Cubie Heather A, Campbell Christine
Global Health Academy and Usher Institute, The University of Edinburgh, Edinburgh, UK.
Womens Health (Lond). 2020 Jan-Dec;16:1745506520914804. doi: 10.1177/1745506520914804.
Cervical cancer is the fourth most common cancer among women globally, with approximately 580,000 new diagnoses in 2018. Approximately, 90% of deaths from this disease occur in low- and middle-income countries, especially in areas of high HIV prevalence, and largely due to limited prevention and screening opportunities and scarce treatment options. In this overview, we describe the opportunities and challenges faced in many low- and middle-income countries in delivery of cervical cancer detection, treatment and complete pathways of care. In particular, drawing on our experience and that of colleagues, we describe cervical screening and pathways of care provision in Malawi, as a case study of a low-resource country with high incidence and mortality rates of cervical cancer. Screening methods such as cytology - although widely used in high-income countries - have limited relevance in many low-resource settings. The World Health Organization recommends screening using human papillomavirus testing wherever possible; however, although human papillomavirus primary testing is more sensitive and detects precancers and cancers earlier than cytology, there are currently costs, infrastructure considerations and specificity issues that limit its use in low- and middle-income countries. The World Health Organization accepts the alternative screening approach of visual inspection with acetic acid as part of 'screen and treat' programmes as a simple and inexpensive test that can be undertaken by trained health workers and hence give wider screening coverage; however, subjectivity and variability in interpretation of findings between providers raise issues of false positives and overtreatment. Cryotherapy using either nitrous oxide or carbon dioxide is an established treatment for precancerous lesions within 'screen and treat' programmes; more recently, thermal ablation has been recognized as suitable to low-resource settings due to lightweight equipment, short treatment times, and hand-held battery-operated and solar-powered models. For larger lesions and cancers, complete clinical pathways (including loop excision, surgery, radiotherapy, chemotherapy and palliative care) are required for optimal care of women. However, provision of each of these components of cancer control is often limited due to limited infrastructure and lack of trained personnel. Hence, global initiatives to reduce cervical mortality need to adopt a holistic approach to health systems strengthening.
宫颈癌是全球女性中第四大常见癌症，2018年约有58万例新发病例。该疾病约90%的死亡发生在低收入和中等收入国家，尤其是在艾滋病毒高流行地区，主要原因是预防和筛查机会有限以及治疗选择稀缺。在本综述中，我们描述了许多低收入和中等收入国家在提供宫颈癌检测、治疗及完整护理途径方面所面临的机遇和挑战。特别是，借鉴我们自己以及同事的经验，我们将马拉维作为一个宫颈癌发病率和死亡率高的资源匮乏国家的案例，描述其宫颈癌筛查及护理提供途径。细胞学等筛查方法——尽管在高收入国家广泛使用——在许多资源匮乏地区相关性有限。世界卫生组织建议尽可能使用人乳头瘤病毒检测进行筛查；然而，尽管人乳头瘤病毒初筛比细胞学更敏感，能更早检测出癌前病变和癌症，但目前成本、基础设施考量以及特异性问题限制了其在低收入和中等收入国家的使用。世界卫生组织认可将醋酸目视检查作为“筛查即治疗”项目的替代筛查方法，这是一种简单且廉价的检测，可由经过培训的卫生工作者进行，从而扩大筛查覆盖范围；然而，提供者之间对检查结果解释的主观性和变异性引发了假阳性和过度治疗的问题。在“筛查即治疗”项目中，使用一氧化二氮或二氧化碳的冷冻疗法是治疗癌前病变的既定方法；最近，热消融因其设备轻便、治疗时间短以及手持式电池供电和太阳能供电型号而被认为适用于资源匮乏地区。对于较大的病变和癌症，需要完整的临床途径（包括环形切除术、手术、放疗、化疗和姑息治疗）以实现对女性的最佳护理。然而，由于基础设施有限和缺乏训练有素的人员，癌症控制的这些组成部分的提供往往受到限制。因此，全球降低宫颈癌死亡率的倡议需要采取全面的方法来加强卫生系统。
