Choropleth Mapping of Cervical Cancer Screening in South Africa Using Healthcare Facility-level Data from the National Laboratory Network.

Caroline B T Makura,Kathryn Schnippel,Cynthia Firnhaber,Bridgette Goeieman,Suzette Jordaan,Carla J Chibwesha,Pamela Michelow

doi:10.3934/publichealth.2016.4.849

Abstract

BackgroundIn South Africa, cervical cancer remains among the most common cancers and a leading cause of cancer death. Co-infection with HIV increases the risk of developing cervical pre-cancer and cancer. We analysed National Health Laboratory Service cervical cytology data to investigate geographic variations of Pap smear coverage, quality, and high grade lesions.MethodsFacility-level data were extracted from the NHLS for April 2013–March 2014. We present results and choropleth maps detailing coverage, adequacy and high-grade Pap smear cytology abnormalities defined as Pap smears suspicious for invasive carcinoma, high-grade squamous intraepithelial lesions (HSIL) or atypical squamous cells: cannot exclude HSIL (ASC-H).Results4,562 facilities submitted 791,067 cytology slides. The interquartile range (IQR) for Pap smear coverage among HIV-infected women was 26–41%; similar to coverage in women aged 30 and older (IQR: 26–42%). 6/52 districts had adequacy rates above the national standard (70%) and 2/52 districts had adequacy rates below 35%. We observed marked variation in Pap smear abnormalities across the country, with the proportion of high-grade cytology abnormalities ≥0.3% in 17/52 districts.ConclusionUsing district-level choropleth maps, we are able to display variations in Pap smear coverage, quality, and results across South Africa. This approach may be used to improve resource allocation, achieving better equity in cervical cancer prevention.

Highlights

In South Africa, cervical cancer is the second most common cancer among women affecting 1 in every 41 and killing 8 women daily [1]; yet, it is one of the preventable cancers through vaccination, early detection and treatment of cervical cancer precursors [2]
We used choropleth maps to: (1) Identify districts that were not reaching the national target of 70% for coverage of Pap smears screening; estimated for all women and HIV-infected women; (2) Identify districts that were performing below the national standard of achieving a 70% Pap smear ―adequacy‖ rate; and
We present one measure of the quality of a Pap smear: smear ―adequacy‖, which is the adequacy rate defined as the proportion of specimens with endo-cervical cells noted as present among all specimens that were satisfactory for examination

Summary

Introduction

In South Africa, cervical cancer is the second most common cancer among women affecting 1 in every 41 and killing 8 women daily [1]; yet, it is one of the preventable cancers through vaccination, early detection and treatment of cervical cancer precursors [2]. Since the introduction of the Papanicolaou (Pap) smear in the 1940s, it is estimated that there has been a 70% reduction in cervical cancer deaths in developed countries [5]. The 2003 South Africa World Health Survey estimated the cervical cancer screening coverage to be under 20% for women aged 25 to 64 a more organized cervical cancer is imperative [8]. We analysed National Health Laboratory Service cervical cytology data to investigate geographic variations of Pap smear coverage, quality, and high grade lesions. Conclusion: Using district-level choropleth maps, we are able to display variations in Pap smear coverage, quality, and results across South Africa. This approach may be used to improve resource allocation, achieving better equity in cervical cancer prevention

Methods

Results

Discussion

Conclusion