A vision for improved cancer screening in Nigeria.

Abstract

As the global burden of disease shifts from infectious diseases to non-communicable diseases (NCDs), cancer has increasingly become a major contributor to morbidity and mortality in low-income and middle-income countries (LMICs). Major reasons for these shifts include increasing life expectancy and changing diets and lifestyles. An estimated 14·1 million new cases and 8·2 million cancer deaths occurred worldwide in 2012, with more than 65% of cancer deaths occurring in LMICs.1Ferlay J Soerjomataram I Ervik M et al.GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase. No. 11. International Agency for Research on Cancer, Lyon, France2013http://globocan.iarc.frGoogle Scholar In Nigeria, cervical cancer and breast cancer are two of the leading causes of cancer deaths in women, accounting for more than 40% of all women's cancer and about two-thirds of cancer deaths.2Jedy-Agba E Curado MP Ogunbiyi O et al.Cancer incidence in Nigeria: a report from population-based cancer registries.Cancer Epidemiol. 2012; 36: 271-278Summary Full Text Full Text PDF PubMed Scopus (182) Google Scholar, 3Awodele O Adeyomoye AA Awodele DF Fayankinnu VB Dolapo DC Cancer distribution pattern in south-western Nigeria.Tanzan J Health Res. 2011; 13: 125-131Crossref PubMed Scopus (25) Google Scholar Despite this, cancer screening efforts lag behind other priorities and resources available for cancer care are insufficient. Because of an absence of information and poor access to health, most women in Nigeria are diagnosed at advanced disease stages, resulting in restricted treatment options and high mortality rates. These poor outcomes are largely attributable to patient and systems barriers in the form of poor education and awareness, financial barriers, shortage of health workers, limited health infrastructure, poor management and planning, inequity in resource distribution, and access to care.4Morhason-Bello IO Odedina F Rebbeck TR et al.Challenges and opportunities in cancer control in Africa: a perspective from the African Organisation for Research and Training in Cancer.Lancet Oncol. 2013; 14: e142-e151Summary Full Text Full Text PDF PubMed Scopus (176) Google Scholar, 5Harford JB Barriers to overcome for effective cancer control in Africa.Lancet Oncol. 2015; 16: e385-e393Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar Various innovative opportunities exist to reduce the morbidity and mortality associated with cervical cancer and breast cancer in Nigeria without affecting other key health and development priorities. Resources designated for cancer care will be most effective if they strengthen primary care and the entire health system and are integrated into platforms already in place for other diseases.4Morhason-Bello IO Odedina F Rebbeck TR et al.Challenges and opportunities in cancer control in Africa: a perspective from the African Organisation for Research and Training in Cancer.Lancet Oncol. 2013; 14: e142-e151Summary Full Text Full Text PDF PubMed Scopus (176) Google Scholar Integrating cervical and breast cancer screening services into existing delivery platforms for sexual, reproductive, and maternal health services has been proposed as an effective and efficient strategy.6Knaul F Bustreo F Ha E Langer A Breast cancer: why link early detection to reproductive health interventions in developing countries?.Salud Publica Mex. 2009; 51: 220-227Crossref PubMed Google Scholar, 7Mwanahamuntu MH Sahasrabuddhe VV Kapambwe S et al.Advancing cervical cancer prevention initiatives in resource-constrained settings: insights from the Cervical Cancer Prevention Program in Zambia.PLoS Med. 2011; 8: e1001032Crossref PubMed Scopus (99) Google Scholar Such integration could address women's multiple needs at once, potentially increase cervical and breast cancer screening, and, ultimately, reduce morbidity and mortality. Family planning, prenatal, postnatal, and HIV treatment clinics provide ample opportunities for contact with women in the reproductive age group who might have little knowledge of cervical and breast cancer issues. At these clinics, tailored educational messages on breast and cervical cancer can be included in these visits to address gaps in knowledge and correct myths and misconceptions. Emphasis must be placed on early detection to reduce the proportion of women diagnosed in late stages. Cervical cancer prevention strategies that include human papillomavirus (HPV) vaccination and visual inspection with acetic acid and same-visit cryotherapy (so-called screen-and-treat) are cost-effective and accessible alternatives to the cytology-based screening programmes9Sahasrabuddhe VV Parham GP Mwanahamuntu MH Vermund SH Cervical cancer prevention in low- and middle-income countries: Feasible, affordable, essential.Cancer Prev Res (Phila). 2012; 5: 11-17Crossref PubMed Scopus (85) Google Scholar that are currently in place in many health centres in Nigeria. The demonstration project on cervical cancer prevention through screening using visual inspection with acetic acid and treatment with cryotherapy done in six African countries including Nigeria showed that the screen and treat approach is acceptable and feasible and can be introduced into existing sexual and reproductive health services.10African Population and Health Research CenterInternational Agency for Research on CancerWHOPrevention of cervical cancer through screening using visual inspection with acetic acid (VIA) and treatment with cryotherapy. A demonstration project in six African countries: Malawi, Madagascar, Nigeria, Uganda, the United Republic of Tanzania, and Zambia. World Health Organization, Geneva2012Google Scholar Through scale up and integration of such programmes into primary health centres in all 774 local governments in Nigeria, the Nigerian Government could facilitate the extension of cancer screening services to hard to reach populations. Although mammography remains the gold standard for early detection of breast cancer,11Paci E Mammography and beyond: developing technologies for the early detection of breast cancer.Breast Cancer Res. 2002; 4: 123-125Crossref Scopus (12) Google Scholar it is cost prohibitive and not readily accessible to a lot of women in Nigeria who live below the poverty line. The Breast Health Global Initiative (BHGI) resource stratified guidelines recommend clinical breast examination as a practical and necessary alternative for early detection in low-resource settings.12Anderson BO Yip CH Smith R et al.Guideline implementation for breast healthcare in low-income and middle-income countries: Overview of the breast health global initiative Global Summit 2007.Cancer. 2008; 113: 2221-2243Crossref PubMed Scopus (356) Google Scholar Training of front-line health providers in visual inspection with acetic acid and clinical breast examination as a screening method for cervical and breast cancer and appropriate referral linkages increases the chances of detection of both cancers at an early stage. Currently a major initiative focused on cervical cancer screening and treatment for women in Nigeria is funded by the Bill & Melinda Gates foundation in partnership with Marie Stopes International, the International Planned Parenthood Federation, Population Services International, and Society for Family Health.13Marie Stopes InternationalMSI joins partnership for cervical cancer screening.https://mariestopes.org/news/msi-joins-partnership-cervical-cancer-screeningDate: May 20, 2013Google Scholar However, Nigeria needs to integrate more creative and innovative partnerships for early detection of cervical and breast cancer being implemented in different low-resource settings. The Pink Ribbon Red Ribbon Initiative, a public–private partnership, operates as a country-aligned partnership with sub-Saharan African countries to reduce the burden of breast and cervical cancer using health platforms established for HIV/AIDS screening and treatment.14Oluwole D Kraemer J Innovative public-private partnership: a diagonal approach to combating women's cancers in Africa.Bull World Health Organ. 2013; 91: 691-696Crossref PubMed Scopus (20) Google Scholar These partnerships and collaborations provide an excellent opportunity to expand the availability of cervical and breast cancer services. Nigeria developed a national cancer control plan in 2008, but implementation has been suboptimal.15Stefan DC Elzawawy AM Khaled HM et al.Developing cancer control plans in Africa: Examples from five countries.Lancet Oncol. 2013; 14: e189-e195Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar Nigeria is in a prime position to take on a leadership role in improving cancer screening for the African continent by implementing policies and relatively inexpensive programmes for women's cancer control. Nigeria must find the political will to provide and coordinate resources in a sustainable way to reduce its burden of cervical and breast cancer. FI is an Atlas Corps Fellow at Susan G Komen. The views expressed in this paper are solely those of the authors. We declare no competing interests.