Strategic Cooperation

1
Cervical cancer screening in remote Nicaragua  A
program evaluation
Howe, Susan L, MPH Vargas, Dora E, IA Granada,
Dorothy, RN Smith, Janice K, MD University of
Texas Medical Branch, Galveston, TX.
Strategic Cooperation
Conclusions
Results
Proportion of High-Risk Women Reached
Indications Program is Working
Success of Follow-up and Treatment

• 3.7 High rate of high-grade Pap results
• 94 High rate of follow-up
• 68 Approaching expected range for
• Positive Predictive Value (PPV )
  of
  
• high-grade squamous cell Pap
  tests
  
• 1.9 Ratio of pre-invasive cases to invasive
  cases
  
• indicates program is moving
  toward
  
• early detection

Pap tests taken at MLO clinic (2003)
Results of Pap tests at MLO clinic (2003)
Comparison to the Alliance for Cervical Cancer
Prevention (ACCP)3 benchmarks and programs in USA
Follow-up timeframe
Introduction
Methods

• In 2003, three organizations combined efforts to
  extend a new cervical cancer prevention program
  into Nicaraguas remote, medically underserved
  North Atlantic Autonomous Region (RAAN) . All
  three organizations have prior experience with
  cervical cancer prevention. Their combined
  efforts have created
• An effective remote rural service network
• Centralized quality-controlled cytology and
  coordinated treatment in the capital, Managua
  
• National strategic planning

The World Health Organizations (WHO) perspective
is that to be effective, screening programs must
operate within a complete system of related
well-coordinated services1.
These counts are for the Ginecobono (25yrs)
program but includes two 24-year-old patients who
were initially screened under the Matagalpa
services, but entered the Ginecobono program when
they returned for follow-up. One remaining 23
year old underwent a hysterectomy through the
Matagalpa services.
Ages of women with high-grade Pap results
The Pan American Health Organization (PAHO) has
guided working groups to develope standards for
performance indicators and data systems. The
indicators used for the program evaluation
presented here are adapted from these suggested
standards2.
Cooperativa Maria Luisa Ortiz Clinica de
Mujeres (MLO Clinic)
Rate and Stage of Disease Detection

• Has been established since 1990
• Is run by a womens cooperative in Mulukuku ,
  Nicaragua
  
• Conducts outreach through health education,
  mobile clinics, a network of 20-40 health
  promoters, radio announcements and transportation
  couriers
• Draws patients from the remote dispersed villages
  of the RAAN
  
• Is accessed by unpaved road, river or horse

Performance Indicators
What Makes this Program Work?

• Proportion of high-risk women reached
• Reliability of detection
• Successful follow-up and treatment
• Rate and stage of disease detection

The key to the good performance of this program
is the partnership between the MLO Clinic,
Ginecobono, and MINSA. This partnership
integrates elements of both centralized and
decentralized systems that help coordinate the
entire process, from the remote villages in the
RAAN to the labs and clinics in Managua.
Where do these women come from?

• MLO Clinic
• Education and outreach
• Tracking and follow-up
• Transportation assistance to Managua
• High-quality committed staff
• Ginecobono
• Reliable quality-controlled detection
• Removal of barriers to access
• Centralized database and services
• High-quality committed staff
• MINSA
• Strategic planning
• Allocation of resources
• Treatment for invasive cancer

Ginecobono Program

• Was established in 2000 by Instituto
  Centroamericano de la Salud (ICAS), a non-profit
  health services research organization
  
• Is designed to remove barriers to cervical cancer
  prevention in Nicaragua
  
• Distributes donated vouchers covering Pap tests
  and any necessary diagnostics and treatment
  
• Coordinates external quality control of both
  cytology and histo-pathology services
  
• Arranges same day diagnostics and treatment
  procedures in Managua
  
• Assists clinics by maintaining centralized data
  information systems

Ratio of Pre-Invasive Disease to
Invasive Disease 1.9 cases of pre-invasive di
sease diagnosed for every one case of invasive
disease
Reliability of Detection
Stratification by Age
Unsatisfactory sample rate 1.0 (low)
Pap results and follow-up were stratified into
two age groups women under 25 and women 25 and
older. The MLO Clinic supports a separate program
for each group.
Positive Predictive Value (PPV) of Pap Tests
Do Pap test results predict biopsy-confirmed
disease?
-- Ginecobono Program

• The Ginecobono program is for women 25 year and
  older
  
• Women under 25 receive screening and treatment
  through a network of cytology, pathology and
  clinic services located in Matagalpa
  
• The evaluation presented here focuses on the
  Ginecobono program
  

The program evaluation presented here
demonstrates that outreach to high-risk women
that provides quality cytology screening and high
rates of diagnostic follow-up can be conducted in
remote, low-resource settings when coordinated
efforts are made to remove barriers and insure
quality.
Notes and References Dra. Vivian Alvarado of I
CAS generously contributed to both the success of
the program and to the information for the
evaluation presented here. One women was pregn
ant and had not yet received LEEP.
1 Miller AB, Quality assurance in screening
strategies. Virus Res. 2002 Nov89(2)295-9.
Review. 2 PAHO Improving country programs via a c
ervical cancer information system A tool for
program management and evaluation.
http//www.paho.org/English/AD/DPC/NC/ccimprovingc
ountryprog.doc 3 Alliance for Cervical Cancer Pr
evention. Planning and Implementing Cervical
Cancer Prevention and Control Programs A Manual
for Managers. (2004). http//www.iarc.fr/ACCP/ACC
P_screen.pdf 4 Lawson Hershel W. et al, Cervical
Cancer Screening Among Low-Income Women
Results of a National Screening Program,
1991-1995, Obstetrics and Gynecology November
1998 (92) No.5 745-752. Results from the US The
National Breast and Cervical Cancer Early
Detection Program (NBCCEDP). 5 Wright TC, et al,
2001 Consensus Guidelines for the Management of
Women with Cervical Cytological Abnormalities,
JAMA, April 24, 2002, 287(16)2120-9.
Nicaraguan Ministry of Health (MINSA)

• Facilitates the National Alliance to Prevent
  Cervical Cancer
  
• Utilizes strategic planning to reach areas in
  most need
  
• Encourages multi-sectoral cooperation

Future Steps

• Cancer support program
• Diagnostics and treatment at the MLO Clinic
• Long term follow-up for missed cancers and
  successful treatment
  
• Inclusion of cancer staging as an indicator of
  early intervention