Download Global Burden of Cervical Cancer

Global Burden of Cervical Cancer Challenges & Opportuni2es for Cervical Cancer Interven2on Annekathryn Goodman, MD MS Massachuse=s General Hospital Harvard Medical School Strategies for Cancer Care Cervical Cancer •  PrevenBon •  Screening •  EffecBve treatment •  PalliaBon •  VaccinaBon •  Pap smear, HPV tesBng, biopsies, •  VIA (visual inspecBon with aceBc acid) •  Surgery, radiaBon, chemotherapy •  Nursing care, home care, pain relief, IV technology, palliaBve surgery Socio-­‐economic and health access determinants of breast and cervical cancer screening in low-­‐income countries: analysis of the World Health Survey. Akinyemiju TF. PLoS One. 2012;7(11):e48834 Socio-­‐economic and health access determinants of breast and cervical cancer screening in low-­‐income countries: analysis of the World Health Survey. Akinyemiju TF. PLoS One. 2012;7(11):e48834 •  Household SES •  Rural residence •  Country health expenditure (as a percent of GDP) •  Healthcare access CERVICAL CANCER SCREENING PROGRAM OF BANGLADESH: EVALUATION & FORMULATION OF QUALITY ASSURANCE STANDARDS & GUIDELINES Basu & Majid 2008 The loca2ons of the screening and referral centers. • 
44 districts have programs •  The VIA screening services at district hospitals. •  Nurses trained to perform VIA & Consultant Gynecologists have been trained to supervise the nurses •  Referral centers with faciliBes to perform colposcopy & cervical biopsy in 7 Medical College Hospitals including BSMMU. •  Cryotherapy & LEEP is available in 3 centers. Cancer Control in Bangladesh Prevalence of Cancer Types (%) Akram and Sullivan, 2013 Bangladesh Barriers •  Socioeconomics –  Poverty –  Culture –  EducaBon •  The built environment –  Roads –  Traffic –  Safety •  Medical infrastructure h=p://www.citypopulaBon.de/Bangladesh-­‐UA.html 2011 :144,043,697 2013 : 163,654,861 City City PopulaBon Metro Region Dhaka
11,086,309 47,424,418 Chittagong
3,669,170 28,423,019 Gaizipur
1,820,374 18,484,858 Narayanganj
1,636,441 Khulna
1,046,341 Rajshahi
763,952 Sylhet
526,412 15,687,759 9,910,219 Google Earth Korail Slum, Dhaka 2011 versus 2013 BANGLADESH Travel Barrier of Distance and Transporta2on Cost to Access Maternity Services in Rural Bangladesh h=p://paa2013.princeton.edu/papers/132360 Financial Barriers and Lack of Healthcare Insurance Healthcare •  No current health insurance programs in Bangladesh •  Healthcare is paid for out of pocket •  For the poor & “ultra-­‐poor” of Bangladesh, majority receive healthcare from nonmedical pracBBoners, government programs, & NGOs Barriers to access to healthcare for the poor •  Inability to afford healthcare •  Lack of awareness of the kind of healthcare services available •  Deficiencies and inconsistencies in the quality of services •  Lack of close proximity to the healthcare facility NaBonal Expenditures on Health: Bangladesh Jpn J Clin Oncol. Dec 2013; 43(12): 1159–1169. 1995 Health share of domesBcally funded govt expenses General govt expenditure on health (% of govt expenditure 2000 2005 2011 0.3 0.7 1.1 1.8 8.8% 7.6% 8.5% 8.9% Treatment Challenges Bangladesh Medical Infrastructure q  In 2006, the total number of hospitals in Bangladesh was 1683. q  678 were government hospitals and 1005 were non-­‐governmental q  Number of private hospitals that treat paying paBents is increasing each year as the middle class of Bangladesh is increasing. q  First cancer hospital opened 1994 q  First paBent treated with cobalt 1995 Healthcare providers •  1 oncologist per 10,000 paBents (US: 1:100) •  Nurse shortage •  Need for advance pracBce nurses •  Need for advanced oncology training Barriers to Cancer Care Informa2on Technology Bangladesh Cancer Sta2s2cs •  Data collecBon •  Tumor registry data uncertain •  Record keeping •  800,000 cancer paBents •  StaBsBcs •  200,000 new cases per year •  Follow-­‐ up •  150,000 cancer deaths per year •  NoBficaBon of results •  Morbidity & Mortality data Barriers to Cancer Care Medical Infrastructure • 
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Examples •  Brachytherapy machines absent Lack of / or faulty equipment or broken Lack of medical training •  Absent surgical training –  both minor and major cancer Nursing support surgery Non-­‐pharmacological supplies •  Ostomy bags, porta cath’s Pharmacy •  Lack of narcoBcs, counterfeit drugs EducaBonal infrastructure, •  Tumor board discussion, mulBdisciplinary input pathology, and radiology support Challenges to Cervical Cancer Care Ø LimitaBons to radiotherapy equipment Ø WaiBng list for radiaBon Ø The infrastructure of surgical care Recurrence of cancer cervix in paBents treated by radical hysterectomy followed by adjuvant external beam radiotherapy. Bangladesh Med Res Counc Bull. 2010; 36, 52-­‐56. •  The NaBonal Cancer InsBtute of Dhaka reviewed the data on 120 paBents with FIGO stage Ib-­‐IIa cervical cancers who had radical hysterectomy followed by external beam pelvic radiotherapy. •  Fiky (42%) paBents developed recurrences and eighty percent of recurrences occurred within 36 months. •  Thirty-­‐four (70%) paBents experienced local recurrence, 13 (26%) distant recurrence and 2 (4%) both local and distant recurrence. •  The median Bme to recurrence was 19 months. RadiaBon Therapy SoluBons •  Radical surgery for advanced disease •  Radical Re-­‐evaluaBon surgery of for radiaBon advanced planning disease •  Re-­‐evaluaBon of radiaBon planning Problems Case Study •  PreoperaBve evaluaBon •  Undergoes a simple hysterectomy •  IntraoperaBve •  Then referred to NCRH •  postoperaBve •  Exam reveals residual cancer in vagina and parametria SOLUTIONS The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and
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Physician educaBon Training Networking Small incremental changes to infrastructure Basic Infrastructure Challenges
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No Sinks
Water Contamination
No Gloves
No Garbage Disposal
No Calstat
The Problem •  Health Care Associated InfecBon •  Health Care Associated InfecBon •  Indiscriminant AnBbioBc Use Dhaka Medical College Hospital Surgeries & IntervenBons: 2011 •  Major Surgeries 25,894 •  Minor Surgery 61,854 Positive associations of nosocomial infections
Bratisletiological
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in surgical ward with
clinical factors.
2011;112(5):273-7.
•  Surgical wards of Dhaka Medical College Hospital, Bangladesh •  Thirty percent of the study paBents, infected with nosocomial infecBon. •  wound infecBon (38.7%) most common type of nosocomial infecBon, 63.5% belonged to postoperaBve •  acute respiratory tract infecBon (19.2%), •  urinary infecBon (26.6%), Conclusions • 
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MulBple details EducaBon Change healthcare provider culture and habits CollaboraBon