|Year : 2020 | Volume
| Issue : 1 | Page : 19-22
A successful model of cancer screening in low-resource settings: Findings of an integrated cancer screening camp from a rural setting of North India
M D Abu Bashar, Arun K Aggarwal, Divya Valecha
Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||27-May-2019|
|Date of Decision||09-Feb-2020|
|Date of Acceptance||14-Feb-2020|
|Date of Web Publication||20-Apr-2020|
Dr. M D Abu Bashar
Assistant Professor, Department of Community Medicine, MM Institute of Medical Sciences and Research, MM Deemed University, Mullana, Haryana - 133 207
Source of Support: None, Conflict of Interest: None
Background: Cancers of cervix, breast, and oral cavity claim millions of deaths each year globally and are the three most common cancers in India. There is a need to develop and test models for organizing integrated cancer screening camps in low-resource settings with intersectoral coordination between different stakeholders. Aim: To test a model of community based integrated screening camp for it's feasibility and to early detect these three common cancers in low-resource rural settings. Materials and Methods: A community-based integrated cancer screening camp was organized in a rural setting of North India in coordination with district health administration and local governing body (Panchayati Raj Institution). Screening methods included clinical breast examination for breast cancer, visual inspection under 5% acetic acid (VIA) for cervical cancer, and oral visual examination (OVE) for oral cavity cancer. Men and women found to be screen positive in the camp were referred to the district hospital and a tertiary care center for further diagnostic tests and were followed up. Results: A total of ninety individuals (forty men and fifty women) above 30 years of age attended the screening camp were included in the study. One (2.5%) out of these forty males was screened positive for precancerous lesion of the oral cavity. Out of the fifty women attending the camp, two were detected with suspected breast lumps, which on further diagnostic tests at district hospital were diagnosed as benign tumors. About half (52.0%) of the women consented for cervical cancer screening, out of which one (3.9%) was screened positive on VIA, which on colposcopy examination and biopsy at a referral center was confirmed as early-stage cancerous lesion of the cervix and was instituted on treatment. Conclusion: The screening camp sets a successful example of community-based cancer control activity for the early detection and management of three common cancers through intersectoral coordination in low-resource settings.
Keywords: Cancer screening, clinical breast examination, low-resource settings, oral visual examination, VIA
|How to cite this article:|
Bashar M D, Aggarwal AK, Valecha D. A successful model of cancer screening in low-resource settings: Findings of an integrated cancer screening camp from a rural setting of North India. Oncol J India 2020;4:19-22
|How to cite this URL:|
Bashar M D, Aggarwal AK, Valecha D. A successful model of cancer screening in low-resource settings: Findings of an integrated cancer screening camp from a rural setting of North India. Oncol J India [serial online] 2020 [cited 2020 May 29];4:19-22. Available from: http://www.ojionline.org/text.asp?2020/4/1/19/282833
| Introduction|| |
Cancer is one of the leading causes of morbidity and mortality worldwide, with approximately 14 million new cases reported annually. It is the second leading cause of mortality globally and was responsible for 8.8 million deaths in the year 2015, with 70% of these deaths occurring in low- and middle-income countries only.
Early detection of cancer greatly increases the chances for successful treatment. There are two major components of early detection of cancer: health promotion including education and early diagnosis through screening. The World Health Organization recommends early detection through screening of at-risk population for common cancers of the breast, cervix, mouth, larynx, colon and rectum, and skin. However, screening programs should be undertaken when the prevalence of the disease is high enough to justify the effort and costs of screening and when facilities exist for follow-up of those with abnormal results to confirm diagnoses and ensure treatment.
Breast and cervical cancers are the most common cancers in Indian women. However, they are easily amenable to screening methods. For breast cancer, it is recommended to have breast self-examination (BSE) aided by clinical breast examination (CBE). For cancer cervix, visual inspection under 5% acetic acid (VIA) and visual inspection with Lugol's iodine are recommended for any low-resource settings. Similarly, oral cancers can easily be screened by visual inspection of the oral cavity even by primary health-care workers and trained nonmedical personnel.
As the three common cancers can be screened using these low-cost screening methods with minimal infrastructure in any low-resource settings, we organized a cancer screening camp in a rural setting for screening and early detection of these three cancers.
| Materials and Methods|| |
An integrated cancer screening camp was organized in the village Kheri of Raipur Rani Community Development Block in district Panchkula of Haryana, North India, which is the rural field practice area of the Department of Community Medicine, PGIMER, Chandigarh. The government middle school within the village was chosen as the site for the camp. District health administration and local governing body participated actively. The village, where the camp was organized, had a total population of 1680. The village sarpanch (local elected village leader under Panchayati Raj Institution [PRI]), other PRI members, and the community health workers such as auxiliary nurse midwives (ANMs) and accredited social health activists (ASHAs) disseminated information about the camp in the adjoining villages, starting 1 month prior to the camp. The eligible population for screening was chosen as those aged 30 years or above of either sexes willing to undergo screening and were not diagnosed previously with these cancers. Informed oral consent was taken before screening of the eligible participants.
Health workforce for camp
The district civil surgeon deputed one gynecologist and one specialist dental surgeon from the nearby community health center, and the district hospital principal medical officer deputed two staff nurses trained in conducting cervical cancer screening. From the department of community medicine, one faculty member, one senior resident, and two junior residents participated. The two female junior residents trained in CBE performed the screening for breast cancer. In addition, school teachers and local village volunteers were actively involved for motivating the villagers to undergo screening.
Setup of the cancer screening site
Screening for the three cancers was performed in three separate different rooms to maintain confidentiality and privacy. Appropriate labels in local language were displayed at the entrance of each room. Participants were explained about the benefit of the screening tests through health talks and only those who consented were screened.
The following three teams were formed: (1) for breast cancer education and screening, (2) for cervical cancer screening, and (3) for oral cancer screening. These teams were given separate rooms in the sequence as depicted in [Figure 1].
|Figure 1: Setup of the integrated cancer screening camp at Kheri village of Haryana, North India|
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In common area for health education, health talk was imparted to the participants about the three common cancers, their risk factors, and importance of early detection and management. They were also told about the importance of periodic checkups even if they do not have any signs or symptoms. At the end, the participants were instructed to move to appropriate rooms for the screening after taking consent.
In room number 1, the specialist dental surgeon assisted by dental assistant did screening for oral cancer by oral visual examination of all the participants. In room 2, the gynecologist assisted by two staff nurses and one female health worker did screening for cervical cancer by VIA technique as per the International Agency for Research on Cancer manual and chart. The system was set up such that sterilized speculums always remained available irrespective of the number of women who may report for examination. Time taken to examine each woman and time to disinfect a speculum were taken into consideration to plan the number of speculums required for the camp. In room number 3, a team of two female resident doctors showed 10-min video on BSE, to the participants in batches of about ten. It was then followed by CBE in sitting and lying down positions by the resident doctors as per the modified version of the Canadian National Breast Screening Study protocol.
Follow-up of screened positives
All the screened positives were linked to the district hospital and a tertiary care institute. They were followed up with the help of ASHAs and the ANMs.
| Results|| |
A total of ninety individuals (forty men and fifty women) of age 30 years or above attended the screening camp. Majority of the participants were in the age group of 40–49 years [Table 1]. All the fifty women consented to undergo screening for breast cancer, out of which two were found to have suspected breast lump on CBE [Table 2] and were referred to the district hospital for confirmatory investigations. Both cases complied with the referrals and, based on further investigations, such as mammography, ultrasonography, and fine-needle aspiration cytology, were diagnosed as cases of fibroadenoma, a benign lesion of breast. They were followed up further for the need of surgery and follow-up investigations. Out of the fifty women, only 26 consented to undergo screening for cervical cancer through VIA technique, out of which one was screened positive [Table 2] and was finally diagnosed with cervical squamous intraepithelial neoplasia-2, an early-stage cancerous lesion of cervix based on colposcopy examination and biopsy test at PGIMER, Chandigarh, the tertiary care institute, and was instituted on treatment from there and undergone loop electrosurgical procedure. She was further followed up for outcome and was declared disease free.
|Table 1: Sociodemographic characteristics of the camp participants (n=90)|
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|Table 2: Screening results of the integrated cancer screening camp in rural Haryana (n=90)|
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All the ninety participants consented to undergo screening for oral cavity cancer, out of which one male participant was found to have leukoplakia, a premalignant lesion of the oral cavity [Table 2]. The person was a chronic bidi smoker with the habit of chewing tobacco. He was informed about the risk of the lesion to turn malignant and counseled for quitting smoking and tobacco chewing.
| Discussion|| |
Increasing community awareness about cancer and screening for common cancers provides the most cost-effective approach for the prevention and control of cancers and has high public health potential. To move toward the Universal Health Coverage (UHC), health systems should devise mechanisms to include noncommunicable diseases including cancer screening and management in the health-care package at district and subdistrict levels.
There are many strengths of our experience. First, using the World Cancer Day, all important sectors were sensitized and involved. All sectors such as district- and subdistrict-level health systems, PRIs, local education department, and department of community medicine of a tertiary care institute, as nodal coordinating department, contributed. Thus, for achieving UHC, if one needs to add a new service, this model demonstrates – how to use some important public health days such as the World Cancer Day, involve political and health system leaders, and demonstrate them the service provision in a limited population. The same service can then be extended to other populations with their support without financial burden on the population –achieving all the three dimensions of UHC. This model also demonstrates that intersectoral coordination can not only help mobilize the resources but also increase the stake of possible stakeholders.
Second, the acceptability of the population for breast cancer screening and oral cancer screening was high as everyone consented to undergo these, giving a response rate of 100%. However, for cervical cancer screening, only 52.0% of women consented. There are other experiences from India where cervical cancer screening rates were reported to be somewhat higher., This may be due to different methodologies followed in organizing these screening camps. In the study by Mishra et al., Tata Memorial Hospital, Mumbai, had set up a community-based cancer screening program with a strong component of health education program (HEP). The program had strong house-to-house survey, followed by HEP, before actual screening was done. In this model, they had used 10th grade qualified workers after providing 3 months' training, to screen the population for cancers. Only the project staff did the screening activity and other sectors were not actively involved. In the study by Sharma et al. from Delhi, cervical cancer screening camp was set up at primary health center level. In these camps, Pap smear More Details as screening test was done among women who were clinically found to have some reproductive morbidity. Although Pap smear is the only screening test which has shown to reduce cervical cancer incidence and mortality, it was not done in our study due to logistic and feasibility issues.
There are some other examples of organizing camps for breast cancer screening., Most of these screening camps were organized at health facilities at district or subdistrict level. In this context, our experience of organizing an integrated cancer screening camp at village level in the community setting by involving specialists and creating a professional setup for examination with intersectoral coordination can be considered successful and a unique model.
It may be argued that diagnostic yield in our camp was less. Only one woman (3.99%) out of 26 screened for cervical cancer was found positive on VIA and 2 (4.0%) out of fifty screened for breast cancer had suspicious breast lumps. Reports of other camps available in published literature show that at most places, only symptomatic or prescreened eligible populations were screened further for cancer screening. In a screening camp at Raichur, Karnataka, 7 out of the 22 women having complaints of reproductive tract morbidities undergoing screening, had suspicious malignancy on Pap smear. The study by Sharma et al. also reported the prevalence of 7.1% carcinoma in situ or high-grade carcinoma on Pap smear among women who were clinically having any reproductive morbidity. In the Mumbai study done on large population with extensive health education and targeted screening of women having some preeligibility criteria, cancer cervix screen positives were 14.9%. Less diagnostic yield in our camp may be due to the fact that no such prescreening was done and women in all reproductive age groups were invited for examination irrespective of their symptom status. On the spot, 20 min' health education talk was given to highlight the need and significance of periodic examinations and the fact that any woman may have cancer without experiencing any symptoms. With this minimal effort, about 50% got themselves screened for cervical cancer. In the Mumbai study, even with extensive efforts, only 70% of women came forward for screening. We believe that with additional health educational efforts during the weeks preceding the camp, screening output could have been increased.
| Conclusion|| |
Our model of community-based integrated cancer screening camp for three common cancers sets a successful example of cancer control activity in low-resource settings. Two cases of undiagnosed precancerous lesions were detected in the camp, which shows its success for early detection of cancers. The current model of organizing integrated cancer screening camp for common cancers may be scaled up for cancer screening and prevention for common cancers in all low-resource settings at district, state, and country levels.
Financial support and sponsorship
Funding to organize the camp was provided by district health administration and local governing body, i.e., PRIs.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]