1. Planning and Implementing Cervical Cancer Programs
Andreas Ullrich WHO Geneva
WHO-IUMSP NCD PROGRAMME MANAGERS SEMINAR, JUNE 2013

2. Overview Principles of the WHO comprehensive approach
From new Evidence in Cervical cancer prevention to new Guidelines
From Guidelines to Implementation: country examples

3. The need for action: cancer screening mostly absent
WHO NCD survey 2010

4. Comprehensive Approach

5. Continuum of Care Natural History of Cervical Cancer Early detection
Diagnosis/ Treatment
PREVENTION
Early detection
Screening
Palliative Care

6. The first-ever comprehensive guide from WHO on cervical cancer control - 2006
Adopted and adapted in many countries, e.g., China, Sri Lanka, Viet Nam, Cambodia, Thailand, Nigeria, Malawi, Zambia, Tanzania, Uganda, some Latin-American countries, and others

7. The first-ever comprehensive guide from WHO on cervical cancer control - 2006
Key messages:
Health education integral part of cervical cancer control
Cytology, but not <25 yrs or annually
VIA /"See and treat", in pilot settings only
HPV testing, in pilot settings only.

8. Purpose of the update Health education to be expanded
HPV vaccines to be included
New data on use of screening tests VIA /HPV
New data on "See and treat"
New data for algorithms (sequential testing)
Program planning chapter
Four regional workshops to introduce Safe Abortion: Technical and Policy Guidance for Health Systems

9. NEED FOR UP DATE Conventional pap smear Hybrid Capture® 2 DNA test
Visual inspection with
acetic acid (VIA)
CareHPV rapid DNA test
It is not one size fits all
Depends on the local infrastructure where the test will be performed and on the treatment capacity and follow-up

10. Choice of a test need to be based on:
Effectiveness of the test (sensitivity/specificity) in the target group.
Capacity to reach (coverage) a significant proportion (100%) of target group
Local infrastructure where the test will be used
Balance between performance of the test vs. coverage
Capacity of the health system to ensure treatment
Cost
Should take into consideration the new environment of HPV vaccines introduction

11. From interventions to policies
Cervical cancer prevention = mandatory part of national health planning and monitoring
UN General Assembly on NCD 2011
World Health Assembly 2013

12. Essentials for program planning
HPV_UNFPA_Strategies for referral_nov10
Essentials for program planning
National policy
Resources allocated, insurance coverage
Public education
Health education for target groups
Screening = organized
Screening linked with treatment, referral system
Heath information system (cancer registries)
Choices depend on test, health infrastructure, socio-economic context, regulations and norms, disease burden

13. Screening program options
HPV_UNFPA_Strategies for referral_nov10
Screening program options
Age: WHO recommends 30+ unless HIV+
Frequency: depends on test and resources, achieve high coverage
Which test: depends on resources and infrastructure
Care provider: doctor, nurse, midwife, technician
Treatment: cryotherapy suitable for most lesions and easy for non-physician to learn; need LEEP for large or advanced lesions
Community outreach: interpersonal through community health workers or women’s groups; local radio; posters
Choices depend on test, health infrastructure, socio-economic context, regulations and norms, disease burden

14. Cervical Cancer Prevention Programmes: Operational framework
Community level
Palliative care
Awareness, Communication
PHC level
VIA
VIA
VIA
VIA
Secondary level
Training
VIA and cryotherapy
Treatment
Tertiary level
Monitoring /Evaluation

15. Introduction of HPV vaccines
Two vaccines available, licensed and WHO- pre qualified: Cervarix (16/18) and Gardasil (16/18 + 6/11)
Up to 30% of Cervical cancer are cause by other types than 16/18
Both vaccines require 3 doses over 6 months

16. Introduction HPV vaccines (continued)
Both vaccines are preventive only , target year old girls
Post vaccination follow up exists only for 9 years
HPV in HIV positives is safe

17. HPV Introduction challenges
Priority setting fro HPV
Cost of vaccine/delivery
Target population/delivery system
Coordination with introduction other vaccines and inclusion in national multiyear plan (cMYP)
HPV is part of an integrated plan fro cx prevention

18. Case report Ghana
No systematic screening, opportunistic cytology (district), VIA pilot project,
HPV introduction: Demonstration project Gardasil, GAVI demonstration project
Challenges: limited human resources, low awareness, socio-cultural beliefs

19. Case report Senegal
No systematic screening, 7 pilot VIA projects, one HPV pilot,
HPV introduction: GAVI demonstration project
Challenges: late presentation of cx, poor coordination between various donor activities, absence of data;

20. Case report Nigeria
National NCCP, National CX policy, Capacity building VIA, 6 screening delivery centers, Advocacy awareness campaigns
HPV introduction program,
Challenges: reach out to rural communities, lack of cancer registries, scaling up screening to national coverage (PHC)

21. Lessons learnt program planning
Cross Ministerial coordination
Cross program coordination > integration of services
Participation of key local stakeholders

22. Resources WHO guidelines and costing tools
WHO Regional offices / country offices focal points
Regional capacity building initiatives (e. g. EUROMED)
WHO partners UNFPA, PATH, GAVI, Pink-Red Ribbon, JHPIEGO, CDC….

23. Conclusion Cervical cancer is part of the NCD agenda
New options for cervical cancer prevention suitable for a variety of settings
Cross over of existing programs (reproductive health, immunization, adolescent health, cancer control )is essential (from vertical to horizontal cross fertilization)