Cervical cancer is the fourth most common cancer in women worldwide. In 2016, SPIDER conducted a needs assessment on cervical cancer screening in Kenya, Rwanda and Zambia and found that women had limited access to screening services. The assessment led to a telehealth project to reduce late diagnosis for cervical cancer through early screening and care. The project is implemented in Uganda by the Uganda Cancer Institute (UCI). Research was carried out on the project by means of interviews, focus group discussions and literature review to gather evidence on the project intervention. Findings are presented below:
The intervention and its results
Cervical cancer care is most effective if it starts at early stages of cancer. Early and timely screening is therefore one of the most effective interventions. However, screening in Uganda is perceived as erratic and opportunistic, and is mainly done by visual inspection with acetic acid (VIA). The screening uptake is very low in rural Uganda and more than 80% of cervical cancer patients go for screening in late stages when the cancer has progressed to stage three or higher.
SPIDER funded UCI to acquire mobile colposcopes for screening cervical cancer, a server, mobile phones, and other related accessories, and to train medical workers on how to use the colposcopes. The screening and training were conducted at UCI in Mulago, Kampala and at UCI’s satellite clinic in Mayuge district, Uganda.
- 560 women were screened using colposcopes (298 in Mayuge and 199 in Kampala).
- 41.6% of the women screened were HIV positive.
- 4 colposcopes were acquired and used in Mayuge satellite clinic which did not have any colposcopes.
- 15 medical workers were trained (10 in Kampala and 5 in Mayuge).
Interviews with medical personnel show that colposcopes were efficient and easy to use. Image outputs were perceived to be very clear and this eliminated errors in the process of analysis. The devices also made it easy to remotely share the pictures with experts for opinion and advice in case of doubt: “When in doubt it is easy to send out the image to cancer institute and a second opinion is got. This is possible with the internet connection that was introduced with the phones.”, noted one of the nurses. Another advantage of mobile colposcopes is the long battery life – once charged they will continue working for several hours even during power outage.
Patients were very satisfied with the use of colposcopes as opposed to use of VIA. They appreciated the former due to the quality of the images. Colposcopes were also helpful in changing mindsets and eliminating doubts about the importance of screening. “More clients at Mayuge are coming in for the screening because a photograph of their cervix is taken. Even those who have not consented for the study are requesting to be screened with a gynocular”, said one of the screening nurses. The pictures also helped the nurses to explain polyps, abnormal growths and positive VIA tests. The nurses mentioned that it is now easier to discuss with patients with the help of visual examples.
UCI staff around a colposcope. Image: UCI
When in doubt it is easy to send out the image to cancer institute and a second opinion is got. This is possible with the internet connection that was introduced with the phones.
Remote screening cut the cost of transportation to screening centres for patients in remote areas in Mayuge. Those with positive test results are usually asked to travel to Kampala for further examinations but the mobile colposcopes brought the services closer to them.
Challenges and recommendations
The research shows lack of awareness among many patients regarding cervical cancer screening for example one of the patients noted that, “I thought my uterus would be taken out, then checked and put back inside. I was relieved that this was not the case.” Research recommended cervical cancer awareness especially in remote areas to be able to have more people screened. Awareness would also increase family support. Only 60% of women screened were supported by their partners.
Medical personnel who conducted screening exercises complained about poor internet connection. The poor internet connections meant that images could not be instantly sent to specialists for analysis and this delayed real time consultations. The solution to this challenge is to provide faster internet both fixed (at screening centres and hospitals) and mobile for those in the field.
I thought my uterus would be taken out, then checked and put back inside. I was relieved that this was not the case.
Nurses found use of colposcopes for screening to be more time consuming than use of VIA. Patients took long in the lithotomy positions as nurses tried to focus and aim for clearer images. Training of nurses to be more efficient and effective at screening would reduce time spent on screening with colposcopes.
The number of cervical cancer cases recorded in the places where screening was carried out suggests that more cases exist among the vulnerable groups. However, the screening team had challenges with access to such groups for example prisoners. Research recommended that screening should be conducted in their places of residence.