The changing dynamics of cervical cancer screening and treatment in Papua New Guinea

Introduction

The Human Papilloma Virus Point of Care (HPV POC) test and treatment strategy is an effective cervical cancer screening and treatment program that is feasible and cost-effective. It has been recommended by the World Health Organization (WHO), and it should be rolled out across Papua New Guinea (PNG) based on available local and international evidence.^1–4 The HPV POC intervention is a ‘One Stop Shop’ where a woman will attend a clinic, self-collect her vaginal specimen, have it tested on the same day, receive her result on the same day and receive treatment on the same day if found to be positive. This will cut back on all the logistical, technical, transportation and patient follow-up requirements that we frequently encounter when utilising other forms of interventions such as the Pap smear test, where results are not available on the same day. An additional benefit of the HPV POC intervention is that the self-collection method of sample collection is associated with less stigma, and is more appropriate in Melanesian society where there are shame barriers associated with examination of a female’s private parts. This remains a significant cultural taboo which results in many women presenting late and dying prematurely from late-stage cervical cancer.⁵ The HPV POC screening and treatment program for cervical cancer is tailored to our needs. It has been trialled and has been found to be highly sensitive, cost effective and acceptable in our setting.^1–3 It is highly recommended by WHO.⁴

Overview of cervical cancer burden

Cervical cancer is the fourth most common cancer of women worldwide with an estimated 570,000 cases and 311,000 cancer-related deaths annually.⁶ Papua New Guinea has the highest cervical cancer incidence and mortality rates in the Asia-Pacific region.⁶ It is the most common cancer in women and leads to approximately 1500 preventable deaths every year in PNG.⁶ It is largely a preventable disease, and the disproportionate burden seen in low- to middle-income countries (LMIC) like PNG, reflects the unequal implementation of highly effective screening and preventive treatments, which are largely unavailable.⁶

Cervical cancer prevention and control has not been considered a priority in PNG. Over the years, there has been a lack of political will and inadequate public sector budget support. In part, this derives from limited access to up-to-date data on the burden of disease, as well as from competing health and development priorities and limited access to the available tools and technology for prevention and control of cervical cancer.

The personal and family impacts of untreated and advanced cervical cancer have been profound. Timely surgical intervention and radiotherapy have not been available. Appropriate medication for pain relief has been lacking and proper palliative services have been absent in PNG. These all lead to unacceptable suffering, incapacitation and isolation within the community, and finally to a terrible demise.

Cervical cancer screening programs in PNG

From 2002 to 2012, Pap smear screening was piloted as a possible national screening programme across 35 clinics in 15 provinces in PNG. It was funded by Meripath, a non-governmental organisation (NGO) from Australia. Unfortunately, only 3.7% of the target population was reached and the majority of clients were lost to follow-up.⁷ From 2011 to 2014, visual inspection with acetic acid (VIA) and cryotherapy was trialled in three provinces. However, overtreatment was associated with this method of screening and there were numerous technical challenges.⁷

More recently, HPV POC testing from self-collected vaginal specimens has yielded results that promise to have wide coverage as a national screening programme for cervical cancer. This strategy is being widely supported and recommended for LMIC by WHO to accelerate access to cervical screening and treatment services.⁴ WHO has also recommended thermal ablation over cryotherapy for the treatment of cervical pre-cancer lesions due to greater cure rates, a more favourable adverse events profile, and reduced logistical requirements.⁴

WHO global elimination strategy

In May 2018, the Director-General of the WHO announced a global call to action towards achieving the elimination of cervical cancer as a public health problem. In November 2020, WHO launched the global elimination strategy⁸ that included the ‘90-70-90’ coverage targets to be met by 2030. The targets are:

Achieving the triple-intervention targets in the next decade would put countries on the path to achieving elimination in the next century, reducing cervical cancer mortality by 99% and saving more than 62 million women’s lives over the next century.⁹

Even with the current unavailability of HPV Vaccines in most LMICs, it should be possible to accelerate and expedite elimination of cervical cancer with HPV POC testing and treatment alone.¹⁰

Scaling up HPV POC screen-and-treat for cervical cancer elimination in PNG

Following the findings from the PNG field trials over the last 8 years^1–3 and with the endorsement by WHO of HPV screen-and-treat for primary screening in 2021, the PNG National Technical Working Group (TWG) on Cervical Cancer recommended the introduction and scale-up of HPV screen-and-treat in December 2021. Currently, there is active advocacy by the PNG Obstetricians and Gynaecologists Society, Public Health Society of PNG, and the Medical Society of PNG for funding support from the national government, local and international collaborations, and donor support to scale up and strengthen this program for implementation to all provincial hospitals within the country. This will ensure that no woman in PNG is left behind as the global elimination agenda advances.

Conclusion

HPV POC test and treatment approach are by far the most acceptable, highly effective, scalable and cost-effective strategy available to optimise the early detection and treatment of cervical cancer. It is a ‘One Stop Shop’ that involves self-collection of vaginal specimens, same day testing, same day results and treatment instituted on the same day. It will need political will and support from all stakeholders and donor agencies to implement this program across the country, to achieve the WHO elimination targets and to reduce the burden of cervical cancer in PNG.