Cervical Cancer in Kenya
Presentation to the Cancer workshop –
KNH
13th April 2012
Dr Nancy Kidula
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
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Global maternal mortality estimates
(MMR)
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~270,000 deaths annually; 88% in low-resource areas
2011 CCA REPORT CARD
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.
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Slide 5
Comparison with Maternal Mortality
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2011 CCA REPORT CARD
Cervical Cancer and HIV/AIDs
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LIMITED ACCESS
TOOF
AHEALTH
HEAVY BURDEN
MINISTRY
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2011 CCA REPORT CARD
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2011 CCA REPORT CARD
WHAT DOES THIS GRAPH TELL US ?
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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)
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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)
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Kenya situation
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Women at risk for cervical cancer
(over 15yrs) -10.3 million
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15
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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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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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
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20
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
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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
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Overview of the National Cervical
Cancer Strategic Plan 2011 -2015
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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.
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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)
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Components of cervical cancer
control
•
•
•
•
Primary prevention
Early detection / screening
Diagnosis and treatment
Palliative care
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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
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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
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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
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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
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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
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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.
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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 1st year
– -Then yearly if normal
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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
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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
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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
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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
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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
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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.
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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
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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
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