Cer v i cal cancerpr ev ent i onandt r eat mentr esear chi nAf r i ca: asy st emat i cr ev i ewf r om a publ i cheal t hper spect i v e Key wor ds: Cer v i cal cancer , Af r i ca, Sy st emat i cr ev i ew, Pr ev ent i on, Tr eat ment , Qual i t yof l i f e, Feasi bi l i t ychal l enges Backgr ound Cer v i cal canceri st hesecondmostcommoncanceramongwomenwor l dwi de, wi t han est i mat ed528, 000newcasesand266, 000deat hsamongwomeneachy ear[ 1] .A di spr opor t i onat enumberoft hesecases( 85%)anddeat hs( 87%)occuramongwomen l i v i ngi nl owandmi ddl ei ncomecount r i es[ 1] .Womenl i v i ngwi t hHI Var eati ncr eased r i skofdev el opi ngcer v i cal cancer[ 2–4]andexper i encemor er api dpr ogr essi onoft he di sease[ 5–7] .Si nce1993, cer v i cal cancerwascl assi f i edasanAI DSdef i ni ngi l l ness[ 8] . TheWor l dHeal t hOr gani zat i on( WHO)adv ocat esacompr ehensi v eappr oacht ocer v i cal cancerpr ev ent i onandcont r ol t oi dent i f yoppor t uni t i est odel i v eref f ect i v ei nt er v ent i ons [ 9] .Cer v i cal cancer r el at edr esear chhasi ncr easedsi gni f i cant l yov ert hepastdecade, r epr esent i ngbi omedi cal , behav i or al , andpol i cyl ev el f i ndi ngs.Exi st i ngr ev i ewpaper s sy nt hesi zeknowl edgeandadv ancement sf ormul t i pl ear easoff ocuswi t hi nt hel ar ger ef f or tofcer v i cal cancerpr ev ent i onandt r eat ment , e. g. , bi omar ker sf orcer v i cal cancer [ 10, 11] , HPVv acci nat i onf ory oungadol escentwomen[ 12–15] , andf easi bl e appr oachest oscr eenandt r eatadul twomeni nl owr esour ceset t i ngs[ 16–20] .The pur poseoft hi ssy st emat i cr ev i ewi st oassessandchar act er i zer ecentr esear chwi t hi n abr oaderpubl i cheal t hf r amewor k, ut i l i zi ngwel l knownpubl i cheal t ht er mi nol ogyt o or gani zeandassesst her angeofef f or t st or espondt ocer v i cal cancer .I nt hi scont ext , t hesei ncl ude: Pr i mar yPr ev ent i on( pr ev ent i ngt hei ni t i al onsetofcer v i cal cancer ) , Secondar yPr ev ent i on( ear l ydet ect i onbyscr eeni ngandt r eat mentofpr ecancer ous cer v i cal l esi ons) , Ter t i ar yPr ev ent i on( t r eat mentofcer v i cal cancert or educemor bi di t y andmor t al i t y ) , andQual i t yofLi f e( post t r eat mentcar eorpal l i at i v ecar ef ort hose wi t houtt r eat mentopt i ons)amongwomeni nAf r i cancount r i es.Li t er at ur ehi ghl i ght i ng f easi bi l i t yconsi der at i ons( accessi bi l i t y , af f or dabi l i t y , heal t hcar ei nf r ast r uct ur e, and pr ov i dert r ai ni ng)andf i ndi ngsspeci f i ct oHI Vi nf ect edwomenar ei nt egr at edas appr opr i at ei neachpubl i cheal t hcat egor y . Pr i mar ypr ev ent i on Vacci nat i oni soneoft hemostcommonl yusedpubl i cheal t hst r at egi est or educet he r i skofi nf ect i onandmi ni mi zet hepr ev al enceoft hedi seasecausi ngagent( HPV)i nt he env i r onment .Near l yal l cases( 99. 7%)ofcer v i cal cancerar ecausedbyhuman papi l l omav i r us( HPV)[ 21] , par t i cul ar l yt y pes16and18whi chcausemor et hant wot hi r dsofal l pr ecancer ouscer v i cal l esi onsandcer v i cal cancer s[ 22, 23] .HPVi soneof t hemostcommonsexual l yt r ansmi t t edi nf ect i ons, wi t hupt o75%ofsexual l yact i v e peopl eest i mat edt obei nf ect edatsomepoi ntdur i ngt hei rl i v es[ 24] .For t unat el y , t wo v acci nesar eappr ov edf oruse.Thebi v al entv acci nepr ot ect sagai nstHPVt y pes16and 18.Thequadr i v al entv acci nepr ot ect sagai nstHPVt y pes16and18andal sot y pes6 and11, whi chcause90%ofgeni t al war t s[ 25] .Si nceHPVi nf ect i onof t enoccur sshor t l y af t ert heonsetofsexual act i v i t y( ov er35%ofwomenar ei nf ect edwi t hi n2y ear sof i ni t i at i ngsexual act i v i t y )[ 26–28] , v acci nat i oncampai gnsshoul dt ar get9–13y earol d y out h, pr i ort osexual debut .Thev acci nesar eov er95%ef f ect i v eatpr ev ent i ngHPV i nf ect i oncausedbyv acci net y peHPVwhent hef ul l t hr eecour sedosei sgi v enov ersi x mont hs[ 29, 30] .Si nce2014, t heWHOr ecommendsat wodoser egi menf orgi r l sand boy saged9–13( quadr i v al entv acci ne)oraged9–14( bi v al entv acci ne)[ 31] , whi chi s noty etl i censedi nal l count r i es, butr educest hef ol l owupbur denwhi l emai nt ai ni ng st r ongpr ot ect i v ecov er age[ 32–35] . TheWHOr ecommendst hei ncl usi onofHPVv acci nat i oni nnat i onal i mmuni zat i on pr ogr amspr ov i dedHPVr epr esent sapubl i cheal t hpr i or i t yandv acci nedel i v er yi s f easi bl eandcost ef f ect i v e[ 31] .Unf or t unat el y , HPVv acci nat i oni snoty etav ai l abl ei n manyAf r i cancount r i es.ByAugust2014, onl y58count r i eshadi nt r oducedHPV v acci nat i onf orgi r l si nt ot hei rnat i onal i mmuni zat i onpr ogr am [ 31] .Whi l et hemaj or i t yof t hesear ehi ghr esour cecount r i es, af ewl owt omi ddl ei ncomecount r i esi nAf r i ca i ncl udi ngRwanda, Sout hAf r i ca, Lesot ho, andUganda[ 36]hav eal soi nt r oducednat i onal HPVv acci nes.I n2013, t heGl obal Al l i ancef orVacci nesandI mmuni zat i ons( GAVI ) beganpr ov i di ngsuppor tf orHPVv acci nat i onst oel i gi bl ecount r i esandwi l l suppor t demonst r at i onpr oj ect si n23count r i es, ofwhi cht enhav ebeenl aunched, pr i mar i l yi n subSahar anAf r i ca[ 37, 38] .Howev er , bar r i er st ov acci nat i on( i . e.concer nsaboutt he saf et yoft hev acci ne, pr ov i derr eser v at i onsaboutr ecommendi ngv acci nat i onf or y oungergi r l s, l i mi t edawar enessoft her el at i onshi pbet weenHPVandcer v i cal cancer , andv ar i edpar ent al accept anceoft heHPVv acci ne[ 39–42] )r esul ti ni nconsi st ent v acci neupt ake, gl obal l y[ 13, 43] .Recentef f or t st ov acci nat ey oungboy shav er ecei v ed l essf ocus, butmayhel pi ndi r ect l ypr ot ectgi r l sbyr educi ngt her i skofr ei nf ect i onwi t h HPVandwi l l hel ppr ev entot herHPVr el at edmor bi di t i esf ormeni ncl udi ngpeni l ecancer , anal cancer , or ophar y ngeal cancer , andgeni t al war t s[ 44] . Ot herpr i mar ypr ev ent i onst r at egi est or educeHPVi nf ect i onandcer v i cal canceri ncl ude del ay i ngsexual debut , r educi ngt henumberofl i f et i mesexual par t ner s, andi ncr easi ng condom use[ 45] .I naddi t i ont or educi ngHI Vacqui si t i onandt r ansmi ssi on, medi cal mal eci r cumci si oni sal sopr ot ect i v ef orHPVi nmal es[ 46–48] , whi chr educest her i skof i ni t i al orr ei nf ect i onofHPVamongwomen. Secondar ypr ev ent i on Scr eeni ngf orear l ydet ect i onandt r eat menti sacor ner st oneofsecondar ypr ev ent i on. Ear l ydi agnosi sandt r eat mentofcer v i cal pr ecancer ousl esi onspr ev ent supt o80%of cer v i cal cancer si nhi ghr esour cecount r i eswher ecer v i cal cancerscr eeni ngi sr out i ne [ 49] .I nhi gheri ncomecount r i es, cer v i cal cy t ol ogy( Papsmear )i nwhi chcer v i cal cel l s ar eexami nedi nor dert odet ectcer v i cal i nt r aepi t hel i al neopl asi a( CI N)becamepar tof r out i necar ei nt he1940’ s[ 50] .Forwomenwhoscr eenposi t i v ef orpr emal i gnantcer v i cal l esi ons( i . e. , CI N) , aconf i r mat or ycol poscopyi sr equi r ed[ 51] .Cer v i cal cy t ol ogy , howev er , i snotaf easi bl emet hodofscr eeni ngi nmanyAf r i cancount r i esgi v ent her equi r edl ev el ofmedi cal andl abor at or yi nf r ast r uct ur eandt r ai nedper sonnel , mul t i pl er et ur nv i si t s wi t hpoorpat i entt r acki ngst r at egi es, andav ai l abi l i t yofsuchser v i cesof t enl i mi t edt o capi t al ci t i es.Thepr opor t i onofwomeni nsubSahar anAf r i car epor t i ngapel v i cexam andpapt esti nt hepr ev i oust hr eey ear si sv er yl ow( 1. 0%i nEt hi opi at o23. 2%i nSout h Af r i ca) , wi t h40%ofwomeni nTuni si at o94%ofwomeni nMal awi hav i ngnev er r ecei v edapel v i cexam [ 52, 53] . Themor ef easi bl e, andWHOappr ov ed, st r at egyf orcer v i cal cancerscr eeni ngi nl ow r esour ceset t i ngsi sv i sual i nspect i onwi t hacet i caci d( VI A)orv i sual i nspect i onwi t h Lugol ’ si odi ne( VI LI ) .Af t erappl y i ngacet i caci dorLugol ’ si odi nedi r ect l yont hecer v i x, pr ecancer ousandcancer ousl esi onst ur nwhi t e, maki ngt hem v i si bl et ot henakedey e [ 54] .Thi smet hodhashi ghsensi t i v i t yamongHI Vi nf ect edanduni nf ect edwomen[ 55, 56] .Resul t sar ei mmedi at e, t huswomenwhoscr eenposi t i v ef orpr ecancer ousl esi ons cant heor et i cal l ybeof f er edcr y ot her apyt r eat mentdur i ngt hesamev i si t , ora“ scr een andt r eat ”appr oach, i ft heheal t hf aci l i t yhast hecapaci t y .Thi sst r at egyhasbeenshown cost ef f ect i v e, af f or dabl e, andani deal f i r st l i net r eat mentf orCI Nofanygr adewhent he cer v i cal l esi onsi zeandl ocat i onal l owst hecr y opr obet i pt omakeadequat econt act [ 57–60] .Thi s‘ scr eenandt r eat ’ st r at egycanav oi dt hebur denofcost l yf ol l owupv i si t s, si gni f i cantdel ay si nt r eat ment , andl osst of ol l owup[ 61, 62] . Cr y ot her apycanbeper f or medatt hepr i mar ycar el ev el bymi dl ev el pr ov i der s, suchas nur sesormi dwi v es, whocanbet r ai nedt oper f or m cr y ot her apywi t hami ni mum of suppl i esandequi pment[ 58, 63] .I ndev el opedcount r i es, cr y ot her apyi sappr oxi mat el y 90%ef f ect i v ef oral l gr adesofCI Naf t er1y ear[ 64] .Themostcommonl yempl oy ed t r eat mentopt i onsf orpr ecancer ousl esi onsar er emov al ofdi seasedt i ssueusi ngl oop el ect r osur gi cal exci si onpr ocedur e( LEEP)whi chr equi r esl ocal anest het i c[ 65, 66]orby f r eezi ngt heaf f ect edt i ssuewi t hcr y ot her apy[ 57] .Theset r eat ment sar et y pi cal l y per f or medbyt r ai nedpr ov i der si nout pat i entcl i ni csatpr ov i nci al orr ef er r al l ev el hospi t al s.Col dkni f econi zat i on[ 65]canbeusedt or emov el esi onst hatcannotbe ef f ect i v el yt r eat edwi t hLEEPorcr y ot her apy . Theopt i mal f r equencyofscr eeni ngi sev er y3–5y ear sdependi ngonscr eeni ngmet hod [ 67] , orwi t hi n3y ear sf orwomenl i v i ngwi t hHI V[ 68] .I fawomancanbescr eenedonl y oncei nherl i f et i me, t hemostst r at egi cagei sbet ween30and39y ear s[ 69] .Recent est i mat esonnat i onal r at esofcer v i cal cancerscr eeni ngar enotav ai l abl ef ormany Af r i cancount r i es, butanumberofst udi esr epor tsel f r epor t edscr eeni ngr at est obel ow ( 8. 3–64%)[ 70–74] , butsl i ght l yhi gheramongwomenaccessi ngHI Vcar e( 9. 4–80%) [ 72, 75, 76] .A2008popul at i onbasedsur v eyi n57count r i esest i mat ed19%ofwomen i ndev el opi ngcount r i eswer escr eenedf orcer v i cal canceri nt hepr ecedi ngt hr eey ear s [ 77] .I naddi t i ont oi nf r ast r uct ur eandr esour cer el at edbar r i er s, awar enessofcer v i cal canceramongr epr oduct i v eagedwomenr emai nsl ow[ 70, 78–81]andani nadequat e pr opor t i onofheal t hcar epr ov i der shasbeent r ai nedt opr ov i dehi ghqual i t yscr eeni ng [ 82, 83] .Ef f or t shav ebeenmadei nmanycount r i est oi nt egr at ecer v i cal cancer scr eeni ngi nHI Vcar e, butr out i nepr ov i si oni sst i l l l i mi t ed[ 77, 84] .HPVDNAt est i ng r epr esent sanemer gi ngst r at egyf orear l ydet ect i onofcer v i cal cancer , par t i cul ar l yi f t echnol ogyi nnov at i onscanper mi tpoi nt of car et est i ngwhi chwi l l el i mi nat e r equi r ement sf orl abor at or yi nf r ast r uct ur eandt echni cal suppor t[ 68, 85] .HPVDNA t est i ngmustbemadeaf f or dabl ef orwi despr eadusei nAf r i cancount r i es. Ter t i ar ypr ev ent i on Womenwi t habnor mal cer v i cal t i ssuear edi agnosedwi t hei t herpr ecancer ousl esi onsor i nv asi v ecer v i cal cancer , bot hofwhi chr equi r et r eat ment .Sev er ecer v i cal dy spl asi at hat r emai nsundi agnosedorunt r eat edcandev el opi nt oi nv asi v ecancer[ 86] .Unf or t unat el y , asi gni f i cantpr opor t i onofwomen( 56–80. 6%)[ ( Keny a)[ 87] ; ( Tanzani a)[ 88] ; ( Ni ger i a) [ 89] )ar ei dent i f i edoncet hei rcer v i cal canceri satanadv ancedst age[ 90] . St agi ngt hesev er i t yofi nv asi v ecer v i cal cancerr equi r esassessmentoft hev agi na, par amet r i um, ur i nar ybl adderandr ect um byacombi nat i onofcl i ni cal andendoscopi c pr ocedur est odet er mi net hest ageofpr ogr essi on( I–I VB)[ 91] .I nadequat el abor at or y f aci l i t i esandper sonnel shor t agesmayr esul ti nt r eat mentdeci si onsbei ngmade wi t houtpr operdi agnosesoradequat ei nf or mat i on.Tr eat ment sf ori nv asi v ecer v i cal cancercani ncl udear angeandcombi nat i onofst r at egi esi ncl udi nghy st er ect omy ( r equi r essur gi cal f aci l i t i es) , r adi ot her apy( ext er nal andi nt r acav i t ar yr adi ot her apy i nf r ast r uct ur e) , andchemot her apy[ 68, 92, 93] .Theav ai l abi l i t yoft heseopt i onsar e t y pi cal l yl i mi t edt ocapi t al ci t i esi nsev er al Af r i cancount r i esor , i nsomecases, not av ai l abl eatal l [ 94] .Consequent l y , pal l i at i v ecar ewi t hsy mpt om cont r ol andsuppor t maybet hemostl i kel yopt i onf orsev er el yl at est agecer v i cal cancerorf orwomenwi t h l essadv anceddi sease, butwhocannotaf f or doraccesst r eat ment .St udi esi ndi cat e t hatonl ybet ween24–67%oft hosedi agnosedwi t hcer v i cal canceri nTanzani a, Zi mbabwe, UgandaorNi ger i ar ecei v edsomef or m oft r eat ment( ei t herr adi ot her apyor hy st er ect omy )[ 88, 89, 95, 96] , wi t hwomeni nadv ancedst ages( I I IandI V)ofdi sease pr ogr essi on[ 96]andwomencoi nf ect edwi t hHI V[ 88]l essl i kel yt obet r eat ed. Cer v i cal cancermor t al i t yr at esi nl owr esour cecount r i esar enear l yt hr eet i mesashi gh asr at esexper i encedi nhi ghr esour ceset t i ngs[ 1, 97, 98] .Sur v i v al dat af orcer v i cal canceri nAf r i cancount r i esar el i mi t ed.Est i mat ed5y earsur v i v al f orwomendi agnosed wi t hcer v i cal canceri n7Af r i cancount r i esbet ween2005–2009was56. 3%( r ange 19. 5–96%)[ 99] .Amongwomenr ecei v i ngt r eat ment( r adi ot her apyand/ orsur ger y ) , sur v i v al pr obabi l i t i esatoney earpostdi agnosi sr angedf r om 73. 9–90. 4%and decr easedpr ogr essi v el yt o32. 5%byf oury ear s[ 87, 95, 96, 100] .Wi t houtt r eat ment , obser v edsur v i v al i s58. 6at1y earanddecr easest o31. 1%by4y ear s[ 95, 96] .St udi es f r om UgandaandZi mbabwesuggestt hatal t hought r eat mentwi t hr adi ot her apy i mpr ov espat i entsur v i v al t wot ot hr eey ear saf t erdi agnosi s, t hi sadv ant agedi sappear s i nl at ery ear s[ 95, 96] . Qual i t yofl i f e Cer v i cal canceri sassoci at edwi t hpsy chol ogi cal andphy si cal mor bi di t i est hat negat i v el yi mpactqual i t yofl i f e[ 101, 102] .Ageadj ust ed, dai l y adj ust edl i f ey ear s( DALY) l ostf r om canceri nAf r i cancount r i esi sconsi st ent l yhi ghert hant hoseofhi ghr esour ce count r i es[ 103] .Theest i mat edDALYl ostf r om cer v i cal canceri nsubSahar anAf r i cai s 641y ear sper100, 000women[ 103] .Qual i t yofl i f ei smostcompr omi sedamong pat i ent swi t hi noper abl ecer v i cal cancert r eat edbyr adi ot her apy , wi t hamaj or i t y r epor t i ngdet er i or at i oni nphy si cal , emot i onal , soci al , andeconomi csuppor t[ 104] , and t hehi ghestr i skf orl ongt er m dy sf unct i onofbl adder , bowel sandpsy chosoci al consequences[ 105] .Ot hert r eat mentr el at edsi deef f ect ssuchasext endedv agi nal bl eedi ngandchr oni cr adi at i onent er i t i scanaf f ectphy si cal andsoci al aspect soft hei r qual i t yofl i f e[ 106, 107] . Si gni f i cantchangesi nt hesexual domai nr esul t i ngi nmar i t al di scor dance[ 104]and wani ngpar t nersuppor tov ert hecour seoft r eat mentandsur v i v al [ 108]hav ebeen r epor t edi nKeny aandSout hAf r i ca.Whi l esuchdat aar el i mi t edf orl owr esour ce set t i ngs, l i t er at ur er ev i ewsf r om hi ghr esour cecount r i esdocumentpost t r eat ment changesi nbodyi mage, v agi nal f unct i on, sexual sat i sf act i on, andsexual r el at i onshi p wi t hpar t ner ; i ndi cat i ngacl earneedf orbet t eri nt egr at i onofsexual i t yr ehabi l i t at i oni nt o r out i necl i ni cal car e[ 109–111] .Fur t her mor e, t her ear ef ewt r eat mentopt i onsav ai l abl e t hatpr eser v ef er t i l i t y[ 92, 112–114] , whi chcanhav esi gni f i canti mpl i cat i onsf ory oung womengi v ent heper sonal andcul t ur al i mpor t anceofchi l dbear i ng[ 115] .Open communi cat i onaboutf er t i l i t yandsexual i t y r el at edi ssueswi t hcer v i cal cancerpat i ent s ofr epr oduct i v eageshoul doccurpr i ort ot r eat ment st ohel pshapeexpect at i onsand qual i t yofl i f edur i ngr ecov er y[ 113] . I nmostAf r i cancount r i es, t her ei sal onghi st or i cal pr ecedentofpr ov i di ngpal l i at i v ecar e athomebyf ami l yorcommuni t ymember s[ 116] .Al t houghst r engt henedbyt heAI DS r esponse, pal l i at i v ecar eef f or t sst i l l f ai l t opr ov i deef f ect i v epai nr el i ef[ 91] , wi t ht he av ai l abi l i t yandaccessi bi l i t yofopi oi dsf orpai nr el i efsev er el yl i mi t edi nAf r i can count r i es[ 117] .I nast udyamongNi ger i ancancerpat i ent s( i ncl udi ngcer v i cal cancer pat i ent s) , t hepr esenceofpai nwassi gni f i cant l yassoci at edwi t hdepr essi v eandanxi et y sy mpt oms, sui ci dal i deat i on, poorsl eep, i mpai r edconcent r at i on, l ackofoppor t uni t yf or l ei sur e, di ssat i sf act i onwi t hheal t h, poorov er al l qual i t yofl i f e, poorabi l i t yt ogetar ound andt heneedf orexcessi v emedi cal t r eat mentt of unct i oni ndai l yl i f e[ 118] .I n2011, onl y f ourAf r i cancount r i eshadi nt egr at edpal l i at i v ecar ei nt ot hei rcancerst r at egi cpl ansand t woot her shadst andal onenat i onal pal l i at i v ecar epol i ci es[ 119] .Pai nmanagementf or cancerpat i ent sshoul dnotbenegl ect edascount r i esdev el opandadaptt hei rr esponse t ocer v i cal andot hercancer s. Feasi bi l i t yconsi der at i ons Gov er nment sgr appl ewi t hchal l engesposedbyl i mi t edf undsandcompet i ngheal t hcar e pr i or i t i esi ncl udi ngaheav ybur denf r om bot hi nf ect i ousandchr oni cdi seases.Whi l et he Af r i canCancerRegi st r yNet wor k( AFCRN) , l aunchedi n2012, suppor t s25cancer r egi st r i esi n19membercount r i esi nsubSahar anAf r i ca[ 120, 121] , manyst i l l l ack est abl i shedcancerpr ev ent i onandcont r ol heal t hpol i ci es[ 94, 122] .Thegeogr aphi c di st r i but i onofcancert r eat mentcent er swi t hcy t ol ogyl abor at or i es, r adi ot her apyand chemot her apyi nf r ast r uct ur esev er el yl i mi t saccessi bi l i t yf orr esi dent si nmor er ur al ar eas[ 49, 54, 85] .A2009si t uat i onal anal y si sofeast , cent r al , andsout her nAf r i can count r i esest i mat edt hatonl y4%ofi nst i t ut i onshadequi pmentt oper f or m out pat i ent t r eat mentmodal i t i essuchascr y osur ger y[ 123] .Thi sdemandf orscar ceser v i ces t y pi cal l yr esul t si nl ongwai t i ngper i ods( medi an3. 8mont hsi nEt hi opi a[ 100] )f or t r eat ment .Thecost sf orr et ur nhospi t al v i si t s, pat hol ogyr epor t s, andsubsequent t r eat mentar ebey ondt her esour cesoft hemaj or i t yofwomeni nt heseset t i ngs[ 124] . Accor di ngt oar ecentst udy , i nf r ast r uct ur ei nv est mentofappr oxi mat el y$59mi l l i on woul dber equi r edt oequi pev er ycer v i cal cancerscr eeni ngf aci l i t ywi t hcr y ot her apy equi pmenti n23hi ghi nci dencesubSahar anAf r i cancount r i es[ 125]t obeabl et o empl oyt her ecommendedscr eenandt r eatappr oach[ 51] .Est i mat i ngt heabi l i t yt o scr eennear l y20mi l l i onwomenov era10y earper i odi nt heset ar get edcount r i es, t he cost sf orscr eeni ng( VI A)woul dbel esst han$10USDperwoman, andt hecost sf or t r eat mentbycr y ot her apyorLEEPwoul dr angebet ween$38t o$71USDperwoman [ 125] .Sy st emst ot r ackandr ef erwomenwhot estposi t i v eandsuppor tt r eat ment r et ent i onar eal sol acki ng; di mi ni shi ngt her et ur noni nv est mentofcur r entscr eeni ng ef f or t s. Met hods Wesear chedsev er al onl i nedat abasesi ncl udi ngPubMed/ MEDLI NE( NCBI ) , Embase ( El sev i er ) , Af r i canI ndexMedi cus( AI M) , andGoogl eSchol arf orpubl i shedst udi es.Our sear chal soi ncl udedhi ghl yr el ev antgl obal andgov er nmentr epor t snotpubl i shedi n peer r ev i ewedj our nal s.I ncl usi oncr i t er i ai ncl udedpubl i cat i onbet ween2004and2014, cer v i cal cancer r el at edcont entper t i nentt ooneoft hef ourpubl i cheal t hcat egor i es ( pr i mar y , secondar y , t er t i ar ypr ev ent i onorqual i t yofl i f e) , andconduct edi nor speci f i cal l yr el ev antt ocount r i esorr egi onswi t hi nt heAf r i cancont i nent .Ref er ence sect i onsofar t i cl eswer er ev i ewedt oi dent i f yaddi t i onal el i gi bl ear t i cl es.Sear chesf or eachoft hef ourf ocusar easwer econduct edsepar at el y , i ncl udi ngcombi nat i onsoft he f ol l owi ngsear chwor ds: 1)pr i mar ypr ev ent i on[ HPVv acci nat i on, Af r i ca, cer v i cal cancer pr ev ent i on, HPVpr ev ent i on, costef f ect i v eness, medi cal mal eci r cumci si on, cov er age] , 2) secondar ypr ev ent i on[ cer v i cal cancerscr eeni ng, Af r i ca, cer v i cal cancersecondar y pr ev ent i on, HPVscr eeni ng, scr eenandt r eat , mal eHPVscr eeni ng] , 3)t er t i ar ypr ev ent i on [ cer v i cal cancert r eat ment , Af r i ca, SSA, pr ecancer ousl esi ons, i nv asi v ecer v i cal cancer , managementofi nv asi v ecer v i cal canceri nAf r i ca, cer v i cal cancersur v i v al , HI V, access t ot r eat ment , chal l enges, ] , and4)qual i t yofl i f e[ cer v i cal cancer , qual i t yofl i f e, Af r i ca, sexual f unct i on, pal l i at i v ecar e, r el at i onshi pchal l enges, par t nersuppor t , t r eat ment r ecov er y ] .Asepar at esear chwasconduct edt oi dent i f yr esear chf ocusedoni ssuesof f easi bi l i t yandi nf r ast r uct ur e[ heal t hcar ei nf r ast r uct ur ef orcer v i cal cancer , Af r i ca, accessi bi l i t y , af f or dabi l i t y , t r ai ni ngheal t hcar epr ov i der s, pr ov i derknowl edge, f easi bi l i t y , HPVv acci ne, scr eeni ng, scr eenandt r eat , t r eat ment ] .Rat hert hancr eat i ngasect i on dedi cat edt of easi bi l i t yi ssues, t hesewer ei nt egr at edi nt ot hepr ecedi ngcat egor i es, dependi ngont hef ocusoft hear t i cl e. Thest udydesi gn, geogr aphi cr egi on/ count r y , f ocusofr esear ch, andkeyf i ndi ngswer e document edf oreachel i gi bl ear t i cl e.Ar t i cl esandr epor t swer emai nt ai nedi nf our separ at espr eadsheet s( r ef l ect i ngt hef ourpr i or i t ycat egor i es)andl at ercombi nedt o r ev i ewandel i mi nat eanydupl i cat i onandt odet er mi net hebestgr oupi ngf orar t i cl est hat mayhav ecov er edmor et hanonepr i mar ycat egor y .Thear t i cl esandr epor t sundereach pr i mar ycat egor ywer et henanal y zedandr ef i nedt ohi ghl i ghtsubt hemes, t y peof l i t er at ur e( or i gi nal r esear ch, r ev i ewar t i cl e, l essonsl ear nedorpol i cypaper )andt he count r yorgeogr aphi cr egi onofr esear ch, Tabl es1, 2, 3and4. Onet housandf i v ehundr edsi xr ecor dswer er ev i ewedt hr oughdat abaseandI nt er net sear ches( Fi g.1) .Amongt hose389mett hecr i t er i af ori ncl usi on.Af t erel i mi nat i ngni ne dupl i cat esamongt hecat egor i es, at ot al of380r ecor dswer ei ncl udedi nt hi sr ev i ew. Publ i cat i onshav ebeenor gani zedaccor di ngt of ourt ar get edcat egor i esofpubl i cheal t h i nt er estt oi l l ust r at et hewei ghtandcov er ageofr esear chi neachar ea.Publ i cat i onst hat spanmor et hanonear eaoff ocus( e. g.secondar yandt er t i ar ypr ev ent i on)wer e cat egor i zedbyt hepr i mar yemphasi soft hepaper . Thi ssy st emat i cr ev i ewdi dnotr equi r eappr ov al f r om anet hi cal r ev i ewboar dor i nf or medconsentwi t hpar t i ci pant sasr esear chef f or t swer el i mi t edt ot her ev i ewand anal y si sofpr ev i ousl ypubl i shedorpr esent edcer v i cal cancerr esear chi nAf r i can count r i es. Resul t s At ot al of380r esear char t i cl es/ r epor t swer ei ncl uded.Themaj or i t y( 54. 6%)ofcer v i cal cancer r esear chi nAf r i caf ocusedonsecondar ypr ev ent i on( i . e. , scr eeni ng) .Thenumberofpubl i cat i on f ocusi ngonpr i mar ypr ev ent i on( 23. 4%) , par t i cul ar l yHPVv acci nat i on, i ncr easedsi gni f i cant l yi n t hepastdecade.Resear chr egar di ngt het r eat mentofpr ecancer ousl esi onsandi nv asi v e cer v i cal canceri semer gi ng( 17. 6%) , buti nf r ast r uct ur eandf easi bi l i t ychal l engesi nmany count r i eshav ei mpededef f or t st opr ov i deandev al uat et r eat ment .St udi esassessi ngaspect s ofqual i t yofl i f eamongwomenl i v i ngwi t hcer v i cal cancerar esev er el yl i mi t ed( 4. 1%) .Acr ossal l cat egor i es, 11. 3%ofpubl i cat i onsf ocusedoncer v i cal canceramongHI Vi nf ect edwomen, whi l e 17. 1%f ocusedonaspect soff easi bi l i t yf orcer v i cal cancercont r ol ef f or t s. Concl usi ons Thenumberofpubl i cat i onsf ocusedoncer v i cal cancercont r ol andt r eat menti nAf r i can count r i eshasi ncr easedov ert hepastdecade.Ter t i ar ypr ev ent i on( i . e.t r eat mentof di seasewi t hef f ect i v emedi ci ne)andqual i t yofl i f eofcer v i cal cancersur v i v or sar et wo under r esear chedar easi nAf r i cancount r i es.Si mi l ar l y , t her ear esev er al count r i esi n Af r i cawi t hl i t t l et onor esear chev erconduct edoncer v i cal cancer .Gi v ent hesi gni f i cant bur denandhi ghmor bi di t yandmor t al i t yexper i encedbywomenwi t hcer v i cal canceri n t hi sset t i ng, t ar get edr esear chi scr i t i cal l yneeded, par t i cul ar l yi mpl ement at i onsci ence r esear cht oi nf or mf easi bl eandsust ai nabl est r at egi est omaxi mi zet henumberof womenr eachedwi t hser v i ces.Lessonsl ear nedr epor t sandpubl i cat i onsdescr i bi ngand ev al uat i ngser v i cei mpl ement at i onar ehi ghl yr el ev ant , asar ecost ef f ect i v enessst udi es t ogui deser v i cest r at egi esf orscal eup.Ther ei saneedt osuppor tnat i onal capaci t yf or dev el opi ngpopul at i onbasedcancerr egi st r i est ot r ackcasesandpr oj ectneeds[ 255] , st r at egi est oi ncr easet heav ai l abi l i t yofcer v i cal cancerscr eeni ngandt r eat ment , and i nnov at i v est r at egi est or et ai ncer v i cal cancerpat i enti nt r eat ment . Abbr ev i at i ons AFCRN, Af r i canCancerRegi st r yNet wor k; AI DS, aut oi mmunedef i ci encysy ndr ome; AI M, Af r i cani ndexmedi cus; AORTI C, Af r i canOr gani zat i onf orResear chandTr ai ni ngCent er ; CI N, cer v i cal i nt r aepi t hel i al neopl asi a; DALY, dai l yadj ust edl i f ey ear s; DNA, deoxy r i bonucl ei caci d; GAVI , gl obal al l i ancef orv acci nesandi mmuni zat i ons; HI V, humani mmunodef i ci encyv i r us; HPV, humanpapi l l omav i r us; LEEP, l oopel ect r i cal exci si onpr ocedur e; LEETZ, l ar gel oopexci si onoft het r ansf or mat i onzone; LMI C, l ow andmi ddl ei ncomecount r i es; NCBI , Nat i onal Cent erf orBi ot echnol ogyI nf or mat i on; SSA, SubSahar anAf r i ca; VI A, v i sual i nspect i onwi t hacet i caci d; VI LI , v i sual i nspect i onwi t h l ugol ’ si odi ne; WHO, Wor l dHeal t hOr gani zat i on Acknowl edgement s Notappl i cabl e. Fundi ng Thi ssy st emat i cr ev i ewwasnotdi r ect l yf unded; howev er , ef f or tf oraut hor sSFKandCW waspar t i al l yf undedbyR01HD076673. Av ai l abi l i t yofdat aandmat er i al s Dat ausedf ort hi sst udyi sl i mi t edt opr ev i ousl ypubl i shedorpr esent edcer v i cal cancer r esear chand, t hus, i spubl i cl yav ai l abl ebyj our nal andconf er encer ev i ew.
