National Cervical Cancer Prevention and Control Program Safina Yuma MD,MPH RH-cancer Unit Sunday, April 16, 2017

Presentation Outline Background & burden of disease Overview of the National CECAP and Control Program Program progress Primary Prevention Secondary Prevention (screening, treatment, referrals) Challenges Lessons learned

Background Cervical cancer is the most common cancer in Tanzania Leading cause of cancer related morbidity and mortality in women in the country Tanzania has one of highest cervical cancer burdens in the world and the highest in Eastern Africa Age-standardized incidence rate (ASR) of 50.9 cases per 100,000 women Despite the high burden, majority of women in Tanzania do not have access to CECAP services

Cervical Cancer Burden Country/Region Incidence Rate (per 100,000) Mortality Rate Tanzania 50.9 37.5 Eastern Africa 34.5 25.3 Africa 25.2 17.6 Sunday, April 16, 2017

NEW CANCER CASES AT OCEAN ROAD CANCER INSTITUTE 2006 - 2011 Type of Cancer 2006 2007 2008 2009 2010 2011 Cervical cancer 955 1006 1288 1374 1510 1881 Kaposi sarcoma 295 404 418 447 681 814 Breast cancer 244 245 275 322 386 526 Esophageal cancer 181 256 282 307 380 511 Head and neck 155 206 272 289 361 Lymphomas 201 199 226 186 269 Leukemias 46 78 87 103 142 261 Urinary bladder 88 98 109 153 Skin cancer 40 108 111 123 129 141 Eye cancers 76 80 95 84 119 Others 598 472 382 390 299 208 TOTAL 2807 3138 3480 3776 4195 5224 4/16/2017

Cervical Cancer Prevention and Control Program in Tanzania The government of Tanzania is committed to address cervical cancer burden 2008 : MoHSW established a RH-Cancer unit through its Reproductive and Child Health Section (RCHS). The Tanzania Cervical Cancer Technical Working Group provides guidance to the national program. To increase demand for CECAP services MoHSW collaboration with partners developed; The National Cervical Cancer Prevention and Control Strategic Plan (2011-2015) Developed Tanzania CECAP and Control service delivery guidelines IEC materials-Posters and Brochures Monitoring Tools Training package-final stage National TOT –for VIA/Cryo National TOT- for LEEP

Strategic Framework Vision: women free from the burden of cervical cancer in Tanzania Mission: The MOHSW is committed to translate cancer prevention and control knowledge into public health action in collaboration with stakeholders including community. The Goal of Strategic Plan : To reduce Cervical Cancer Incidence, morbidity and Mortality in Tanzania

Program progress HPV vaccine launched in Tanzania as demonstration project may 2014 Launch of the community awareness Campaigns for cervical and breast cancer strong support by the First Lady, mama Kikwete (WAMA Foundation) Cervical cancer indicators included into the DHIS Monitoring Sunday, April 16, 2017

Secondary Prevention MoHSW endorsed low cost tech VIA screening test as a national strategy to promote access feasible to implement at low levels of the health care system. Main focus: SVA –screening and treatment using Cryotherapy (all facilities-with skilled personnel) LEEP (Regional & District level facilities) Target group: 30-50 years & HIV positive at any age Screening frequency: 3 years (HIV-/Unk) and yearly for HIV+ women Integration: RCH services /HIV care services/gyn clinic Coverage: more than 200 screening sites

CURRENT STATUS OF PARNER REGIONAL SUPPORT CER12 SECONDARY PREVENTION CURRENT STATUS OF PARNER REGIONAL SUPPORT IMA World ICAP MST EGPAF/MST 12D EGPAF EGPAF/ WHO ICAP/ THPS ENGEND EGPAF UMATI DSM: MDH/ JHPIEGO THPS DOD JHPIEGO/PSI JHPIEGO DOD Focus: Regional level Hospitals District level Hospitals Few Health Centers EGPAF Upcoming: 1.PSI-Private Hospitals 2.Mtwara: EGPAF/THPS 3.UMATI sites WHO

Referral Pathway Large lesions: Regional Hospitals, District Hospitals with skilled providers Suspicious for Cancer: CCS site-Regional Hospital, or referral to MNH or to ORCI Confirmed Cervical Cancer: referred to ORCI for radiotherapy treatment and palliative care (upcoming Bugando MC)

Challenges Shortage of staffs & work overload -providers doing CECAP as one amongst other services Linkages of CCS Lack of pathology services at regional level facility Referral system for suspect cancer cases and large lesions Maintenance of cryotherapy units Re-screening of one year follow up clients is still very low Essential equipment still not included within MSD catalogue eg. Cryo and LEEP machines Long term sustainability of the program Sunday, April 16, 2017

Lessons Learned Acceptability of the program is very high Referral system for SC/LL needs improvements Mechanism for maintenance of Cryo & LEEP machines need to be strengthened Not easy to include CCS budget line item in CCHP (competing priorities) National level advocacy of CECAP program is highly needed Updating CECAP training curriculum in pre service education for nursing & medical schools must be the future direction to ensure sustainability of CECAPC program With strong partnership and collaboration we can easily scale up CCS services in the country Sunday, April 16, 2017

Breast cancer Mass Screening Campaigns for breast cancer No standardized guidelines Solicit funds for the program Sunday, April 16, 2017