Our PSRH team was in Samoa as part of the Cervical Cancer Prevention Programme in the Pacific. This was a multiagency workshop which gave opportunities for many leading clinicians from the Pacific to share the work in their own countries for cervical cancer prevention and screening. The two key recommendations out of the workshop include:

1. The continued need for research; and
2. The need for a regional policy for cervical cancer screening, treatment and vaccination.

Over the two days we heard about programme strengths and challenges that are in place in Fiji, Vanuatu, New Zealand, Malaysia, PNG and other initiatives that are in progress in Samoa and Tonga. We had delegates from UNFPA, WHO, Fiji and Samoa Cancer Society, many respected academics from New Zealand, Australia, USA and the Pacific. We also had ministerial presence from the Government of Samoa and the New Zealand High Commission Team.
Members of the past and present PSRH leadership contributed including Pushpa Nusair, Salausa John Ah Ching, Paula Puawe, Alec Ekeroma, James Fong and Ireen Manuel. PSRH is proud to be in this pathway with our member countries and we will stay committed to developing a regional policy on cervical cancer prevention.
Media Release: Samoa Observer:  http://sobserver.ws/en/30_05_2018/local/33586/Tackling-cervical-cancer-in-the-Pacific-region.htm  and Radio NZ:  https://www.radionz.co.nz/international/programmes/datelinepacific/audio/2018647539/hopes-for-a-cervical-screening-programme-in-samoa

Glen DL Mola,¹ Pamela J Toliman,² and Andrew J Vallely^2,3
1School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea.
²Papua New Guinea Institute of Medical Research, Goroka, Eastern Highlands Province, Papua New Guinea
³Kirby Institute, University of New South Wales (UNSW) Sydney, Australia
Cancer of the uterine cervix is one of the most common cancers to affect women globally. Estimates from the Global Burden of Cancer Collaboration Group reported that in 2013, there were 485,000 cases worldwide and 236,000 deaths resulting from cervical cancer.^1-3 Low- and middle-income countries experience 85% of the global burden of cervical cancer. In Papua New Guinea (PNG) and other countries in the Pacific region, cervical cancer is the most common cancer among women⁴; in PNG alone, an estimated 1000-1500 women die every year from the disease.⁵
Cervical cancer is caused by a sexually transmitted infection with certain oncogenic types of human papillomavirus (HPV).  When most people get an HPV infection they mount an immune response and eradicate the infection from their bodies within a few months.  In some people however, the HPV infection is not cleared in this way and the infection persists.⁶ The precise reasons for this are unclear, but persistence appears more likely following infection with certain HPV types, among women who smoke, and among those living with HIV infection.⁷ Women who experience persistent infection with one or more oncogenic HPV type are at increased risk of developing cervical pre-cancer and cancer, typically many years or decades after they were first infected.⁷
The epidemiology of cervical cancer would suggest that it should be relatively straightforward to prevent infection and to screen for the disease.  Nothing could be further from the truth.  Over the past several decades Pacific countries have followed various strategies to try and reduce the burden of cervical cancer, and yet the disease remains the commonest women’s cancer in most settings.
The development of safe, highly-effective HPV vaccines has revolutionised primary prevention for cervical cancer and brought the elimination of cervical cancer as a public health priority within our reach.⁸  The benefits of protective vaccination have so far however been largely conferred in high-income settings: much more needs to be done to accelerate the introduction and roll-out of HPV vaccine in Papua New Guinea and other high-burden countries in the Pacific.⁹
Secondary prevention (or screening) is a more difficult issue.  The first screening strategy developed was based on microscopic examination of a cells collected from the cervix and either smeared onto a glass slide (the Pap test) or suspended in a liquid preservative (liquid-based cytology). Specimen collection can only be carried out by a health worker and requires a vaginal speculum examination, which many women find uncomfortable and/or embarrassing. Following collection, specimens are sent away to a specialist laboratory for cytological examination and the results communicated back to the health worker at a later date. Women found to have high-grade lesions on cytology (or ‘cervical pre-cancer’) are then asked to return for colposcopy and biopsy, a procedure requiring considerable gynaecological expertise. Biopsy specimens are sent to a specialist laboratory for histological examination, the results of which then enable health staff to decide the best treatment plan for each woman. Screening programs using such multi-step strategies have been the basis of cervical cancer prevention programs in high-income countries for decades and contributed to the steady decline in deaths due to cervical cancer in these settings.^10-12 However, the resource requirements of such programs are high and include the need for highly-trained clinical and laboratory personnel and substantial laboratory capacity. Additionally, the follow-up of women with positive cytology by colposcopy and biopsy requires considerable coordination and resources.
For these reasons, establishing and sustaining cytology-based screening programs in low-income settings has been extremely difficult.^13,14 For example, in Papua New Guinea, a cervical screening initiative was established in 1999 by a non-governmental charity (the MeriPath program), and provided a service from more than 30 health facilities in 16 provinces.¹⁵ The program was able to achieve only modest coverage however, with around 45,000 women screened over ten years (2001-2011), representing less than 4% of the target population aged 20-59 years. Also, as specimens were sent to Australia for testing, more than half of those found to have high-grade disease were lost to follow-up and therefore did not receive treatment, due to the delay between testing and recall. As such it was concluded that this Pap test screening strategy was not an effective one for the prevention of cervical cancer in this setting.⁵
Similar experiences globally prompted the World Health Organization (WHO) to recommend alternative approaches to screening in low- and middle-income countries, and in particular, to advocate ‘screen and treat’ strategies based on same-day testing or clinical examination followed by ‘freezing treatment’ of the cervix (cryotherapy) for women who test positive.¹⁶ A WHO-endorsed ‘screen and treat’ approach that has been used extensively in low-income settings around the world is visual inspection of the cervix with acetic-acid (VIA) or Lugol’s iodine (VILI). This strategy involves the application of acetic acid or Lugol’s iodine to the cervix and observing aceto-white staining (VIA) or areas where iodine has not been taken up (VILI), that are said to indicate underlying tissue abnormality.  Favourable performance characteristics for the detection of histologically-diagnosed cervical ‘pre-cancer’ (cervical intraepithelial neoplasia (CIN) grade 2 or worse) in research settings¹⁷ has led to VIA being advocated as an accurate, low-cost screening strategy, and to its implementation in several low-income settings including Bangladesh, Tanzania and Thailand.^18-20 Many countries have however experienced difficulties scaling up VIA while maintaining adequate quality, and have reported much lower sensitivity for the detection of cervical pre-cancer compared to research settings.^17-22
In PNG, many of us held out high hopes that this approach would be more successful compared to the earlier Pap test program because it should not be necessary to locate the woman again, as the whole process could be concluded on one day. Pilot testing of VIA in two provincial sites has been disappointing for a number of reasons. First of all the finding that VIA positivity is not associated with HPV infection,²³ or with underlying cervical pre-cancer.²⁴ We have also found cervical cryotherapy cumbersome and time-consuming to administer in the clinic; and logistically challenging to sustain due to the need for a continuous supply of carbon dioxide (in our setting, obtained in cylinders transported considerable distances by road from the supplier).
In the last decade, the effectiveness of HPV testing for the detection of cervical pre-cancer and cancer has been demonstrated in large-scale studies,^25,26 leading to the introduction of HPV testing for primary cervical screening in many high-income countries. The WHO recently recommended that HPV testing also be integrated into cervical screening programs in low-income settings, and that countries evaluate how best such testing strategies might be introduced and scaled-up.¹⁶ In PNG, we are currently evaluating a ‘test and treat’ strategy based on point-of-care HPV testing (using the GeneXpert HPV Test: http://www.cepheid.com/en/cepheid-solutions/clinical-ivd-tests/sexual-health/xpert-hpv) plus same-day treatment using a battery-powered heat probe (the WISAP C3 thermo-coagulator: https://www.thermo-coagulation.com/c3-mobile-coagulator/). The thermo-coagulator is optimised for low-resource settings and can be operated off a standard mains electricity power or via a small battery pack (invaluable for outreach screening activities). Other features of the WISAP C3 thermo-coagulator include a built-in LED examination light, a retractable heat protection safety guard, and a simple easy-to-use handling mechanism for accurate and safe treatment.
We have found that HPV test results using self-collected vaginal specimens (i.e. those collected by women themselves) are as good as test results using clinician-collected cervical specimens.²⁷ We have also found that testing self-collected specimens for HPV infection can be used to identify women with underlying cervical pre-cancer:²⁸ around 92% of women with high-grade disease can be detected and treated if screened by HPV testing alone, compared with less than 50% when screening is based on VIA examination alone (Table 1). This means that HPV testing alone is far more sensitive for detecting women with cervical pre-cancer than VIA examination alone. Only 8% of all women with disease were ‘missed’ (i.e. were not offered treatment) when HPV testing alone was used for screening, compared with 53% of women being missed when VIA examination alone was used to screen. Furthermore, using HPV testing alone to screen resulted in less women being over-treated (13%) compared to VIA examination alone (17%).
Using self-collected specimens means that only those who test HPV positive (around 10-15% of all those screened) require a pelvic examination.  This means that experienced clinical staff can focus their time on providing counselling and treatment for those most at risk of disease. The use of a highly-portable, easy-to-use, battery-powered treatment device that requires 40 – 60 seconds treatment time per patient compared to around 10 minutes treatment time per patient with cryotherapy, has greatly reduced logistical and operational constraints in the clinic, and is also proving highly-acceptable to women. We are now working with colleagues in other Asia-Pacific countries to evaluate our point-of-care ‘test and treat’ approach in other high-burden settings in our region.
We recommend that health policy makers and political decision makers in the Pacific take note of these findings and allocate sufficient funds for HPV vaccination programs to prevent cervical cancer in the next generation, and for HPV testing and pre-cancer treatment in this generation, so that the scourge of cervical cancer can be reduced and eventually eliminated from our communities.
Table 1: HPV testing compared with VIA examination for the detection and treatment of underlying high-grade disease (cervical pre-cancer)

	Women with high-grade disease who were treated appropriately	Women with high-grade disease who were not treated (‘missed’)	Women without disease who were treated (‘over-treated’)
HPV testing alone	92% (33/36)	8% (3/36)	13% (64/491)
VIA examination alone	47% (17/36)	53% (19/36)	17% (80/491)

 
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