Cervical cancer is an important public health problem worldwide. It is the second most common cancer among women, ranking first in many developing countries. Of 468,000 new cases and 233,000 deaths of invasive cervical cancer estimated for the year 2000, 80% occurred in less developed countries1. Screening by conventional cytology has had an impact on reducing cervical cancer rates in many developed countries, but this same impact has not been observed in developing countries2.
In Peru, cervical cancer is the leading cause of cancer deaths among women. The estimated incidence rate for cervical cancer is 48.2 per 100,000 and the estimated mortality rate is 24.6 per 100,0003. Screening services have been in place for over 30 years and cervical cancer is a declared national priority.
Since 1998, Peru has put in place the National Plan for the Prevention of Gynecological Cancer. The plan includes strategies for cervical cancer prevention as well as breast cancer prevention. In 2000, the Ministry of Health developed the Manual of Standards and Procedures for the Prevention of Cervical Cancer, which includes conventional cytology as the screening technique, as well as Visual Inspection with Acetic Acid, and cryotherapy as a treatment method for precancerous lesions.
The screening services in Peru, however, have had several inherent challenges4. Women have been screened opportunistically and those women most at risk of developing the disease, women aged 35-50 years, have not been systematically screened. In addition, there have been challenges with the cytology tests such as a high proportion of inadequate samples, limited laboratory infrastructure and personnel to process the samples in a timely manner, and sub-standard quality control procedures. Furthermore, the follow up care after abnormal cytology screening has been poor, as there have been unusually long delays in obtaining cytology test results, women may not have been informed of their screening test results and treatment has not been accessible5.
Recognizing these systemic challenges, the Peru Ministry of Health solicited the support of the Pan American Health Organization and PATH to investigate methods that could improve the effectiveness of the cervical cancer screening program. To this end, a cervical cancer demonstration project was developed, named TATI (acronym for the Spanish term tamizaje y tratamiento inmediato). The Region of San Martín was selected for the TATI demonstration project, as this is an area of low resources with limited access to health services, organized by well established health networks with high levels of community participation. The TATI project was implemented during the period May 2000-December 2004. This report summarizes the methods, results and lessons learned from the TATI demonstration project.
About the TATI Project
An effective cervical cancer prevention program consists of three service delivery components that must be linked together:
community information and education,
screening services, and
diagnostic and/or treatment services6.
With this in mind, the TATI project was developed to put this model in place and to test a 'see, triage and treat' approach in the Region of San Martín, a low-resource setting.
Project Goal: The project aimed to screen 80% of women aged 25-49 years in the San Martín region over a three-year period, using a 'see, triage and treat' approach. The screening method was Visual Inspection with Acetic Acid (VIA), the triage method was Visual Inspection with Acetic Acid Magnified (VIAM), and the treatment of precancerous lesions was by cryotherapy.
Assess the effectiveness of VIA as a screening test and the effectiveness of VIAM as a triage test.
Assess the effectiveness of cryotherapy treatment for pre-cancerous cervical lesions delivered by primary care physicians.
Evaluate the cost and feasibility of incorporating visual inspection screening methods and cryotherapy in the routine delivery of women's health services at the primary-care level.
The TATI demonstration project also included a research sub-component to evaluate the use of two additional cervical cancer screening tests: human papillomavirus (HPV) DNA testing by hybrid capture and liquid-based cytology (LBC).
The TATI project demonstrated that it is safe, feasible and affordable to incorporate VIA testing and cryotherapy treatment into the routine women's health services at the primary-care level.
While the project did not meet its full coverage target, it reached many women who had never previously been served and achieved better test sensitivity and treatment completion than previously achieved by the cytology based program.
It is possible to implement a sustainable cervical cancer screening program in a low-resource setting, and it would be feasible to replicate a program based on screening with VIA to other regions of the country.
We learned that community promotion activities can make a measurable difference in the success of this new public health intervention. In addition to these measurable outcomes, promotion teams reported changes in the equity of relationships with their partners, experiencing a new respect by community members, and initiating active roles in community politics. This is illustrated in the video Changing Women's Lives Through Community Participation, which documents the experiences of three community promotion team members7.
Mechanisms to increase participation of hard-to-reach women should be an integral and sustainable part of a prevention program. Additionally, a 'screen, triage and treat' approach with the VIA test and cryotherapy treatment in primary-care settings can be effective to help solve the problem of cervical cancer in a very practical way with little additional infrastructure. It is still early to conclude whether this approach will, in the long term, have a significant impact on the incidence and mortality rates of cervical cancer. Only additional studies that evaluate the long-term effectiveness of the VIA test and cryotherapy treatment can provide the answers.
1 Parkin DM, Bray F, Ferlay J, Pisani P. Estimating the world cancer burden: Globocan 2000. Int J Cancer 2001; 94: 153-156.
2 Sankaranarayanan R, Budukh AM, and Rajkumar R. Effective screening programmes for cervical cancer in low- and middle-income developing countries. Bull World Health Org 2001; 79: 954-962.
3 Ferlay J., Bray F., Pisani P. and Parkin D.M. GLOBOCAN 2002: Cancer incidence, mortality and prevalence worldwide. IARC CancerBase No. 5, Version 2.0, IARCPress, Lyon, 2004.
4 Pan American Health Organization (PAHO). Protocolo proyecto tamizaje y tratamiento inmediato de lesiones cérvicouterinas. Washington: PAHO; 2000.
5 Gage JC, Ferreccio C, Gonzales M, Arroyo R, Huivin M, Robles S. Follow-up care of women with an abnormal cytology in a low-resource setting. Cancer Detect Prev 2003; 27 (6): 466-471.
6 Alliance for Cervical Cancer Prevention (ACCP). Planning and Implementing Cervical Cancer Prevention and Control Programs: A Manual for Managers. Seattle: ACCP; 2004.
7 Centro Producción Calandria. Changing women's lives through community participation. Seattle: PATH;2006.