1. MINISTRY OF HEALTH Cervical Cancer in Kenya Presentation to the Cancer workshop – KNH 13 th April 2012 Dr Nancy Kidula

2. MINISTRY OF HEALTH WHY FOCUS ON CERVICAL CANCER? Second most common cancer in Women worldwide, currently affecting over 1 million women Leading cause of death from cancer among women in developing countries Over 90% of cases are in developing countries

3. MINISTRY OF HEALTH Global maternal mortality estimates (MMR)

4. MINISTRY OF HEALTH ~270,000 deaths annually; 88% in low-resource areas 2011 CCA REPORT CARD

5. MINISTRY OF HEALTH Slide 5 Adolescent pregnancies - Mothers too soon: In Bangladesh, 65 percent of 20- to 24-year-old women were married before the age of 18. (source UNICEF). Adolescent girls and young women are at high risk of contracting sexually transmitted diseases or HIV. In Malawi and Ghana, around one third of girls reported that they were “not willing at all” at their first sexual experience.

6. MINISTRY OF HEALTH Comparison with Maternal Mortality 2011 CCA REPORT CARD

7. MINISTRY OF HEALTH Cervical Cancer and HIV/AIDs

8. MINISTRY OF HEALTH LIMITED ACCESS TO A HEAVY BURDEN

9. MINISTRY OF HEALTH 2011 CCA REPORT CARD

10. MINISTRY OF HEALTH 2011 CCA REPORT CARD

11. MINISTRY OF HEALTH WHAT DOES THIS GRAPH TELL US ?

12. MINISTRY OF HEALTH Cervical Cancer: sub-Saharan Africa (Anorlu. Reprod Health Matters 2008;16:41)  22% of all cancers in women (IARC 2003)  Survival rate (2002) 21% vs 70% in US (Ca 2005;55:74)  Important factors:  Endemic HPV  High rates of HIV  Unavailability/inaccessibility of cytology-based screening: poor health infrastructure, limited human capacity, cost  Loss to follow-up: poverty, residence far from health centers, lack of effective mechanisms for recall of women with abnormal paps (60-80% default among those with cytologic abnormalities-Cronje 2004)

13. MINISTRY OF HEALTH Cervical Cancer: sub-Saharan Africa (Anorlu. Reprod Health Matters 2008;16:41) Lack of effective treatment resources: surgical expertise, radiotherapy (2003: 15 African countries did not have RT capacity-Ashraf. Lancet 2003;361:2209) Inadequate palliative care: most pts present in late stages: only 11/47 African countries use morphine for chronic pain (Harding. Lancet 2005;365:1971)

14. MINISTRY OF HEALTH Kenya situation

15. MINISTRY OF HEALTH Women at risk for cervical cancer (over 15yrs) -10.3 million 15

16. MINISTRY OF HEALTH Kenya statistics Annual number of cervical cancer cases- 2454 Annual number of cervical cancer deaths-1676 Projected new Ca cervix cases in 2025- 4261 Coverage of Cervical cancer screening for all women 18 - 69yrs- 3.2%

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18. Kenya statistics ctd Prevalence of abnormal cytology in general population - 3.6% Prevalence of abnormal cytology in HIV positive women – much higher HPV 16 and 18 prevalence in women with HGSIL- 60.9%

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20. The Kenya Situation- Screening Currently over 100 sites are regularly screening across the country Screening Methods: cytology- pap smear, VIA/VILI HPV testing – mainly in research and private sector 20

21. MINISTRY OF HEALTH Kenya situation- Treatment Treatment of dysplasia available in only 30% of screening sites Hence In many cases patients with dysplasia are over treated or not treated at all ( e.g. TAH for CIN 1!!) About 100 sites now offer cryotherapy equipment for treatment of dysplasia

22. MINISTRY OF HEALTH Kenya situation:- Cancer Average age at presentation for invasive cancer is 42 years In most cases it is diagnosed late (>90% are stage IIB or worse) KNH is the only national hospital with radiotherapy Several regional hospices offer Palliative care

23. MINISTRY OF HEALTH Overview of the National Cervical Cancer Strategic Plan 2011 -2015

24. MINISTRY OF HEALTH NCCPP 2011-2015 Vision Kenyan women free from cervical cancer Goal: To reduce incidence, prevalence, morbidity and mortality from cervical cancer and improve quality of life of cervical cancer patients in accordance to the Health policy framework, the National RH policy and National RH strategy.

25. MINISTRY OF HEALTH Objectives: To create an enabling environment for expansion of the National Cervical Cancer Program To create demand for cervical cancer prevention and control services. To provide high quality cervical cancer prevention and treatment services. To strengthen referral system for the cervical cancer program (linkages)

26. MINISTRY OF HEALTH Components of cervical cancer control Primary prevention Early detection / screening Diagnosis and treatment Palliative care

27. MINISTRY OF HEALTH Primary prevention strategies The following Primary prevention strategies are advocated for use in Kenya –Promote Abstinence or delayed sexual debut for adolescents (A) –Promote faithfulness to one partner for those in relationships, (B) –Promote Condom use - C –Promote HPV Vaccination –Promote male circumcision

28. MINISTRY OF HEALTH HPV vaccination The target for vaccination will be Pre and young adolescent girls before first coitus. The recommended age group is 9-13 years. Either bivalent or quadrivalent type of vaccine may be used Out of school population will be targeted through facility or outreach approach No boosters will be given The roll out of this programme will be led by the Division of Vaccine and immunization

29. MINISTRY OF HEALTH 29 VMMC The Kenyan program has provided VMMC services to more than 400,000 clients, reaching more men and boys than any other national program. Nyanza province contributes more than 80% of the effort but implementation is also in Teso, Turkana and Nairobi

30. MINISTRY OF HEALTH Screening Approaches The following screening approaches are recommended for public health use in Kenya –VIA/VILI, –Pap smear cytology –HPV testing Other screening approaches may be used for research or teaching purposes

31. MINISTRY OF HEALTH Target Population For screening to be cost effective, women in the high-risk age group have to be targeted. The recommended target group is women 25-49 years (Women outside this group who wish for screening or for whom screening is advisable will not be denied services) The recommended screening interval is 5 years for HIV negative women

32. MINISTRY OF HEALTH Entry Points for screening Cervical Cancer Screening will be provided as an Integrated service at all KEPH levels The recommended initial entry points for cervical cancer screening are: –the MCH/FP clinics, –the Comprehensive Care Clinics and –the Gynecology clinic. Cervical cancer screening will also be integrated into other RH outreach activities e.g. during integrated RH/FP camps, and campaigns in order to reach more women especially in hard to reach areas.

33. MINISTRY OF HEALTH Screening in HIV positive women All HIV positive women with history of sexual activity 18-65 years old will be screened for cervical cancer The screening cycle for HIV will be as follows: –- At diagnosis –-6 monthly in the 1 st year –-Then yearly if normal

34. MINISTRY OF HEALTH Screening during pregnancy Screening will be offered to women in pregnancy until 20 weeks gestation. No treatment will be offered in pregnancy unless there is evidence of a malignant lesion. If cervical dysplasia is noticed, the woman will be advised to return at 6 -12 weeks post partum for re-screening and treatment. Eligible women will also be offered screening at 6 weeks postpartum

35. MINISTRY OF HEALTH Treatment of Pre- cancer The following are the recommended treatment strategies for precancerous lesions for the Kenya program: –Cryotherapy –Loop Electrosurgical Excision Procedure (LEEP) –Cold knife Conization

36. MINISTRY OF HEALTH Treatment approaches The specific treatment of precancerous lesions will depends on the severity, size, and location of the lesion The program recommends availability of cryotherapy from KEPH level 3. The programme recommends availability of LEEP at level 5 and above As far as possible the Single Visit Approach should be employed

37. MINISTRY OF HEALTH Providers of treatment services It is recommended that Cryotherapy at district hospitals and below be done by appropriately trained non-physicians (nurses, Clinical Officers & doctors) provided they are competent in the procedure

38. MINISTRY OF HEALTH Treatment of advanced disease Only gynecologists should do LEEP; it should be done at provincial or referral hospitals Gynecologists should do cancer diagnosis and staging at provincial and referral hospitals Palliative care is an integral part of the programme and should be strengthened at all levels

39. MINISTRY OF HEALTH Data management A basic set of standardised data tools will be introduced to facilitate data management. These include: Cervical cancer screening form A daily register A monthly summary tool A data use poster A support supervision tool Key indicators will also be incorporated into the routine HIS data capturing tools i.e. Mother Child booklet and the Longitudinal registers.

40. MINISTRY OF HEALTH A team approach to cervical cancer Prevention and control Cervical cancer control requires a multi- sectoral and multidisciplinary effort. It also requires strong linkages and team work between providers at all levels of Health care system

41. MINISTRY OF HEALTH Conclusion Cervical Cancer is a major public health concern in Kenya due to its prevalence, morbidity and mortality Overt cancer is expensive to treat Investing in cervical cancer prevention and control saves lives, improves the quality of the woman’s life and is cost saving to the country