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“One stop” approach may be effective in preventing cervical cancer in Thailand

BMJ 2003; 326 doi: http://dx.doi.org/10.1136/bmj.326.7389.568/c (Published 15 March 2003) Cite this as: BMJ 2003;326:568
  1. Susan Mayor
  1. London

    Treating women for potentially precancerous cervical lesions the same day they are detected could offer a practical approach to preventing cervical cancer in some developing countries, a study in Thailand has shown.

    A group of 12 specially trained nurses offered women in four districts in Roi Et province—a mainly rural area—screening for cervical cancer using visual inspection of the cervix with acetic acid wash. Those who tested positive (showing raised and thickened white plaques) were offered cryotherapy during the same visit, after counselling about the benefits, potential risks, and probable side effects.

    Results showed that 13% of the 5999 women who were screened during the seven month study tested positive. Nearly all (99%) of the women who were considered eligible accepted immediate treatment with cryotherapy. Eligibility criteria for treatment included the abnormalities not being suspicious for cancer, not extending on to the vaginal wall, occupying less than 75% of the cervix, and extending less than 2 mm beyond the cryotherapy probe. Oral non-narcotic analgesics were offered to women with bothersome cramping during treatment.

    No major complications with treatment were recorded, with only 4% of women treated returning with a perceived problem and 2% needing clinical management other than reassurance about side effects. Follow up data showed no clinically apparent pelvic inflammatory disease or stenosis as a result of cryotherapy (Lancet 2003;361:814-20).

    The researchers, from the Royal Thai College of Obstetricians and Gynaecologists and the JHPIEGO Corporation, a non-profit making organisation affiliated to Johns Hopkins University, Baltimore, Maryland, said: “A single visit approach with visual inspection of the cervix with acetic acid wash and cryotherapy seems to be safe, acceptable and feasible in rural Thailand. It is a potentially efficient method of cervical cancer prevention in such settings.”

    To run the study, the 12 nurses carrying out the screening and treatment attended a two week, competency based course. They then offered the prevention programme to women aged 30-45 years at a hospital or through regular visits to rural primary health centres. Few problems were reported with the cryotherapy units, which were transported between sites for mobile services.

    Dr Lynne Gaffikin, an epidemiologist at Johns Hopkins University and one of the study authors, said: “Simple, low technology testing and treatment methods such as used in this study are urgently needed.”

    She added: “The advantage of a single visit approach is that women who are at highest risk of cancer can be identified and offered treatment—or referral, as indicated—at the same visit. This avoids system drop outs, a major problem in many low resource settings, even in developed countries.”

    Although cervical cancer is preventable by screening linked with treatment, many women in developing countries die because few have access to prevention programmes because of the complex infrastructure needed for traditional, cytology based programmes. Only 5% of women in Thailand are likely to have been screened for cervical cancer at any point in the previous five years, compared with up to 70% in industrialised countries. As a result, cervical cancer is the leading cause of female cancer deaths in parts of Africa, Asia, and Latin America.

    The trial was designed to test the feasibility and safety of a single visit approach to preventing cervical cancer, not the efficacy. However, at one year follow up (attended by 94% of study participants), a total of 94% of women tested negative to visual inspection of the cervix with acetic acid wash. One woman had an indeterminate test and one had suspected cancer (later confirmed as adenocarcinoma in a polyp, stage IA). No squamous cell cancers were identified.

    The project in Thailand has now expanded to the remaining 12 districts in Roi Et province. Nurses from each district have been trained, and the researchers are evaluating what is needed to achieve higher screening coverage. Overall, it has been estimated that if women are screened only once in their lifetime with a single visit approach there could be a 30% reduction in the incidence of cervical cancer.

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