Battling cervical cancer in the developing world

The non-profit humanitarian organization Medecins Sans Frontieres, or Doctors Without Borders, is well known for its work fighting on the front lines in some of the world’s most vulnerable regions against some of the most imperative public health threats. In Malawi, the organisation is enacting a robust and systematic programme to tackle the nation’s ongoing cervical cancer crisis, and highlights the importance of their efforts here.

Cervical cancer is the fourth most common type of cancer in women, with an estimated 528,000 new cases and 266,000 deaths occurring each year around the world. The vast majority (>85%) of cervical cancer cases are in developing countries and mortality is 18 times as high as in the developed world. In Malawi, cervical cancer is classified as a public health issue due to the sheer number of people that it affects. Every year, approximately 3,700 Malawian women develop cervical cancer and 62% of them die from the disease. This situation is exacerbated by inadequate screening and poor treatment services throughout the country. With 4.76 million women aged 15 years and older in Malawi, a huge number of individuals are currently at risk of developing cervical cancer.  

MSF is developing a project in Malawi to address this issue. The project aims to develop a comprehensive cervical cancer programme that will target all stages of the disease: HPV infection, development of pre-cancerous lesions and high-grade lesions, progression into invasive cancer and metastatic cancer. The programme will include activities such as HPV vaccination, health promotion, screening and treatment of precancerous lesions using visual inspection with acetic acid (VIA) and cold coagulation, and histopathology support and treatment (surgery, radiotherapy, chemotherapy, and palliative care). The full range of the programme, from prevention to specialised treatment, must be made available at hospitals in addition to being embedded and adapted to a model of continuous care that may be provided at patients’ homes, community centres and health centres. Through this project, MSF will gain valuable experience in treating cervical cancer in a resource-limited context, which will help to design affordable, adaptable quality care models for health authorities at regional, national and international levels.

MSF will be providing a variety of specialist treatment and care. This includes:

Launch of hospital-based cancer care activities

Hospital-based care is being implemented over the course of 2019, with the setting up of out-patient and in-patient wards, an operating theatre and the launch of a series of activities at Queen Elizabeth Central Hospital (QECH) in Blantyre. These activities include diagnosis and staging, Loop Electrosurgical Excision Procedure (LEEP), onco-surgery and palliative care. Diagnostic, staging, LEEP and palliative care activities start in Q2 2019 and will scale-up in Q3 when the day centre opens. Surgery and palliative care hospitalisation will start in 2020.

Implementing safe preparation and handling of hazardous drugs

Chemotherapies are currently not safely prepared at QECH. Inexperienced nurses are assisting in preparing chemotherapies in an open room in the oncology ward without proper protective gear. The same room is also used for patients to receive procedures or wound dressing, and there is very poor hygiene. MSF aims to set up a clean room with biosafety cabinets that will centralise all chemotherapy treatments for QECH.

Supporting consumables for histopathology

For histopathology support, MSF will provide basic reagents and consumables to run the histopathology services, thereby allowing patients to have access to free histopathological services inside QECH. Due to the absence of a histopathologist, samples will initially be sent to an external laboratory until a histopathologist is identified or until the telemedicine system can be put in place.

Exploration of radiotherapy centres in neighbouring countries

Radiation therapy is an effective treatment modality for cervical cancer and is also the core treatment choice for patients who have progressed beyond stage IB2 and IIA2. There will be patients who may potentially be curable through concurrent chemo radiation therapy and brachytherapy. However, there are no radiation therapy centres in Malawi. MSF teams of radiation technicians and specialists will travel to treatment centres in neighbouring countries to explore potential referral centres. Only a handful of patients will be able to be supported for treatment due to the limited resources. MSF will need to work on defining the selection criteria and methods to prioritise patients for treatment.

Social workers and psychologists

The project will hire two social workers, with one dedicated to patients in IPD/OPD care and the other for patients in palliative care. An expatriate psychologist will also help patients cope with ideas of cancer and death. The psychologist will develop strategies and tools on how best to disclose the cancer diagnosis and prognosis, support patients with depression, and help them to make end-of-life choices. Patient education tools on post-operative management (lymphedema), sexuality, appearance and survivorship will eventually need to be developed.

EMR for an adaptive and rapid-learning health system

As the field of oncology is relatively new for MSF, the project will look for best practices from international clinical guidelines (primarily NCCN and ESGO guidelines) and will conduct rigorous monitoring and evaluation using Electronic Medical Records (EMR). This will allow MSF to operate a rapid learning system to improve and maintain the quality of care. The project will aim to collect accurate and comprehensive data on the baseline information of patients at the time of diagnosis, their treatment course and patient outcomes. Data will be analysed regularly and used to understand why some patients have better outcomes than others. 

Standardising diagnosis and treatment according to international clinical recommendations

MSF will set up a routine multidisciplinary team meeting where all of the cases will be discussed to decide the best possible treatment course for the patients based on evidence. This will function as a control mechanism to prevent patients from receiving unnecessary surgeries and chemotherapies. The systemised use of telemedicine platforms will be invaluable.

Partnerships with professional medical societies to develop subspecialty programmes and support specialist rotations

MSF is working on signing a memorandum of understanding with the European Society of Gynaecological Oncology (ESGO) to make oncogynaecology specialists available for short-term assignments for fieldwork and to establish a scientific advisory committee to advise the project when international guidelines cannot be applied due to the scarcity of resources. With the College of Medicine and ESGO, MSF will work to build a training programme for registrars and fellows.

Although there are numerous advantages to developing a comprehensive programme in oncology, this approach also poses unique operational challenges:

Multi-sectoral partnership

A comprehensive programme against cervical cancer requires multi-sectoral partnerships on a national level. For example, in primary prevention, the HPV vaccination is a school-based vaccination programme targeting school-aged children. This requires MSF to collaborate not only with traditional partners such as the Ministry of Health but also with the Ministry of Education and private and public schools, partners with whom MSF has very little experience. Collaboration with the EPI programme, Gavi, UNICEF, and the WHO to procure the HPV vaccine will require strong coordinated advocacy both in the country and at international level.

Multi-disciplinary care coordination

The project requires good coordination across many different MSF activities and also with external partners. For example, coordinating care for neoadjuvant chemotherapy would require that preoperative assessment and surgery are provided at the appropriate time after chemotherapy. Adjuvant radiotherapy requires patients to receive radiotherapy in a neighbouring country at the right time and to return to receive follow-up care to deal with potential long-term adverse effects of radiotherapy. Any relevant information must be shared accurately and in a timely manner across the various health services involved in the overall treatment plan. The medical team will also work with social workers, community leaders and local religious leaders to tackle practical issues such as socioeconomic barriers that might prevent access to care. Synchronising and coordinating each activity requires good organisation and investment in data systems.

Intersectoral collaboration

Intersectoral collaboration with the private sector is also crucial as some private practices offer services not available within the public healthcare infrastructure. Advocacy efforts will focus on lowering the prices of the HPV vaccine and oncology drugs. MSF will also form partnerships with the College of Medicine, the Medical Council and other professional medical societies in Malawi and abroad to develop training programmes and build capacity.

Shift in approach and ethical challenges

Lastly, the extensive nature of the programme will challenge the project to continuously evaluate and reflect on how to best allocate resources. Not all patients will benefit from cancer treatment and the programme will need to re-evaluate its strategy as more experienced is gained. Each activity (vaccination, screening, surgical, inpatient care, home-based care) will have its own set of practical challenges. Coordinating the activities to create a comprehensive programme with a consistent and coherent strategy will certainly be a challenge in itself.