dr Kochi  warned  that the determination of the Gates Foundation to have its favored research used to guide policy ‘‘could have implicitly dangerous consequences on the policy-making process in world health.’’

Dr Kochi's warnings regarding the Gates Foundation also apply to global cervical cancer prevention efforts.  

IN 1999 , the Gates Foundation established the Alliance for Cervical Cancer Prevention. Seattle-based PATH, a non-profit corporation, was the organizing partner of the Alliance. PATH receives half of its budget from the Gates Foundation and is considered an agent of the Gates Foundation, rather than an independent grantee. The cancer research branch of the WHO was also an Alliance partner organization. The self-serving yet incorrect founding assumption  of the Alliance was that novel technology, rather than Pap screening, is the most likely solution for cervical cancer in lower-income countries.

That unfortunate assumption has decimated political will for the moral imperative of Pap screening in lower-income countries.

In 2002, the Alliance formally  dismissed  our suggestion that Pap screening be implemented in lower-income countries.

FROM 1999 UNTIL 2009 , the Alliance and the cancer research branch of the WHO conducted an  experiment  in Osmanabad, India. The Osmanabad experiment used premeditated, preventable death as the yardstick to compare the effect of Pap screening to the effect of no screening at all. That experimental design was every bit as absurd as using death as the yardstick to compare the effect of “No-Smoking” to the effect of smoking cigarettes. The Osmanabad experiment has been  condemned  by public health experts and ethicists because physicians deliberately withheld cervical screening from women who subsequently died from cervical cancer. The US Office for Human Research Protections, which determined the Mumbai experiment was unethical, has no authority to investigate human research funded by the Gates Foundation. It is uncertain whether anyone has such authority.

Shockingly, the Osmanabad experiment concluded that high-quality Pap screening does not prevent cervical cancer. That shocking conclusion is every bit as absurd as an experimental conclusion that “No Smoking” does not prevent lung cancer.

A subsequent  re-analysis  of the Osmanabad data set showed that scientific data may have been falsified to create the appearance that Pap screening did not prevent cervical cancer in India.  Concerns  have also been raised about  financial partnerships  among PATH, the Alliance, and HPV test manufacturers.

However, because the WHO conducted the Osmanabad experiment, it is politically mandatory for the WHO to accept the experiment’s absurd scientific conclusion that Pap screening does not prevent cervical cancer.

NIH PHYSICIAN  Mark Schiffman  praised  the Alliance experiment without questioning the scientific plausibility of its conclusions or the ethics of the barbaric methods used to obtain them.

The scientific absurdity that Pap screening does not prevent cervical cancer is politically expedient in several ways:

-        It increases the marketability of HPV tests and HPV vaccines. 

-        It provides an illusion of vindication for the incorrect founding assumption of the Alliance.

-        It provides an illusion of vindication for delaying the implementation of Pap screening throughout India for 18 years or more.

As exemplified in the chilling video clip above, that absurd conclusion has also provided an illusion of ethical justification for deliberately withholding Pap screening from women who subsequently die from cervical cancer. 

Because of the Bill & Melinda Gates Foundation, one of the world's big, fixable problems is being fixed far too slowly -- with catastrophic, lethal consequences -- while income is transferred from lower-income countries to PATH and to other corporations that market HPV tests and HPV vaccines.  

​                                                                        **********  

FURTHER HUMAN CATASTROPHE  may be averted if Dr Schiffman formally acknowledges that Pap screening actually does prevent cervical cancer; that the results of the Osmanabad experiment were scientifically absurd; and that the methods used to obtain those results were unethical.

Those acknowledgements will be important steps toward encouraging the WHO and other organizations to promote the moral imperative of Pap screening for lower-income countries.

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• Introduction
• Conclusions
• Article Information

a After assessment for eligibility and exclusion, those eligible for randomization were stratified into 3 groups: due for screening, overdue for screening, or unknown screening history.

b Research funding constraints necessitated weekly enrollment targets to meet overall accrual targets. If the number eligible in a given week exceeded the target, a sample of individuals was programmatically randomly selected for randomization.

c Indicates Kaiser Permanente Washington.

a Kit requested by 485 individuals. b 39 Other high-risk HPV-positive only and 5 unsatisfactory results. c 32 Other high-risk HPV-positive only and 7 unsatisfactory results. d 2 Returned kits untested (1 received beyond specimen stability and 1 with mold on the swab) and rescreened in clinic <6 mo postrandomization; and 6 returned a tested kit after in-clinic screening (kit results did not impact outcomes). e 20 Requested a kit but completed in-clinic screening (1 returned a kit untested [mold on the swab] and rescreened in clinic <6 mo postrandomization; and 4 returned a kit after in-clinic screening [kit results did not impact outcomes]). f 17 Other high-risk HPV-positive only and 3 unsatisfactory results. g 3 Returned a kit after in-clinic screening (kit results did not impact outcomes). h Kit requested by 157 individuals. i 10 Other high-risk HPV-positive only and 2 unsatisfactory results. j 7 Requested a kit but completed in-clinic screening. k 1 Returned a kit untested (mold on the swab) and did not rescreen in clinic <6 mo postrandomization.

Trial Protocol

eTable 1. Baseline Characteristics by Randomization Group and Cervical Cancer Screening History

eTable 2. Sensitivity Analysis: Screening Completion by Randomization Group With Regression Models Weighted by Days of Follow-Up to Account for Disenrollment in Outcome Ascertainment

eTable 3. Screening Initiation by Randomization Group

eTable 4. Time to Screening Completion for All Allocation Groups

eTable 5. Time to Screening Completion for Screening Modality Within Each Randomization Group

eFigure. Cumulative Incidence of Screening Completion for All Allocation Groups and Screening Modality Within Each Randomization Group

Data Sharing Statement

• Patient Information: Cervical Cancer Screening JAMA JAMA Patient Page November 28, 2023 This JAMA Patient Page discusses screening for cervical cancer, including who should be screened, recommendations for handling positive results, and the prevention of cervical cancer. Rebecca A. Voelker, MSJ

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Winer RL , Lin J , Anderson ML, et al. Strategies to Increase Cervical Cancer Screening With Mailed Human Papillomavirus Self-Sampling Kits : A Randomized Clinical Trial . JAMA. 2023;330(20):1971–1981. doi:10.1001/jama.2023.21471

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Strategies to Increase Cervical Cancer Screening With Mailed Human Papillomavirus Self-Sampling Kits : A Randomized Clinical Trial

• 1 Department of Epidemiology, University of Washington, Seattle
• 2 Kaiser Permanente Washington Health Research Institute, Seattle
• 3 Biological Sciences Division, Department of Public Health Sciences, University of Chicago, Chicago, Illinois
• 4 Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
• 5 Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
• 6 Washington Permanente Medical Group, Seattle
• 7 UnitedHealthcare Community Plan of Washington, SeaTac
• 8 GRAIL LLC, Menlo Park, California
• JAMA Patient Page Patient Information: Cervical Cancer Screening Rebecca A. Voelker, MSJ JAMA

Question   Does a strategy that offers mailed human papillomavirus (HPV) self-sampling kits (via direct-mail distribution or opt-in choice) compared with educational materials alone increase cervical cancer screening?

Findings   In this randomized clinical trial of 31 355 individuals, 36% of those overdue for screening and 62% who were screening-adherent (due) were screened after receiving a direct-mail kit vs 19% of those overdue and 48% who were due for screening after receiving education only. Differences were significant. The opt-in choice was minimally effective vs education alone in individuals who were due for screening or had unknown screening history.

Meaning   Health care systems implementing HPV self-sampling kits should prioritize direct-mail outreach for individuals who are due and overdue for screening to maximize screening adherence.

Importance   Optimal strategies for increasing cervical cancer screening may differ by patient screening history and health care setting. Mailing human papillomavirus (HPV) self-sampling kits to individuals who are overdue for screening increases adherence; however, offering self-sampling kits to screening-adherent individuals has not been evaluated in the US.

Objective   To evaluate the effectiveness of direct-mail and opt-in approaches for offering HPV self-sampling kits to individuals by cervical cancer screening history (screening-adherent and currently due, overdue, or unknown).

Design, Setting, and Participants   Randomized clinical trial conducted in Kaiser Permanente Washington, a US integrated health care delivery system. Individuals aged 30 to 64 years with female sex, a primary care clinician, and no hysterectomy were identified through electronic health records (EHRs) and enrolled between November 20, 2020, and January 28, 2022, with follow-up through July 29, 2022.

Interventions   Individuals stratified as due (eg, at the time of randomization, these individuals have been previously screened and are due for their next screening in ≤3 months) were randomized to receive usual care (patient reminders and clinician EHR alerts [n = 3671]), education (usual care plus educational materials about screening [n = 3960]), direct mail (usual care plus educational materials and a mailed self-sampling kit [n = 1482]), or to opt in (usual care plus educational materials and the option to request a kit [n = 3956]). Individuals who were overdue for screening were randomized to receive usual care (n = 5488), education (n = 1408), or direct mail (n = 1415). Individuals with unknown history for screening were randomized to receive usual care (n = 2983), education (n = 3486), or to opt in (n = 3506).

Main Outcomes and Measures   The primary outcome was screening completion within 6 months. Primary analyses compared direct-mail or opt-in participants with individuals randomized to the education group.

Results   The intention-to-treat analyses included 31 355 randomized individuals (mean [SD] age, 45.9 [10.4] years). Among those who were due for screening, compared with receiving education alone (1885 [47.6%]), screening completion was 14.1% (95% CI, 11.2%-16.9%) higher in the direct-mail group (914 [61.7%]) and 3.5% (95% CI, 1.2%-5.7%) higher in the opt-in group (2020 [51.1%]). Among individuals who were overdue, screening completion was 16.9% (95% CI, 13.8%-20.0%) higher in the direct-mail group (505 [35.7%]) compared with education alone (264 [18.8%]). Among those with unknown history, screening was 2.2% (95% CI, 0.5%-3.9%) higher in the opt-in group (634 [18.1%]) compared with education alone (555 [15.9%]).

Conclusions and Relevance   Within a US health care system, direct-mail self-sampling increased cervical cancer screening by more than 14% in individuals who were due or overdue for cervical cancer screening. The opt-in approach minimally increased screening. To increase screening adherence, systems implementing HPV self-sampling should prioritize direct-mail outreach for individuals who are due or overdue for screening. For individuals with unknown screening history, testing alternative outreach approaches and additional efforts to document screening history are warranted.

Trial Registration   ClinicalTrials.gov Identifier: NCT04679675

In the US, more than 50% of cervical cancers are diagnosed in individuals overdue for guideline-recommended screening. 1 - 4 Screening adherence decreased from 86% to 77% between 2005 and 2019, 5 declining further with COVID-19–related disruptions. 6 Patient-centered strategies that promote access and adherence are essential to mitigate the impacts of missed or delayed cervical cancer screenings.

US guidelines endorse primary screening from age 30 to 65 years by human papillomavirus (HPV) testing of clinician-collected samples (with automatic reflex Papanicolaou testing of samples when indicated). This is a preferred strategy 7 or recommended alternative to Papanicolaou testing administered alone or Papanicolaou/HPV cotesting, which is one of only 2 of the grade A cancer screening recommendations put forth by the US Preventive Services Task Force. 8 HPV testing is more sensitive than Papanicolaou testing for detecting cervical precancer. 7 Unlike Papanicolaou testing, HPV tests can use self-collected samples, which have comparable sensitivity and specificity to clinician-collected samples. 9 - 11 Quiz Ref ID Self-screening addresses barriers including required clinic appointments and negativity about pelvic examinations. 1 , 12 - 15 Although multiple countries offer HPV self-sampling for cervical cancer screening, 16 the US Food and Drug Administration has not yet approved it.

Our 2014-2017 HOME trial, 17 which was embedded in a US health care system, found that mailing HPV self-sampling kits to underscreened individuals increased screening by 9% over usual care (26% vs 17%), similar to international trials. 18 , 19 However, most individuals remained unscreened with low follow-up of HPV-positive results and patient understanding of testing. 18 - 21

As US health care systems introduce primary HPV screening with possible self-sampling, they need data to inform implementation. HPV self-sampling trials 22 have not specifically evaluated kit uptake among populations that are screening-adherent or have unknown screening history (where potential overscreening is a concern). 23 To address gaps identified in the HOME trial and generalize findings to key populations, we designed the STEP trial (Self-Testing options in the Era for Primary HPV screening for cervical cancer). 24 STEP evaluated direct-mail and opt-in approaches to offering HPV self-sampling to populations defined by screening history: screening-adherent and now due, overdue, or unknown.

The STEP pragmatic, parallel, single-blind, randomized clinical trial compared cervical cancer screening completion across groups of individuals with due (screening-adherent), overdue, or unknown screening history. These individuals were randomized to receive usual care (patient reminders and clinician electronic health record [EHR] alerts), education (usual care plus educational materials about screening), direct mail (usual care plus educational materials plus a mailed HPV self-sampling kit), or to opt in (usual care plus educational materials plus the option to request a self-sampling kit). The trial was embedded within Kaiser Permanente Washington (KPWA), a mixed-model managed care system providing health care and insurance coverage. Winer et al 24 reports details about pragmatic aspects per PRECIS-2 (Pragmatic Explanatory Continuum Indicator Summary) criteria. 25 STEP was approved by the KPWA institutional review board and followed CONSORT (Consolidated Standards of Reporting Trials) guidelines ( Figure 1 ). The trial protocol is available in Supplement 1 . To reduce participation bias, individuals were enrolled under a waiver of consent. 25

We used KPWA EHRs and administrative claims to identify eligible individuals operationalized into the following categories: due (previously screened, due for screening in ≤3 months), overdue (cotesting >5.25 years ago, Papanicolaou testing alone >3.25 years ago, or no Papanicolaou testing with continuous KPWA enrollment ≥3.25 years), or unknown (KPWA enrollment ≥6 months and <3.25 years, no recorded screening). Patients of KPWA are assigned a primary care clinician at enrollment unless they receive care outside of KPWA clinics. Usual care includes sending letters approximately 60 days before screening due dates, with electronic and postal mail reminders every 60 days if overdue or with unknown history. Clinicians receive automated EHR alerts when seeing patients with overdue or unknown history. Weekly, from November 2020 through January 2022, we identified individuals who received letters or reminders.

Inclusion criteria were current KPWA insurance, current female sex, age between 30 and 64 years, intact cervix, having a KPWA primary care clinician, and being due or overdue for screening. Exclusion criteria were indication in the EHR that the patient was not on a routine screening schedule (eg, recent positive screen), previous randomization to the HOME intervention, 22 previous invitation to focus groups developing STEP materials, opting out of research, current pregnancy, or a flag in the EHR that a language interpreter would be needed (kit materials were English-only).

Eligible individuals were stratified by screening history then randomized into usual care, education, direct-mail, or opt-in groups by prespecified allocation percentages ( Figure 1 ). STEP was powered to detect 5 and 3 percentage point differences in screening completion for participants randomized to direct-mail and opt-in groups vs the education group. For individuals with due dates between March 2020 and August 2020, when COVID-19 halted routine screening, randomization was delayed 12 months (if still eligible). Randomization allocation was concealed by the study programmer and revealed to investigators only for necessary safety monitoring. The usual care group received no study-related interventions or contact.

Participants in the education group received usual care plus a packet, mailed 1 week after randomization, stating the study objective was learning if educational materials would motivate individuals to undergo screening. The packet included an information sheet stating that participation was voluntary, a telephone number for opting out of including individual data in the research, and an educational brochure about cervical cancer screening.

Participants in the direct-mail group received usual care plus a packet stating that the study objective was to test ways to offer home-screening kits; using the kit was voluntary; any screening option was available; and it included an educational brochure about cervical cancer screening and a self-sampling insert with information about the kit, notification of results, and follow-up of positive results. Unless participants opted out, staff mailed an HPV self-sampling kit after 1 week with illustrated instructions and a prepaid return box to KPWA’s central laboratory. The kit contained a dry testing swab (COPAN FLOQswab 552C.80) with a patient specimen label.

Participants in the opt-in group received the same intervention as those in the direct-mail group, except the information sheet provided a toll-free number and a website link for ordering a self-sampling kit. Kits were sent within 1 week of request.

To mirror KPWA’s standard outreach, if direct-mail or opt-in kits were not returned within 21 days, study staff conducted up to 3 reminder calls offering replacements for lost or not-received kits.

Specimens were tested (Cobas 4800 HPV testing [Roche Diagnostics]), and results were documented in the EHR and reported per usual care. Standardized protocols were developed in accordance with American Society for Colposcopy and Cervical Pathology primary HPV screening management guidelines. 26 Results requiring follow-up were routed to the patient’s primary care clinician and a centralized licensed practical nurse. This nurse monitored adherence through follow-up visit completion, which included directly communicating results, scheduling in-clinic colposcopy for patients with HPV-16–positive or HPV-18–positive results, or reflex Papanicolaou testing for other high-risk HPV-positive results, and sending registered letters to nonresponsive patients. Per study-approval requirements by the US Food and Drug Administration, those with HPV-negative results were recommended for 3-year screening intervals (vs 5-year intervals for clinician-collected samples). 24

Outcomes were obtained from the EHR and claims. The primary outcome was screening completion within 6 months postrandomization, which was defined as follows: 1, in-clinic screening; 2, kit return with negative or HPV-16–positive or HPV-18–positive results; or 3, kit return with in-clinic reflex Papanicolaou testing for other high-risk HPV-positive or unsatisfactory results.

Secondary outcomes were incremental cost-effectiveness ratios, screening initiation (in-clinic or kit return without requiring in-clinic reflex Papanicolaou testing when indicated), time from randomization to screening completion, and completion of recommended follow-up after positive kit result within 6 months postrandomization. For individuals randomized to the direct-mail and opt-in groups, secondary outcomes were screening choice (none, kit return, in-clinic screening), qualitative information from focus groups on patient preferences, and health system costs to implementing home testing.

Incremental cost-effectiveness ratios, patient preferences, and costs will be reported separately.

Characteristics at randomization (age, self-reported race and ethnicity, health plan enrollment duration, time overdue [if applicable], primary care clinician visit within the prior year, census block median household income, census tract Social Vulnerability Index, 27 travel time to primary care clinic, body mass index, tobacco use, and Charlson Comorbidity Index 28 ) were derived from EHR data. Race and ethnicity were included to characterize screening history groups.

Researchers had access to limited aggregate data for all participants (including screening and diagnosis outcomes) under a waiver of consent, including individuals who did not return kits or opted out of EHR review. 24

We stratified analyses by screening history, analyzing individuals by assigned study group, using intention-to-treat principles. The analytic sample excluded only those identified as randomized in error (underwent Papanicolaou testing or disenrolled from the KPWA health plan prior to randomization) ( Figure 1 ). A priori primary analyses used the education group as the referent to estimate the impact of self-sampling outreach beyond educational materials. 24 Modified Poisson regression estimated relative risk (RR) of screening completion within 6 months for the direct-mail and opt-in groups, relative to the education group. Models were fit using generalized estimating equations with a working independence correlation structure and robust sandwich error estimation, accounting for clustering of participants with the same primary care clinician. Models for individuals due for screening and with unknown screening history were unadjusted; models for those overdue for screening were adjusted for overdue duration (<3 years; ≥3 years). The same methods were used to analyze the secondary outcome—screening initiation. Other secondary analyses estimated the effects of educational materials alone, direct mail, and opt in relative to usual care. Kaplan-Meier log-rank tests compared study groups for time to screening completion, with follow-up censored at 6 months for noncompleters. Statistical significance was defined as a 2-sided P value of less than .05.

Outcome ascertainment may be incomplete if individuals disenroll from KPWA before 6-months. Outcomes were defined based on data observed in the EHR and claims, regardless of follow-up time; thus, there were no exclusions due to missing data. Sensitivity analyses used duration of follow-up as regression weights to account for disenrollment.

We used the Fisher protected least-significant difference approach to protect against multiple comparisons for participants stratified as due for screening. 29 Analyses were performed using Stata version 15. 30

Randomization took place from November 2020 through January 2022 for 13 356 individuals due for screening, 8682 who were overdue, and 10 733 with unknown screening history. Excluded from analysis were 1416 (4.3%) randomized in error ( Figure 1 ). Mean (SD) age was 46.5 (10.4) years for participants who were due (13 069), 47.4 (10.1) years for those overdue (8311), and 43.8 (10.3) years for those with unknown screening history (9975). The numbers of White individuals were 9039 (73.4%; due), 5230 (73.6%; overdue), and 3828 (64.2%; unknown) ( Table 1 ). Individuals visiting a primary care clinician or obstetrician-gynecologist in the prior year were 8635 (66.8%; due), 3085 (37.3%; overdue), and 3058 (30.8%; unknown). Participants with unknown screening history and to a lesser extent, those who were overdue had considerable missing data for race, ethnicity, body mass index, and tobacco use. Within shared screening history, baseline characteristics were similar across study groups (eTable 1 in Supplement 2 ). Six-month study follow-up was complete for 93.2% (due), 90.1% (overdue), and 81.9% (unknown) and similar across groups within screening-history status (data not shown).

Quiz Ref ID Among those due for screening, 914 (61.7%) individuals randomized to receive direct mail and 2020 (51.1%) to opt in completed screening vs 1885 (47.6%) in the education group. Screening completion RR was 1.30 (95% CI, 1.23-1.36) for direct mail compared with education (absolute difference, 14.1% [95% CI, 11.2%-16.9%]). For the opt-in group compared with education, the RR for screening completion was 1.07 (95% CI, 1.02-1.12; absolute difference, 3.5% [95%CI, 1.2%-5.7%]) ( Figure 2 , Table 2 ). For direct mail compared with the opt-in group, the RR for screening completion was 1.21 (95% CI, 1.15-1.27).

Among overdue individuals, 505 (35.7%) randomized to receive direct mail completed screening vs 264 (18.8%) who received education (RR, 1.90 [95% CI, 1.68-2.16]; absolute difference, 16.9% [95% CI, 13.8%-20.0%]).

Among individuals with unknown screening history, 634 (18.1%) in the opt-in group completed screening vs 555 (15.9%) in the education group (RR, 1.14 [95% CI, 1.03-1.25]; absolute difference, 2.2% [95% CI, 0.5%-3.9%]).

In a priori secondary analyses, RRs comparing education vs usual care showed no significant difference, regardless of screening history, with small absolute differences (range, −1.7% to 0.6%; Table 2 ). Sensitivity analyses accounting for study attrition yielded similar results (eTable 2 in Supplement 2 ).

Adherence to follow-up of other high-risk HPV-positive or unsatisfactory kits (ie, in-clinic reflex Papanicolaou testing) was high ( Figure 2 ). Thus, screening initiation and completion results were nearly identical (eTable 3 in Supplement 2 ).

Compared with education, time to screening completion was shorter for the direct-mail and opt-in groups and similar for usual care across screening-history groups ( Figure 3 ; eTable 4 in Supplement 2 ). Median days to completion for individuals randomized to the education group were 82 (IQR, 47.5-123) for those who were due, 75 (IQR, 33-116) for overdue, and 75 (IQR, 34-124) for those with unknown screening history (eTable 4 in Supplement 2 ). Results were similar for individuals in intervention groups who went directly to in-clinic screening (direct-mail participants due for screening, median days: 75 [IQR, 40-124]; opt-in participants due for screening, median days: 84 [IQR, 48-123]; direct-mail participants overdue for screening, median days: 62 [IQR, 21-113.5]; and opt-in participants with unknown screening history, median days: 75 [IQR, 34-122.5]). Time to screening completion was shorter for individuals who returned an HPV kit (direct-mail participants due for screening, median days: 28 [IQR, 17-39]; opt-in participants due for screening, median days: 39 [IQR, 26-60]; direct-mail participants overdue for screening, median days: 28 [IQR, 16.25-42]; and opt-in participants with unknown screening history, median days: 41 [IQR, 25-58.5]) (eFigure and eTable 5 in Supplement 2 ).

Of 1474 participants who returned kits, 140 (9.0%) required follow-up (had HPV-positive or unsatisfactory results). Follow-up completion among these 140 individuals was as follows: 85.2% (46/54) of due direct-mail participants, 87.0% (40/46) of due opt-in participants, 87.0% (20/23) of overdue direct-mail participants, and 58.8% (10/17) of opt-in participants with unknown screening history. Proportions of kit returners with HPV-16– or HPV-18–positive results were 1.7% (due direct-mail participants), 1.6% (due opt-in participants), 0.9% (overdue direct-mail participants), and 4.2% (opt-in participants with unknown screening history) ( Figure 2 ). Of these, the following proportions received colposcopy: 70.0% (7/10) of due direct-mail participants, 85.7% (6/7) of due opt-in participants, 66.7% (2/3) of overdue direct-mail participants, and 80.0% (4/5) of opt-in participants with unknown screening history. Proportions of kit returners with unsatisfactory or other high-risk HPV-positive results were 7.4% of due direct-mail participants; 9.0% of due opt-in participants; 6.2% of overdue direct-mail participants; and 10.1% of opt-in participants with unknown screening history ( Figure 2 ). Of these, the following proportions completed in-clinic reflex Papanicolaou testing: 88.6% (39/44) of due direct-mail participants, 87.2% (34/39) of due opt-in participants, 90.0% (18/20) of overdue direct-mail participants, and 50.0% (6/12) of opt-in participants with unknown screening history.

Among direct-mail or opt-in participants, screening by kit vs in clinic varied. For those who were due, 919 (62.0%) in the direct-mail group initiated screening (598 [40.4%] by kit and 321 [21.7%] in clinic) ( Figure 2 ). For those who were due in the opt-in group, 2025 (51.2%) initiated screening (435 [11.0%] by kit and 1590 [40.2%] in clinic). For those who were overdue, 507 (35.8%) in the direct-mail group initiated screening (322 [22.8%] by kit and 185 [13.1%] in clinic). For those with unknown screening history, 640 (18.3%) in the opt-in group initiated screening (119 [3.4%] by kit and 521 [14.9%] in clinic).

Among 3956 individuals who were due for screening and in the opt-in group, 485 (12.3%) requested a mailed kit, and 435 (89.7%) were returned. Of the 50 who requested but did not return a kit, 20 (4.1%) completed in-clinic screening, and 30 (6.2%) did not. Among 3506 individuals with unknown screening history in the opt-in group, 157 (4.5%) requested a kit, and 119 (75.8%) were returned. Of the 38 who requested but did not return a kit, 7 (4.5%) completed in-clinic screening, and 31 (19.7%) did not ( Figure 2 ).

No unexpected adverse events were reported, but 7 expected adverse events 24 were self-reported as mild discomfort (4 dysuria and 3 vaginal pain).

In this pragmatic randomized clinical trial, directly mailing HPV self-sampling kits to individuals enrolled in a US health care system increased cervical cancer screening by more than 14% compared with education alone. Absolute effect sizes were similar between participants in the due and overdue groups. Conversely, an opt-in approach minimally increased screening. Time to screening completion was shorter in the direct-mail group.

Among overdue individuals, the absolute difference in screening completion for direct mail vs education was 16.9%. Meta-analysis of the HOME trial and 27 non-US trials found a 13.2% pooled absolute difference for underscreened populations receiving mail-to-all self-sampling vs usual care invitations and reminders for in-clinic screening. 22 The absolute screening increase with direct mail almost doubled the 8.9% increase in HOME. 18 Notably, the STEP and HOME trials had similar proportions choosing in-clinic screening after kit receipt (13.1% STEP; 14.5% HOME), but kit uptake was higher in STEP (22.6% vs 12.1%). Intervention and contextual changes between trials likely account for effect size increases. During HOME, cervical metrics from the Healthcare Effectiveness Data and Information Set (HEDIS) did not consider HPV self-sampling as screening; therefore, HOME recommended in-clinic screening even after negative self-tests. 17 STEP was conducted after US cervical guideline changes; 8 the trial implemented HPV testing using HEDIS cervical metrics regardless of who collected the sample. 31 Patients were likely more familiar with HPV testing after KPWA’s 2020 transition to primary HPV screening and may have felt comfortable self-collecting after COVID-19 self-testing.

We applied lessons from HOME, 20 , 21 optimizing kit materials to emphasize self-sampling reliability and HPV test efficacy and promote confidence in self-collection. We added an introductory, advance-notice mailing that allowed participants to opt out, based on HOME participants’ preferences. Because the notification letter was an additional contact point, the primary analysis reference was education-only (attention control), to evaluate kit outreach impact beyond education or the additional contact. Education and usual care had similar screening rates, suggesting that education alone does not increase screening.

A limitation of self- vs clinician-collected HPV testing samples is that some results require in-clinic Papanicolaou testing to complete screening. STEP piloted a new KPWA strategy that implemented central nurse management of abnormal cervical results and follow-up contacts. In-clinic screening completion after other high-risk HPV-positive or unsatisfactory kit results was higher in STEP (90%) among overdue participants than HOME (74%), 18 supporting this population health-management approach to follow-up. Colposcopy completion after HPV-16– or HPV-18–positive kit results was suboptimal, even with navigation (76%), yet higher than in HOME (63%) and comparable to US health care system data on colposcopy completion after abnormal screening results. 32

To enhance STEP generalizability, we included individuals who were previously screening-adherent or with unknown screening history (common in the US given lack of universal health care and population-based screening registries as well as patient movement among health care systems). Although HPV self-sampling is available outside the US, 16 to our knowledge, STEP is the first randomized clinical trial of HPV self-sampling uptake to include an evaluation of screening-adherent individuals. The absolute increase in screening for direct-mail vs education group participants (14.1%) was similar to increases in overdue populations, 22 suggesting direct mail effectively increases screening participation, regardless of screening history. Quiz Ref ID Additionally, use of direct mail resulted in decreased time to screen, a benefit because health systems invest time and resources in screening reminders, and calendar-year–based quality metrics motivate health system implementation.

For participants due for screening, the opt-in group had minimally increased screening (3.5% over education) compared with the direct-mail group, similar to 12 trials on opting in that included underscreened populations (4.4% pooled absolute screening difference vs usual care). 22 An additional trial of underscreened individuals in Norway evaluated opt-in and mail-to-all (with 1 reminder call) groups. Screening was increased by 12.3% over usual care for participants randomized to the opt-in group, but direct mail increased screening by 22.9%. 33 We did not evaluate an opt-in group among overdue participants because international trial data supported direct-mail superiority. 9 We only evaluated the opt-in group among unknown screening history participants because of potential overscreening. Compared with education, screening was increased by only 2.2% in the opt-in group.

STEP was strengthened by the pragmatic design. Generalizability was enhanced by using EHR data and standardized definitions and practices to identify and randomize individuals eligible for HPV self-sampling and directly integrating interventions into primary care using existing clinical protocols.

Offering HPV self-sampling within a study may have positively or negatively influenced decisions to use a kit. Resource constraints meant kit materials were English-only, excluding non–English-speaking individuals (6.0% of otherwise eligible potential participants). Results may not generalize to non–English-speaking individuals or those without health insurance. The opt-in participants did not receive postinvitation reminders, but some data suggest that reminders boost opt-in effectiveness. 33 Finally, STEP launched during the COVID-19 pandemic. Response to mailed kits may change postpandemic. Although routine screening resumed before STEP, avoiding in-clinic visits may have motivated patients to use kits.

Within a US health care system, direct-mail self-sampling increased cervical cancer screening by more than 14% in individuals who were due or overdue for cervical cancer screening. The opt-in approach minimally increased screening. To increase screening adherence, systems implementing HPV self-sampling should prioritize direct-mail outreach for individuals who are due and overdue for screening. For individuals with unknown screening history, testing alternative outreach approaches and additional efforts to document screening history are warranted.

Accepted for Publication: October 1, 2023.

Corresponding Author: Rachel L. Winer, PhD, MPH, Department of Epidemiology, University of Washington, 3980 15th Ave NE, Box 351619, Seattle, WA 98195 ( [email protected] ).

Author Contributions: Dr Winer had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Winer, Lin, Anderson, Tiro, Meenan, Sparks, Buist.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Winer, Lin.

Critical review of the manuscript for important intellectual content: Lin, Anderson, Tiro, Green, Gao, Meenan, Hansen, Sparks, Buist.

Statistical analysis: Lin, Anderson, Gao.

Obtained funding: Winer, Tiro, Green, Buist.

Administrative, technical, or material support: Lin, Tiro, Green, Hansen, Sparks, Buist.

Supervision: Winer, Green, Hansen, Sparks, Buist.

Conflict of Interest Disclosures: Dr Winer reported grants from the National Cancer Institute (NCI) during the conduct of the study and outside the submitted work. Mr Lin reported grants from NCI during the conduct of the study. Ms Anderson reported grants from NCI during the conduct of the study. Dr Tiro reported grants from the NCI during the conduct of the study and from the NCI (UM1CA221940) outside the submitted work. Dr Green reported grants from NCI during the conduct of the study; grants from NCI and the Centers for Disease Control and Prevention; and other (contract) from the Patient-Centered Outcomes Research Institute (PCORI) outside the submitted work; and other (steering committee membership and travel reimbursement for meetings) from the National Colorectal Cancer Round Table. Ms Gao reported grants from NCI during the conduct of the study. Dr Meenan reported grants from Kaiser Permanente Washington Health Research Institute during the conduct of the study. Ms Hansen reported grants from NCI during the conduct of the study. Dr Sparks reported personal fees from Washington Permanente Medical Group (as her employer until February 2022) and personal fees from UnitedHealthcare Community and State (her current employer as of March 2022) outside the submitted work; and Dr Sparks is currently employed by UnitedHealthcare and receives equity in the company; however, apart from review of the manuscript, her role in the design and execution of this study was done while employed by the Washington Permanente Medical Group. Dr Buist reported grants from NCI during the conduct of the study; and grants from NCI and PCORI outside the submitted work.

Funding/Support: This work was supported by the NCI/National Institutes of Health (R01CA240375).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: Results were presented in part at the 35th International Papillomavirus Conference, April 19, 2023.

Data Sharing Statement: See Supplement 3 .

Additional Contributions : We appreciate the dedicated work of research specialists Brandie Sevey, MA-C, and Caitlin Dorsey, BAH, and the Survey Research Program (Kaiser Permanente Washington Health Research Institute [KPWHRI]), for their significant contributions to trial operations. We are grateful to James Greene, MD, Sarah Levy, MD, Barbara Detering, MD, Susan Carol Bradford, MS, DT Tran, BS, Theresia Tutt, LPN, and Wendy Robinson, MN (Kaiser Permanente Washington), for their valuable input and assistance with designing and integrating the trial into the clinical delivery system and for serving as critical operational and clinical champions for this work. We thank Dina Greene, PhD, Sony Kilgore-Martin, MD, and Judy Rose, MD (laboratory, Kaiser Permanente Washington), for their substantial efforts in clinically validating the HPV assay on self-collected samples and implementing the laboratory components of the intervention. We thank Catherine Troja, MPH (University of Washington), for her input on the manuscript; and John Dunn, MD, MPH, Annie Chun, MD, and Margaret Chin, MD (Kaiser Permanente Washington), for their support in implementing the trial in the delivery system. We thank KPWHRI’s communications and graphics team for their help developing educational materials for the trial and Chris Tachibana, PhD (KPWHRI), for providing support in the scientific editing of this article.

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Open Access

Peer-reviewed

Research Article

Experiences of cervical cancer survivors in Chitwan, Nepal: A qualitative study

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Community Medicine, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Affiliation Department of Cancer Prevention, Control and Research, B.P. Koirala Memorial Cancer Hospital, Bharatpur, Chitwan, Nepal

Roles Formal analysis, Writing – original draft, Writing – review & editing

Affiliation B.P. Koirala Institute of Health Sciences, Dharan, Sunsari, Nepal

Roles Conceptualization, Data curation, Supervision, Writing – review & editing

• Gambhir Shrestha, 
• Rashmi Mulmi, 
• Prabin Phuyal, 
• Rahul Kumar Thakur, 
• Bhola Siwakoti

• Published: November 5, 2020
• https://doi.org/10.1371/journal.pone.0234834
• See the preprint
• Peer Review
• Reader Comments

Introduction

Cervical cancer is a global leading cause of morbidity and mortality. The majority of cervical cancer deaths occur in developing countries including Nepal. Though knowledge of cervical cancer is an important determinant of women’s participation in prevention and screening for cervical cancer, little is known about this topic in Nepal. This study explores the experiences of cervical cancer survivors and assesses the attitude of family and community towards it and stigma related to this disease in Bharatpur, Nepal.

The study design was qualitative methods involving two focus-group discussions. A total of 17 cervical cancer survivors, who have completed two years of cancer treatment were selected purposively from Chitwan. All qualitative data were transcribed and translated into English and were thematically analyzed.

The majority of the participants had scant knowledge about cervical cancer, its causative agent, showed less cervical cancer screening, delayed healthcare-seeking behavior despite having persistent symptoms before the diagnosis. The main reasons identified for not uptaking the cervical screening methods were an embarrassment and having no symptoms at all. Most of them endured social stigma related to cervical cancer in the form of physical isolation and verbal abuse.

Conclusions

There is an urgent need for interventions to make women and the public aware of cervical cancer and launch effective health education campaigns, policies for cervical cancer prevention programs. This implementation can save the lives of hundreds of women and help them avoid going through all the negative experiences related to cervical cancer. More studies are required to gain the perspectives, knowledge, experiences, and attitudes of cervical cancer survivors to add to the research.

Citation: Shrestha G, Mulmi R, Phuyal P, Thakur RK, Siwakoti B (2020) Experiences of cervical cancer survivors in Chitwan, Nepal: A qualitative study. PLoS ONE 15(11): e0234834. https://doi.org/10.1371/journal.pone.0234834

Editor: Pranil Man Singh Pradhan, Tribhuvan University Institute of Medicine, NEPAL

Received: May 29, 2020; Accepted: October 21, 2020; Published: November 5, 2020

Copyright: © 2020 Shrestha et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Cervical cancer is the second most common cancer in females mainly in low and middle-income countries. Around 310,000 deaths occur annually due to cervical cancer [ 1 ]. Human papillomavirus (HPV) infection is the major cause of cervical cancer. Although most cases of HPV will resolve on their own, persistent infection with certain types of HPV (types 16 and 18) on the cervix can lead to precancerous lesions that can progress to cervical cancer [ 2 ]. Nepal has a population of 10.1 million women aged 15 years and older who are at higher risk of acquiring cervical cancer. Cervical cancer is the most frequent cancer among women between 15–44 years and it also ranks as the first most frequent cancer among women in Nepal. According to the latest data of 2018 around 1,928 women die yearly out of a total of 2,942 women who are diagnosed with cervical cancer yearly in Nepal [ 3 ].

Early detection of HPV infection through the utilization of Papanicolaou (Pap) testing has been shown to decrease rates of cervical cancer [ 4 ]. Because of restricted access to the health care facility and limited knowledge about the preventive techniques for cervical malignancy, the greater part of the women in Nepal has never had a pap test in entire life. Women have reported a lack of knowledge of cancer screening, limited health care facilities, lack of time and money, logistics barriers, and lack of social support as obstacles to receiving regular cancer screening services [ 5 , 6 ]. Since early-stage cervical cancer is curable, it is significantly important to focus on the methods to improvise the quality of life of such patients [ 7 , 8 ]. The five-year survival rate for cervical cancer is around 68%, in developed countries, but is very less in developing countries [ 9 ].

Females diagnosed with cervical cancer often face many difficulties associated with cancer itself, cancer treatments and their side-effects, social understandings, and monetary constraints [ 10 ]. With a very strong association of cervical cancer with sexual practices in women, cervical cancer has a very strong impact on the quality of life of cancer survivors [ 11 ]. Social shame and the absence of satisfactory information concerning the improvement of cervical disease have supported a low quality of life. Besides, cervical cancer patients have been found to have more terrible personal satisfaction scores when contrasted with everyone as well as when contrasted with other gynecological malignancy survivors [ 12 ].

A very minimal subjective investigation has been done to draw out the experience of the malignancy survivor in Nepal. The objective of the study is to understand how a survivor of cervical cancer and their caregivers understood, experienced, and were impacted by stigma as well as their perspectives on how to measure and intervene to reduce this stigma.

Study design and data collection

The qualitative research design using focus group discussion (FGD) was used to explore the experiences of cervical cancer survivors. Two FGDs were conducted, consisting of 8 members in one and 9 members in the other. The study was conducted from January 2019 to October 2019. An interview guide was prepared by an expert panel of faculty with the help of already published articles [ 10 , 13 ]. FGD was conducted in the Nepali language using the interview guide by the principal investigator (GS) along with a female Nepalese researcher (RM). The principal investigator conducting the FGD had a postgraduate degree in community medicine with experience in qualitative research. The FGDs were conducted in the meeting room within B.P. Koirala Memorial Cancer Hospital (BPKMCH) premises. An initial introduction was done among the participants and the research staff before beginning the FGD session. The FGD was facilitated by GS and RM. The questionnaire consisted of open questions regarding personal experiences with cervical cancer, perceptions of what might have caused their cervical cancer, experience with any symptoms, Pap screening, diagnosis, and treatment, and if there were any barriers experienced in cervical cancer screening. FGD was conducted over 60–90 minutes. With the help of two moderators, the FGDs were conducted. All the participants were comfortable with the Nepali language, hence the Nepali language was used for the discussion. At first, information regarding sociodemographic factors was collected. All the discussion was audio tape recorded for further translation and transcriptions. Similarly, all the participants were encouraged to share their knowledge, belief, and stigmata in society as experienced by them. Further, a dedicated note-taker took detailed field notes to complement the audio recorded FGDs. To maintain confidentiality and privacy of the participant’s information, it was ensured none other than the participants and the moderators attended the sessions.

Participant selection

The inclusion criteria were any cervical cancer survivors residing nearby BPKMCH, who have completed more than two years of cancer treatment. They were selected purposively and contacted via telephone to participate in the study. A total of 17 participants who agreed to participate in the research were invited to BPKMCH for further study. Only two FGDs were possible as obtaining the cancer survivors within the vicinity of the Cancer Hospital was limited.

Data analysis

After the collection of data, the audio records and notes were translated and transcribed from the Nepali language to the English language by two members of the research team (GS, RM). Transcripts were examined line-by-line and analyzed using the framework approach. The themes were taken based on previous studies. This approach was chosen, as it allows deductive analysis based on our study objectives. Three members of the research team (GS, RM and PP) independently coded the FGD through discussion and agreed on the coding framework. The data was organized into charts. This helped to put the analyses of responses according to the participants. The socio-demographic characteristics of the survivors were presented in frequency, percentage, mean and standard deviation.

Ethics approval and consent to participate

The study protocol was approved by the Ethical Review Board of Nepal Health Research Council (Reg. No. 152/2019). All participants were explained about the research objectives, their expected role, and the voluntary nature of participation. They were also informed that their decision to participate or decline participation would not affect any benefits or services received by them. A written informed consent (if literate) or thumbprint in presence of a witness (if illiterate) was obtained before participation in the study and permission to audio record the conversation was taken.

Socio-demographic characteristics of the survivors

The mean age of the participants was 53 years (SD 10.8) ranging from 35 to 81 years. On average, the age of diagnosis of cervical cancer among the participants was 47 years (SD 8.7). In our study, all the participants were ever married with 88% currently married and 12% widowed. The majority (70.6%) were Hindu by religion followed by Buddhism (23.5%) and Christianity (5.9%). Most (64.7%) of the participants were illiterate. A quarter of the participants had a history of cancer in their families ( Table 1 ).

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https://doi.org/10.1371/journal.pone.0234834.t001

Awareness of survivors about cervical cancer

In each group, survivors were asked about their idea of how they might have acquired cervical cancer. All the survivors shared their knowledge about the cause of cervical cancer. The majority of the women responded that they truly had no idea regarding the cause of cervical cancer ( Table 2 ). Women described cancer as a painful experience they ever had. As one survivor stated,

" . . . . Look , I have no idea what the cause behind my cervical cancer is . It came out of nowhere . It was such a devastating time when I discovered I had cervical cancer . I thought I was dying . All I did was sit and ask myself why . . . . why it happened to me , did I do anything wrong ? " . . . . [60-year-old]

https://doi.org/10.1371/journal.pone.0234834.t002

While the majority remained clueless, few of them came along with some ideas of how they might have acquired cervical cancer. The ideas about getting cervical cancer varied among individuals and included fair skin color, short birth spacing, bearing too many children, unhealthy dietary habits, smoking and chewing tobacco, and the use of homemade menstrual cloths. One of the survivors even referred to the physical weakness in female as one of the causes of cervical cancer. When they were further asked specifically if they knew about the human papillomavirus (HPV), most of the survivors responded that they had never heard about the virus. Most of them did not know about the virus as the main causative agent of cervical cancer, while two of them came to know about the virus from their doctors after they discovered their cervical cancer.

Symptoms they experienced prior to diagnosis

Episodes of vaginal bleeding..

All the survivors were enquired about the symptoms they experienced before they were diagnosed with cervical cancer. The majority of the women reported that they had episodes of unexplained vaginal bleeding. One of them even attributed the bleeding episode to hemorrhoids.

"One day when I was in the bathroom , I saw blood in the pan , but falsely I attributed it to be from the hemorrhoids . I was not aware of what that could mean , but to be safe I went to see a doctor . After examination , the doctor told me that something isn't right and recommended me to undergo a cervical biopsy . After a couple of days , I found out I had cervical cancer . He [the doctor] suggested me for the removal of my uterus , but I was reluctant to undergo surgery . Then I underwent an imaging test [MRI] , and thanks to God my cancer had not spread to my surrounding organs [urinary bladder] , and given the options , I opted for the radiotherapy" [46-year-old]

Attributing vaginal bleeding to physiological changes.

Many times, women attributed their episodes of vaginal bleeding to the post-menopausal changes. Thinking bleeding as a physiological change that can occur at any time after they have reached menopause, many women did not seek immediate medical consultation.

"At age 45 , I had an episode of vaginal bleed and I discussed it with my friends . They believed that this [vaginal bleed] is pretty much common after you attain menopause and there is no need for any medical consultation . But later , I had an episode of huge bleeding [from the vagina] and I was totally scared . Fearing there might be something wrong going on , I went for the medical consultation right away . The doctor described me as I had some kind of wound in my cervix and urged me to undergo a cervical biopsy . Later , the report came as cervical cancer and I got operated and got my uterus removed . " [54-year-old] "As far as I can remember , I did not bleed for long after I reached menopause . And suddenly out of nowhere , I started having vaginal bleeding . I used to see blood even while passing urine . It was hot weather , which I believed was the reason behind my bleeding . It did not improve for long which made me worried . I went to meet the doctor . After all the examinations and tests like a biopsy , it came out to be cervical cancer . " [81-year-old]

Acute severe vaginal bleeding.

In addition to the above symptoms in which women did not seek immediate medical consultation, one of the women had heavy vaginal bleeding which brought her to the emergent medical attention, and through this, her cervical cancer was diagnosed.

"I used to have lots of episodes of vaginal bleeding , which did not bother me initially . Later , I had a heavy bleeding episode and even had clots in the bleed . It was like blood everywhere . Then without thinking much , I decided to see a doctor . I was referred to a cancer specialist from a local hospital . They [doctors] told me to get a cervical biopsy right away and asked me to see them in a week . My son collected my reports later and the opposite of what I expected the results came back as positive for cancer . That moment is indescribable . " [60-year-old]

On and off abdominal pain.

One of the women reported that she had on and off abdominal pain which she could not attribute to cervical cancer. She vividly recalled the event when she was diagnosed with cancer as devastating news for her.

"Initially , I used to have pain , on and off , in my lower belly and I took medicine from the nearby pharmacy thinking it as a urinary tract infection . I don't remember for how long I had that [abdominal pain] . Later , I was advised to see a doctor . During an appointment , he [the doctor] told me my reports were concerning , and after biopsy , it turned out to be cervical cancer . The diagnosis hit me very hard . I felt my world spinning around me when I knew I had cancer . I cried a lot . I had no idea whether it is a genetic or something else . " [49-year-old]

Barriers to cervical cancer screening

Women were enquired about their experiences with the Pap screening before getting diagnosed with cervical cancer. Surprisingly, none of them ever had any type of cervical cancer screening before they were diagnosed with cervical cancer. All of them avoided screening in the past because of embarrassment or shame. As reported by them, women feel shy to expose their private parts to doctors.

"Well , I have to say most of the women feel too shy to go for screening and expose their private parts to the medical professionals . Regarding me , I am not much comfortable with it , like , how can I show my private parts to the people other than my husband . " [61-year-old] "To be honest (smiling) , women are not comfortable showing their private parts to others . Even when we know about the medical camps in the nearby hospital or health post , we pretend to be fine if we were asked by someone else and avoid going for the screening programs . . . . " [45-year-old]

Feeling healthy or having no symptoms at all was also mentioned to be one reason for women to not go for screening.

"I had a very bad experience . Back in time about 10 years ago , a cervical screening camp was organized in our village . Without thinking much about it , I did not go there for the screening , as I was feeling well and believed nothing could be wrong going with me . But what I did was a mistake . Later I got cancer and had to undergo surgery . If I had been careful enough and had undergone the routine screening process , I could have avoided surgery and all the difficulties associated with it . I am also a political leader in my ward so , I conducted a survey and you will be surprised knowing that 72 out of 100 females did not have their routine screening done . " [59-year-old]

Cervical cancer in Nepalese society

Women were enquired about how their family members and society treated them after knowing that she had cervical cancer. The responses we got varied among individuals. Some of them were well treated by their family and society, while others endured the stigma associated with cervical cancer. The majority of the participants believed that even in present-day cervical cancer is stigmatized in the Nepalese society because of the misconceptions people have towards cancer as a whole ( Table 3 ).

https://doi.org/10.1371/journal.pone.0234834.t003

Drivers of stigma.

According to the women, the general themes acting as the driving factors for cancer stigma in society are the people’s perception of cancer as an ultimate death result and cancer as a communicable disease. Cancer as a whole is stereotyped as a cause of death and is contagious in society and despite providing clear information by the affected person, most of the time it was hard to change their views. It is due to the lack of clear information regarding cancer, such beliefs do exist in society. As the respondents mentioned,

“When the people in my neighborhood knew I had cervical cancer , they all [neighbors] believed that it [cervical cancer] is a communicable disease and thought like you know , cancer is incurable , I am not going to live for long . ” [60-year-old] “The very first thing I used to hear from them [relatives] was "You are going to die soon from cancer" . In return , I used to give them the information about my disease and say that this is curable and I would be fine . But they did not believe me . ” [47-year-old]

Manifestation of stigma.

The fear that existed among the society members that it can be transmitted via casual close contact and communication lead to the physical isolation or marginalization of the cancer patients in their family as well as in the society. According to respondents, neighbors started avoided coming close to them or inviting them in social events, and even verbally abused and pitied them. Most of the time, they felt that they were hated by society just because they had cancer. They mentioned how physical isolation and marginalization resulted in the loss of their social support.

"When I was undergoing chemotherapy for my cancer , my neighbors stopped coming near to me thinking that they would get cancer from me . Even my family members wore a mask when they had to come near me . ” [60-year-old] "Back in our time , people from our village used to take cancer in a very negative way . When I got cancer , they [villagers] didn't even allow me to go near them and used to say "go away" if I attempted to do so . ” [81-year-old] "I had a very hard time dealing with my diagnosis of cervical cancer . That was the first time anyone outside my family came to see me and pitied me . During my chemotherapy , I lost my hair and my neighbors believed it was happening due to my cancer . I don't know why but they [neighbors] always gave me a disgusting look when I said I am undergoing radiotherapy . I felt like everyone hated me . ” [47-year-old]

Self-stigma of fear associated with cancer.

The fear related to cancer and its treatment also existed in those living with cancer. Due to the negative connotations of cancer, women having cancer often feared to undergo the treatment. As one of the respondents mentioned,

"Initially I was reluctant to undergo the treatment of my cancer [cervical cancer] , as one my friend told me not to go for treatment as cancer will eventually kill me and also the radiotherapy is very difficult to undergo . Later I met a woman with cervical cancer who encouraged me to undergo treatment . After hearing her experience my perspective towards chemotherapy and radiotherapy changed . Meeting her eased my fears . I am grateful that I met her , otherwise , I would not have gone for the treatment and only God would know what would have happened to me … hahaha . . . .. " [40-year-old]

Social support and family encouragement.

According to them, the love, care, and support they got from their family and friends were the key elements for them to fight cancer and stay optimistic through the journey of cancer.

''I had very good support from my friends and family (smiling) . They treated me very well when I got cancer and was undergoing treatment . I am so glad that they were all so supportive and with me when I needed them the most . " [46-year-old] "My family looked after me very nicely . I can't say enough about them who cared for me during my hard time . Now , I love them more than ever . They are the most important person in my life . " [45-year-old] "Yes , family support played a great role in my survival . I do not have enough words to express my gratitude for the care , help , and love I got from them . They were always by my side I needed them . " [59-year-old]

According to a few respondents, society’s perception overturned with time as they saw the patients with cervical cancer doing well with the treatment and also with the increasing awareness via media. As one of the survivors stated,

“At present , the situation is quite different than the previous one . With the awareness arising from the media and campaigns , their perspective towards cancer changed . Now they [society] feel ashamed of how they previously treated cancer patients . These day people are very supportive towards the cancer patients …… " [81-year-old]

Unexpected misconceptions

A few uncommon views regarding the cancer were identified from our interview. People have few misconceptions regarding the type of food they should take and the use of herbal medicine. They avoided a certain type of food during their period of cancer. One of the survivors avoided meat and eggs, while one patient consumed only pulses, milk, and fruits. Among them, one took some herbal medicines recommended by her friend, which she does not know about.

"I did not like to eat for a month . I just eat pulses , soups , milk , and fruits only during my treatment . Sometimes I used to panic a lot and pray to god for my survival . I believe I would not survive if God was not there …… " [60-year-old] "I did not eat meat for 1 year and also the eggs …… " [61-year-old] "One of my neighbors was diagnosed with some serious disease , I don't know exactly what it was , but I know is she was doing fine by taking some herbal medicines . She named about 13 types of herbal medicines she was taking . Seeing her I also started taking those [herbal meds] on daily basis . I believe that also gave great benefits to my health . " [53-year-old]

Message of the survivors

The majority of the women did not go for the Pap screening for cervical cancer, and also after being diagnosed few of them were reluctant to undergo treatment. However, though lately, but with their own experiences with cancer, they realized the importance of screening methods for early detection and treatment of cervical cancer.

"I heard about one cancer patient who did not undergo radiation therapy because of all the negative comments she heard about radiotherapy , its complications . I don't know where she is now . That is certainly a mistake . Please don't do that , please go and get your treatment before it is a delay so that you don't have to regret it forever . " [51-year-old] "Today I am living a new life . For those women out there who are healthy , I suggest them to go for screening regularly . And to those living with cervical cancer , don’t worry much about it . Yes , cancer is a disease but is not always a killer; they can be cured with treatment . " [60-year-old]

Thus, they advised other healthy women to undergo regular screening for early detection and undergo treatment if they are diagnosed case of cervical cancer.

This qualitative study done to explore the experiences of cervical cancer survivors is the first of its type that had been conducted in Nepal. Survivors expressed their perspectives of cervical cancer and its cause, symptoms they had prior to diagnosis, their cervical cancer screening behavior, and the personal and social consequences they had faced after the diagnosis. Several findings can be derived from the study.

Paucity of information

The majority of women we interviewed, had scant information about the cause of cervical cancer, and almost all of them had never heard about HPV before. Among the participants, 64.7% of the women are illiterate, and illiteracy is perhaps the reason behind their lack of knowledge about cervical cancer. Several other studies in Nepal reported a lower level of knowledge in women about cervical cancer. For instance, in a study in Rukum, Nepal only 5% of the 600 participants had ever heard about cervical cancer and only 30% among themselves were able to relate HPV as its causative agent and concluded their poor awareness about cervical cancer to illiteracy and lower household income [ 14 ]. In another study in Eastern Nepal, only 21.5% of women could identify HPV as a causative agent of cervical cancer [ 15 ], and another study in rural Nepal reported 76.24% of women did not know anything about cervical cancer [ 16 ]. Similarly, the lower degree of awareness of cervical cancer was reported in a study among cervical cancer survivors in North Carolina, USA [ 10 ]. This highlights the importance of implementing educational programs and campaigns to educate women and make them aware of cervical cancer.

The barriers to cervical cancer screening identified from the study are feeling well or having no symptoms at all and embarrassment that results from showing their private parts to the health professionals. In the same way, previous studies reported illiteracy [ 14 , 17 , 18 ], lack of awareness about cervical cancer and its screening methods, embarrassment, having no symptoms at all [ 19 , 20 ], fear of finding out cancer [ 16 ], sociocultural barriers, service providers’ behavior, geographical challenges, poor financial condition [ 20 ] as significant barriers to cervical cancer screening uptake behavior in Nepal. On contrary, living in a rural area [ 18 ], participating in awareness programs, support from family and women’s group [ 20 ] were shown to be facilitators to increase the screening uptake in women. Similarly, a study in Morocco also reported poor awareness about cervical cancer and having no symptoms at all as a cause for poor Pap screening uptake practice [ 21 ]. Moreover, stigma related to cervical cancer was a major barrier to cervical cancer screening in Karnataka, India [ 13 ], and poor finances and lack of insurance, sense of well-being, transportation issues, and dissatisfaction with the behavior of service provider were related to poor screening behavior among survivors in North Carolina, USA [ 10 ]. Prior bad experiences with the detection of cancer were also described as a barrier to cervical cancer screening among older African American and Hispanic urban women [ 22 ].

The findings suggested the need for interventions at multiple levels to increase the screening uptake behavior in women. First, women should be made aware of the fact that early detection of cervical cancer from regular screening and timely treatment can significantly save women’s lives. Second, there seems to be a need for the implementation of cervical cancer screening programs in Nepal to make it accessible to women in all the geographical areas and cheap enough to make it affordable. Awareness programs via media, mass campaigns, healthcare professionals all can equally increase the screening uptake behavior in women. As per the literature, educating women about the importance of screening [ 23 , 24 ] and using the newer information technologies, like reminders and messages via the cellphones [ 25 ] or involving the social media influencers [ 26 ] for increasing awareness have shown increased participation of women in a cervical cancer screening program.

Unconcerned towards the symptoms

The majority of women demonstrated delayed healthcare-seeking behavior despite experiencing symptoms for a long. As per our results, the women’s sense of well-being and their inability to relate their symptoms to a possible serious disease or attributing their symptoms to normal physiological changes like menopause possibly explain the delayed healthcare-seeking behavior. Similarly, delayed healthcare-seeking behavior despite persistent symptoms was also noted in cervical cancer survivors in North Carolina [ 10 ]. On the other hand, some studies articulated the delayed healthcare seeking to the stigma related to cervical cancer [ 13 ]. This behavior seems concerning as this frequently leads to delayed presentation to medical attention thus, leading to delayed diagnosis and treatment which can increase the negative impact of disease in affected individuals. The women should be educated about the fact that the sense of well-being does not ensure everything going alright in them and should never be used to rule out the need for routine screening measures or medical consultation. Women should be educated about the symptoms related to cancer, encouraged to seek medical care when they had any symptoms. Likewise, effective communication seems important between the health-care providers, policymakers, and the public via educational programs, and media to improve the knowledge about cancer in women.

Manifestation of stigma related to cervical cancer

Even in today’s modern era, cervical cancer is still being stigmatized in our society. It is quite surprising that despite being such a highly prevalent disease, the public has misunderstood cervical cancer, and has different perspectives about it. The misconceptions regarding cervical cancer seem to originate stigma related to cervical cancer and keep perpetuating it. Our study revealed that pertaining cervical cancer to ultimate death and fear of transmission assuming it as a communicable disease are the driving factors for the origin of stigma. The perceptions that are driving the stigma related to cervical cancer such as cancer is a communicable disease and leads to ultimate death are described in studies conducted in India [ 13 ] and in Brazil [ 27 ]. Furthermore, the mind of the people is constantly preoccupied with ideas of attributing cervical cancer to the individual’s promiscuous sexual behavior, like sleeping with multiple men, or relating it to sexually transmitted disease [ 27 ] or blaming cervical cancer as a punishment to individual’s bad deeds/transgressions, like assuming they must have done something wrong [ 13 ], and these reasons naturally rooted the stigma related to cervical cancer. Blaming cervical cancer to the promiscuous sexual behavior was also described as a driving factor for stigma related to cervical cancer in studies conducted in America and Zambia. society [ 28 – 30 ].

The stigmas associated with cancer manifested in various forms in the communities and women had to endure the discrimination and negative impacts arising because of it. Although all the women were not the victim of stigma, the majority of the interviewees described the enacted stigma as discrimination in the form of social isolation or marginalization ranging from community people no longer coming in close contact to the person with cancer, inviting them to participate in social events using masks by the family members while coming in contact to them. Verbal stigma was also described as offensive remarks towards cancer patients like “do not try coming near to me, go away”, “you are going to die soon from cancer”. The physical or social isolation and verbal abusive comments were also described as a manifestation of stigma in India [ 13 ], and in rural Kenya [ 31 ].

Unsurprisingly, the stigmatization does have negative impacts on cancer patients on both personal and social levels. Interviewees reported how the marginalization of them from society led to the loss of their social support. A study in Karnataka, India described how the diagnosis of cervical cancer generated a fear inside a cancer patient and their kin whether to disclose their diagnosis to others or not and how they kept the diagnosis within their close family members only. The stigmas related to cervical cancer was a potential barrier to screening and often led to delayed healthcare-seeking behavior among women having symptoms [ 13 ]. As described in a study done in America, women felt guilt, embarrassment, and shame as a result of their disease, and it generated a fear inside them about being misjudged by the society upon disclosure of diagnosis, which ultimately led to the loss of their social support [ 28 ]. A study in Canada described the discriminative behaviors towards cancer (of any type) survivors in their workplace like discrimination while hiring, harassment, bullying, demotivating them to quit their job, or retire early [ 32 ]. Though workplace discrimination is not explored in this study, cervical cancer survivors may face the same consequences at their workplace.

The study adds to the body of research seeking a broader understanding of stigma and its impact on women’s personal and social life. As reported by few respondents that with time when the cervical cancer patient got better with treatment, it overturned the thoughts and beliefs of most people towards the stigma related to it. Thus, it shows the importance and needs to implement the awareness programs at an individual and community level to change the way cancer is stereotyped in society.

Message of survivors

The survivors, though late, realized the importance of regular screening in early detection and treatment of cancer, and changed their perspective towards cancer. Almost all survivors urged other women to seek medical care when they had any concerning symptoms. Cancer is a devastating diagnosis to face and digest and can scare anyone. Forming a group of survivors and providing an opportunity for cancer patients to interact with them can ease resolve the fear of cancer and encourage them to opt for the treatment.

Study strength and limitation

This is the first study conducted in Nepal to explore the experiences and perspectives of cervical cancer survivors. The qualitative study design itself is the strength of this study. By using this qualitative approach, we were able to assemble the comprehensive understandings of the survivor's perspective of cervical cancer and their journey through this cancer. The conclusion drawn from this study can add a vital element in this research area which can help improve and modify accordingly the awareness campaigns and health care policies, that will implement soon. This study will also help design appropriate interventions and uplift the lifestyle of a cervical cancer survivor, hence accelerate the achievement towards Sustainable Development Goals.

Limitation.

The study findings cannot be generalized as the chosen sample for the study is purposive and from Chitwan district only and does not reflect the entire female population of Nepal. The knowledge, experiences, and stigma women endured through in the urban settings may be different compared to those experienced by women in the rural setting. We interviewed only those who are alive and volunteered to share their story with us. It would add much more flavor in our study if we add the perspectives of the community and women living with cervical cancer.

This study demonstrated poor awareness about cervical cancer, delayed healthcare-seeking behavior, and the stigma related to cervical cancer. Thus, there is an urgent need of intervening at multiple levels, at the community level to make women and the public aware of cervical cancer to the federal level for launching effective health education campaigns and making policies for cervical cancer prevention programs. Additionally, the survivors should be included as an integral part of the health policy formation. The implementation of such programs may save the lives of hundreds of women and overturn people’s perspective towards cervical cancer thus, saving women from going through all the negative experiences related to cervical cancer. This study also recommends more qualitative studies with the cervical cancer survivors in both urban and rural settings to gain their perspectives, knowledge, experiences, and attitudes about it and add them to our research.

Acknowledgments

We would like to thank all the cervical cancer survivors and their accompanying persons for their generous contribution to this research. We would also like to thank Dr. Rabin Gautam for helping us revise the manuscript.

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• 2. Centers for Disease Control and Prevention. Cervical cancer. U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention. 2009 [cited 3 May 2020]. Available: http://www.cdc.gov/cancer/cervical/
• 3. ICO/IARC. Nepal: Human Papillomavirus and Related Cancers, Fact Sheet. 2018 [cited 16 Mar 2020]. Available: https://hpvcentre.net/statistics/reports/NPL_FS.pdf

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HPV vaccine slashes cervical cancer rates across society

16 May 2024

The NHS HPV vaccination programme is preventing the highest number of cervical cancer cases in the most deprived groups, according to our latest study of data from England .

The findings, which reflect the fact that more deprived groups have higher rates of cervical cancer, show that the HPV vaccine is reaching people from all backgrounds.

In 2021, the same research team, led by Professor Peter Sasieni, found that offering the HPV vaccine to girls aged between 12 and 13 prevents almost 9 in 10 cervical cancers . Still, some scientists had been concerned that differing levels of vaccine uptake could be increasing cervical cancer inequalities.

There’s more work to do to address those inequalities, but it’s now clear the HPV vaccine is a big part of the solution. Sasieni’s team at Queen Mary University of London estimates that it has prevented more than three times as many cases in the most deprived group in England (around 190) than in the least (around 60).

Our research highlights the power of HPV vaccination to benefit people across all social groups. Historically, cervical cancer has had greater health inequalities than almost any other cancer and there was concern that HPV vaccination may not reach those at the greatest risk. Instead, this study captures the huge success of the school-based vaccination programme in helping to close these gaps and reach people from even the most deprived communities. In the UK, the elimination of cervical cancer as a public health problem in our lifetime is possible with continued action to improve access to vaccination and screening for all.

More work to do to prevent cervical cancer

Around 3,300 people are diagnosed with cervical cancer in the UK every year.* Research has shown that the HPV vaccine, combined with cervical screening, can bring that number right down.   

However, the percentages of eligible people receiving an HPV vaccine and attending screening have both fallen in the wake of the COVID pandemic.   

And, although this research shows that the HPV vaccine is preventing cervical cancer in all socioeconomic groups, rates are still higher in people from deprived backgrounds.  

That’s why we’re calling on the government to do more to ensure that as many young people as possible get the HPV vaccination. We’re also pushing for better reporting on uptake by deprivation and ethnicity, along with more research, to help us understand how to reach those most at risk.  

Our scientists helped to prove the link between HPV and cervical cancer 25 years ago . That discovery made it clear that we could use HPV vaccines to prevent cervical cancer. It also helped improve cervical cancer screening.

Thanks to these scientific developments, cervical cancer rates in the UK have fallen by almost a third since the early 1990s.**

Who is eligible for the HPV vaccine?

After decades of research, the HPV vaccination programme was first introduced for girls aged 12-13 in England in 2008. Since September 2019, the vaccine has also been available to boys of the same age. Anyone who missed their vaccine can request it through the NHS up to the age of 25.   

The vaccine is also available to men who have sex with men and some transgender people up to the age of 45 through sexual health and HIV clinics.  

We encourage people to take up the HPV vaccine if they are eligible. If you are concerned that you or your child has missed out on the HPV vaccine, you can contact your child’s school nurse, school immunisation service or GP surgery to find out more.

Gem’s story

36-year-old Gem Sofianos, from London, found out that she had cervical cancer after a screening appointment in 2015.

The HPV vaccination programme launched after Gem had left school. Now she’s a strong advocate that eligible people should take up the offer of the vaccine, as well as cervical screening.

Gem said: “If I had been offered the vaccine when I was younger, I wouldn’t have hesitated to take it up. My younger sister was given the HPV vaccine in the first rollout at school. It gives me comfort knowing that she and others are protected against HPV, and therefore less likely to develop cervical cancer.”

Gem was 28 when she was diagnosed. “I was young and healthy and hadn’t experienced any symptoms, so to be told I had cervical cancer took me completely by surprise. It was a lot to take in.”

Because Gem’s cancer was caught early, she had surgery a month later and the treatment was successful. Gem is now free from cancer, but she still attends regular screening.

“I still suffer from the aftermath of my diagnosis,” she said, “and I hope one day we live in a world where cervical cancer is eliminated. With advances in research and more people getting the HPV vaccine, this could be a reality.”

* Based on the average annual number of new cases of cervical cancer (ICD10 C53) diagnosed in the United Kingdom in the years 2017-2019.

* Based on the percentage change in incidence rates from 14 cases per 100,000 women in the UK between 1991-1993 to 10 cases per 100,000 women between 2017-2019.

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HPV vaccination is a highly effective way of reducing cervical disease, finds research led Professor of Cancer Epidemiology, Peter Sasieni

The human papillomavirus (HPV) vaccination programme in England has been associated with a substantial reduction in cervical disease across all socioeconomic groups .  

HPV is one of the most common sexually transmitted infections and many countries, including the UK, now offer routine vaccination to girls and boys at age 12-13 to protect them against strains that can cause cancer in later life.   

The n ew study, published today by the British Medical Journal (BMJ) and led by Professor Peter Sasieni from the Wolfson Institute of Population Health, analysed cancer data from NHS England for vaccinated and unvaccinated women aged 20-64. Researchers concluded that the vaccine reduced cervical cancer incidence rates by nearly 90% and pre-cancerous conditions by around 95% in women. The study also found that the vaccine was much more effective when taken up by people in year 8 (aged 12-13) than later years.  

Between 1 January 2006 and 30 June 2020 there were 29,968 diagnoses of cervical cancer and 335,228 of grade 3 precancerous cervical lesions (CIN3) in women aged 20-64 years. In the group of women offered vaccination at age 12-13, rates of cervical cancer and CIN3 in the additional year of follow-up were, respectively, 84% and 94% lower than in the older unvaccinated group. Overall, the researchers estimate that by mid-2020, HPV vaccination had prevented 687 cancers and 23,192 CIN3s.  

While the incidence of cervical cancer was higher in areas of the most deprivation, the study showed that the HPV vaccination had prevented the greatest numbers of cervical cancer cases in women in the most deprived areas of England.  

Professor Peter Sasieni, lead author from Queen Mary University of London, said: “Our research highlights the power of HPV vaccination to benefit people across all social groups. Historically, cervical cancer has had greater health inequalities than almost any other cancer and there was concern that HPV vaccination may not reach those at greatest risk. Instead, this study captures the huge success of the school-based vaccination programme in helping to close these gaps and reach people from even the most deprived communities. In the UK, the elimination of cervical cancer as a public health problem in our lifetime is possible with continued action to improve access to vaccination and screening for all.”  

Cancer Research UK’s senior health information manager, Sophia Lowes, said: “Every year, around 3,300 people receive a cervical cancer diagnosis in the UK. This research shows us that HPV vaccination works, and increased coverage can help to bring about a future virtually free from this disease. But we can't lose momentum. We're calling for targeted action to ensure that as many young people as possible get the lifesaving HPV vaccine. Better reporting on uptake by deprivation and ethnicity, along with more research, will help us understand how to reach those most at risk.  

"We encourage people to take up the HPV vaccine if they are eligible. If you are concerned that you or your child has missed out on the HPV vaccine, you can contact your child’s school nurse, school immunisation service or GP surgery to find out more."  

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PROJECT PROPOSAL CERVICAL CANCER SCREENING T VENGESAI

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Women living with Human Immunodeficiency Virus (WLHIV) have a higher risk of developing cervical cancer due to their immune-compromised state. Cervical cancer screening leads to early detection and treatment. The aim of the study was to determine the knowledge, attitude, and practices of cervical cancer screening among women infected with HIV in Kasenengwa District, Eastern Province, Zambia. A descriptive cross-sectional study design using a semi-structured questionnaire was used to collect data from 266 WLHIV. Basic descriptive statistics were done using SPSS version 23.0. Almost two-thirds (62.7%) of the 266 WLHIV in the study had adequate knowledge about cervical cancer screening. Almost three-fifths of the respondents (57.1%) had a negative attitude toward cervical cancer screening. The majority (78.2%) had been counselled by healthcare workers on cervical cancer screening with good emotional support from family members (72.9%). About twothirds (68.4%) of the respondents had been screened for cervical cancer. Most women indicated that they didn't have access to cervical cancer screening services because they did not know where to go (61.5%) and distant screening sites (56.3%) WLHIV in the study had adequate knowledge, but unfavorable attitude towards cervical cancer screening, while two-thirds had been screened for cervical cancer. Accessibility to screening sites was poor. More education and sensitization are needed in the district to eliminate misconceptions about cervical cancer screening, which may influence uptake.

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Time Between HPV Tests for Cervical Cancer Might Be Safely Extended

By Dennis Thompson HealthDay Reporter

WEDNESDAY, May 22, 2024 (HealthDay News) -- HPV testing to prevent cervical cancer might not have to happen as often as currently recommended, a new study says.

Current standards require women to undergo human papillomavirus (HPV) screening every five years. Nearly all cervical cancers are caused by HPV .

But researchers found that waiting eight years for follow-up HPV screening after a woman test negative for the virus is safe and effective.

The safety of an eight-year interval is the same as that of the standard three-year interval between a Pap smear, researchers report.

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“These findings should provide assurance that the five-year interval recommended for HPV screening is even safer than the three-year interval for cytology [Pap] screening,” said researcher Anna Gottschlich , an assistant professor at Wayne State School of Medicine, in Michigan.

During the past two decades, the United States has been transitioning from Pap smears to HPV-based screening for cervical cancer, researchers said in background notes.

The U.S. Preventive Services Task Force currently recommends that women routinely get a Pap smear every three years, HPV screening every five years, or combined Pap and HPV screening every five years.

Each year, about 11,500 U.S. women are diagnosed with cervical cancer and about 4,000 women die from it, according to the U.S. Centers for Disease Control and Prevention.

But these advanced screening methods have led the World Health Organization to call for the global elimination of cervical cancer by 2030, researchers said.

For the study, researchers analyzed data from a Canadian HPV screening trial conducted between January 2008 and December 2016, with an average 14-year follow up.

They found that the risk of women developing a precancerous lesion of the cervix was 3.2 cases per 1,000 within eight years of a single negative HPV test, and 2.7 per 1,000 within eight years of two negative HPV tests.

That was similar to women’s three-year risk following a single negative Pap test (3.3 per 1,000) or two negative Pap tests (2.5 per 1,000), researchers noted.

After six years -- a year longer than current five-year guidelines -- HPV screens showed lower risk after one (2.5 per 1,000) and two (2.3 per 1,000) negative tests.

The findings were published May 21 in the journal Cancer Epidemiology, Biomarkers & Prevention .

“HPV screening performs better than [Pap smears] by detecting more precancer earlier, which can then be treated earlier,” Gottschlich said in a journal news release. “We saw that in our study population, even those who had only one negative HPV test were at very low risk for the development of cervical precancer for many years after the negative test.”

These results might lead to changes in screening guidelines, but that depends on each country and their specific population, Gottschlich noted.

For example, countries will need to make sure that their health systems are good at following up with patients, as a longer screening interval means that some will forget they are due for their next check-up, the researchers noted.

More information

The U.S. Centers for Disease Control and Prevention has more on cervical cancer screening .

SOURCE: American Association for Cancer Research, news release, May 22, 2024

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Now, thanks to the ongoing efforts of NCI’s Index of Studies (INS), you have a newly upgraded web-based resource to help you access the information you need.

Using a redesigned, automated data gathering process, INS finds and sifts through content from NIH RePORTER , NIH iCite , and NCBI PubMed to give you information on an ever-increasing curation of NCI programs. You can display those findings in a revamped “ Explore Page ,” with easy-to-read tables, charts, and graphs.

You can search NCI’s programs by focus area or cancer type and see who’s funding that research (e.g., which NCI division, office, or center). You also can filter your search to examine the results from specific areas, such as Cancer Moonshot SM  and health disparities. You’ll see the results (including the associated publications, grants, and projects for those programs) in an easy-to-navigate table.

To date, INS features:

• 83 programs
• 757 projects
• 3,065 grants
• 22,199 publications

As noted by Zachary Dorman, technical project manager, Center for Technical Operations Support at NCI’s Frederick National Laboratory for Cancer Research, “The INS shows some important steps toward transparency and accessibility of NCI information, but it’s far from comprehensive. We have more work to do. Over the next months, we’re planning to continue to enhance this resource to make it even more useful for the community.”

To that end, NCI’s seeking feedback on the next steps for INS.

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