Cancer Screening In sub-Saharan Africa Research Articles

Socioeconomic inequalities in cervical cancer screening in sub-Saharan Africa: Decomposition analysis

Abstract Background Cervical cancer remains prevalent in sub-Saharan Africa (SSA). Despite global efforts to eliminate this disease, its incidence continues to rise due to barriers in screening, vaccination, and treatment access. While studies address access barriers, little has explored inequality, often limited to single countries. Here, we examine socioeconomic inequalities in cervical cancer screening in SSA. Methods Data from the Demographic and Health Surveys of 10 SSA countries was used for the analysis. We stratified the study by wealth index and educational attainment as a measure of socioeconomic status. Socioeconomic status inequalities in cervical cancer screening were constructed using concentration curves. We then computed the concentration index to quantify socioeconomic inequality. To examine the factors associated with high socioeconomic inequality in cervical cancer screening, a decomposition analysis was conducted. Results Concentration curves showed screening uptake skewed towards the wealthy and educated across all countries, reflected by positive concentration indices (CIX=0.21; p-value<0.0001) except in Burkina Faso and Mauritius. Decomposition analysis revealed significant positive concentration indices for women with complete secondary (CIX=0.74) and higher education (CIX=0.91), those in the richest wealth index (CIX=0.35), separated women (CIX=0.08), currently working women (CIX=0.02), as well as those who were exposed to reading newspaper/magazine (CIX=0.19), listening to radio (CIX=0.10), and watching TV (CIX=0.44). Conclusions Cervical cancer screening in SSA exhibits pro-rich and pro-higher educational inequalities. Urgent interventions are needed to restructure existing screening programs to prioritize accessibility and inclusion, particularly for women from poorer households and with a lower level of education. These findings are vital for policymakers and public health practitioners to address cervical cancer screening disparities in SSA. Key messages • Addressing socioeconomic inequalities in cervical cancer screening is crucial for improving public health in sub-Saharan Africa. • Combatting socioeconomic disparities in cervical cancer screening is critical for achieving health equity in sub-Saharan Africa.

Determinants of cervical cancer screening among women of childbearing age in four sub-Saharan African countries: insights from large population surveys

BackgroundCervical cancer is the most common cause of cancer-related mortality among women in Africa. Cervical cancer screening in women is associated with decreased incidence and mortality of cervical cancer. There is a dearth of recent data regarding the prevalence and associated factors of cervical cancer screening in sub-Saharan Africa. Therefore, this study is intended to determine the prevalence and associated factors impacting cervical cancer screening among women in four sub-Saharan African countries.MethodsData from the recent demographic and health surveys of four countries in sub-Saharan Africa conducted between 2022 and 2023. Multilevel mixed-effects logistic regression was used to determine the factors associated with the outcome variable. Variables with a p-value < 0.05 were declared statistically significant.ResultsThe prevalence of cervical cancer screening among women of childbearing age in four sub-Saharan African countries was 8.90% (95% CI: 8.67%, 9.13%). At the individual level, being older, educated, non-breastfeeding, employed, wealthier, sexually active, using contraceptives, having media exposure, visiting healthcare facilities in the last 12 months, and residing in urban areas were associated with higher odds of cervical cancer screening. At the community level, being from communities with a high level of literacy and media exposure increases the odds of cervical cancer screening among women in sub-Saharan Africa.ConclusionThe prevalence of cervical cancer screening among childbearing-age women was found to be low. To improve cervical cancer screening practices among women of childbearing age, it is therefore advised to support women’s empowerment, mass media campaigns, and regular visits to healthcare facilities.

Experiences and perspectives regarding human papillomavirus self-sampling in sub-Saharan Africa: A systematic review of qualitative evidence

IntroductionCervical cancer screening coverage remains low in sub-Saharan Africa (SSA) due to limited access and low uptake of available services by women. The use of HPV-based self-sampling intervention for cervical cancer screening has the potential to increase screening coverage in the region. This study aimed to analyse qualitative evidence on the experiences and perspectives of women, healthcare workers, and policymakers regarding HPV self-sampling. MethodsWe reviewed qualitative studies from January 2011 to March 2023 in PubMed, Scopus, Medline Ovid, Cochrane, and WEB of Science databases for articles with qualitative data on HPV self-sampling from different countries in SSA. The socio-ecological model was used to guide data analysis and the study findings. ResultsThirteen qualitative studies were included for analysis, and they revealed themes under the intrapersonal, interpersonal, community, and health systems constructs of the Socio-ecological model. Intrapersonal themes included the acceptability of self-sampling, self-efficacy, and the perceived value of self-sampling. The interpersonal construct had themes such as women's spousal relationships, peer support, and the health worker's relationship with the women. The community construct had two themes: social stigma and misinformation, and the influence of cultural norms and religion. Finally, the health systems construct had themes such as the setting for self-sampling, follow-up availability of treatment services and education and awareness. ConclusionThis study highlights the factors influencing the acceptability and uptake of an HPV-based self-sampling intervention for cervical cancer screening in SSA. Considering these findings when designing interventions in SSA is crucial to ensure acceptance and demand among end-users. Self-sampling interventions offer the potential to reach many unscreened women and increase cervical cancer screening coverage in SSA, which is an essential strategy towards achieving the World Health Organisation's cervical cancer elimination targets by the close of the century.

Healthcare providers' knowledge, attitude, and practice towards cervical cancer screening in Sub-Saharan Africa: systematic review and meta-analysis.

Cervical cancer is a prevalent cancer among women in low and middle-income countries, but it can be largely prevented through screening programs and HPV vaccination. This study aimed to determine the level of knowledge, attitudes, and practices regarding cervical cancer screening among healthcare providers in Sub-Saharan African countries. Systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Relevant databases including PubMed, Cochrane Library, AJOL, Google Scholar, and ScienceDirect databases were used to retrieve and search articles. The study included published and unpublished research written in English between January 2013 and May 16, 2024 for studies reporting knowledge, attitude, and practice towards cervical cancer screening among healthcare providers in Sub-Saharan Africa. This review has been registered on PROSPERO. The heterogeneity of the data was evaluated using the I2 statistic. A meta-analysis was conducted using STATA 17 software, with a 95% confidence interval. The researchers also conducted publication bias and sensitivity analysis. The review included 30 studies involving 7542 healthcare providers. The pooled magnitude of good knowledge status towards cervical cancer was 67.93% (95% CI: 53.36-82.50) whereas the pooled magnitude of positive attitude towards cervical cancer was 55.26% (95% CI: 34.28- 76.23). The results also showed that about 49.68% (95% CI: 33.18-66.17) of healthcare providers had good knowledge status about cervical cancer screening, 66.63%(95% CI: 50.36- 82.89) had a positive attitude towards it, and only 17.23% (95% CI; 6.08-28.37) had ever screened for cervical cancer. The overall magnitude of knowledge and attitude of healthcare providers in Sub-Saharan Africa towards cervical cancer and its screening was suboptimal. Furthermore, a low percentage of female healthcare providers in the region had undergone screening for cervical cancer. As a result, policymakers and program administrators should focus on improving the knowledge, attitude, and practices of healthcare providers to meet the global health goal of cervical cancer screening and effectively eliminating cervical cancer. Healthcare providers must serve as role models for other women who should also undergo screening. https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023495241.

Mapping evidence on the acceptability of human papillomavirus self-sampling for cervical cancer screening among women in sub-Saharan Africa: a scoping review

ObjectivesThe objective of this scoping review was to map evidence on the acceptability of self-sampling for human papillomavirus testing (HPVSS) for cervical cancer screening among women in the sub-Saharan Africa...

Comparison of human papillomavirus-based cervical cancer screening strategies in Tanzania among women with and without HIV.

Cervical cancer is the most common female cancer in Eastern Africa, and the World Health Organization (WHO) recommends human papillomavirus (HPV)-based screening as a key element to eliminate the disease. In this cross-sectional study from Tanzania, we compared nine HPV-based cervical cancer screening strategies, including HPV testing at standard cut-off; HPV testing at increased viral load cut-offs; HPV testing with partial/extended genotyping, and HPV testing with visual inspection with acetic acid (VIA). We pooled data collected during 2008 to 2009 and 2015 to 2017 from 6851 women aged 25 to 65. Cervical cytology samples were HPV tested with Hybrid Capture 2, and HPV positive samples were genotyped with INNO-LiPA Extra II. Human immunodeficiency virus (HIV) testing and VIA were done according to local standards. We calculated sensitivity, specificity, positive and negative predictive value of screening strategies, with high-grade cytological lesions as reference, separately for women with and without HIV. HPV testing at standard cut-off (1.0 relative light units [RLU]) had highest sensitivity (HIV+: 97.8%; HIV-: 91.5%), but moderate specificity (HIV+: 68.1%; HIV-: 85.7%). Increasing the cut-off for HPV positivity to higher viral loads (5.0/10.0 RLU) increased specificity (HIV+: 74.2%-76.5%; HIV-: 89.5%-91.2%), with modest sensitivity reductions (HIV+: 91.3%-95.7%; HIV-: 83.5%-87.8%). Limiting test positivity to HPV types 16/18/31/33/35/45/52/58 improved specificity while maintaining high sensitivity (HIV+: 90.2%; HIV-: 81.1%). Triage with VIA and/or partial genotyping for HPV16/18 or HPV16/18/45 had low sensitivities (≤65%). In conclusion, HPV testing alone, or HPV testing with extended genotyping or increased viral load cut-offs, may improve cervical cancer screening in Sub-Saharan Africa.

Colorectal cancer screening in sub-Saharan Africa

Colorectal cancer screening in sub-Saharan Africa

Leveraging breast cancer screening to promote timely detection, diagnosis and treatment among women in sub-Saharan Africa: a scoping review protocol

IntroductionFemale breast cancer is now the most often diagnosed cancer in the world. Breast cancer screening aims to reduce mortalities related to cancer, and morbidity associated with advanced stages of...

Breast cancer screening in sub-Saharan Africa: a systematic review and ethical appraisal

BackgroundThe aim of this systematic review was to evaluate the evidence and clinical outcomes of screening interventions and implementation trials in sub-Saharan Africa (SSA) and also appraise some ethical issues related to screening in the region through quantitative and qualitative narrative synthesis of the literature.MethodsWe searched Pubmed, OvidMEDLINE, Embase, and Web of Science to identify studies published on breast cancer screening interventions and outcomes in SSA. Descriptive statistics were used to summarize the frequency and proportions of extracted variables, and narrative syntheses was used to evaluate the clinical outcomes of the different screening modalities. The mixed methods appraisal tool was used to assess the quality of studies included in the review.ResultsFifteen studies were included, which consisted of 72,572 women in ten countries in SSA. 63% (8/15) of the included publications evaluated Clinical Breast Examination (CBE), 47% (7/15) evaluated mammography and 7% (1/15) evaluated ultrasound screening. The cancer detection rate was < 1/1000 to 3.3/1000 and 3.3/100 to 56/1000 for CBE and mammography screening respectively. There was a lot of heterogeneity in CBE methods, target age for screening and no clear documentation of screening interval. Cost-effective analyses showed that CBE screening linked to comprehensive cancer care is most cost effective. There was limited discussion of the ethics of screening, including the possible harms of screening in the absence of linkage to care. The gap between conducting good screening program and the appropriate follow-up with diagnosis and treatment remains one of the major challenges of screening in SSA.DiscussionThere is insufficient real-world data to support the systematic implementation of national breast cancer screening in SSA. Further research is needed to answer important questions about screening, and national and international partnerships are needed to ensure that appropriate diagnostic and treatment modalities are available to patients who screen positive.

Prostate Cancer Screening, Diagnostic, Treatment Procedures and Costs in Sub-Saharan Africa: A Situational Analysis.

PurposeProstate cancer mortality is predicted to nearly double by 2040 in Sub-Saharan Africa (SSA). The lack of prostate cancer screening in SSA contributes to late-stage diagnosis, treatment delays, and poor survival among patients. We analyzed the availability and use of prostate cancer screening, diagnostic and treatment guidelines, procedures, and costs in few SSA countries to determine factors for consideration in the development of prostate cancer screening guidelines for SSA.MethodsWe applied mixed methods approaches to collect data through an electronic survey administered to clinicians (oncologists, urologists, pathologists, nurses, and radiation oncologists) providing prostate cancer screening, diagnosis, and treatment services in multiple sub-Saharan countries.ResultsInconsistencies in respondents’ understanding of the availability and use of prostate cancer screening guidelines in their countries were noted. Prostate Specific Antigen (PSA) and Digital Rectal Examination (DRE) were the most commonly available screening modalities. Available diagnostic procedures included a combination of prostate biopsies, transrectal ultrasonography, and DRE. Our study’s data suggest that PSA and DRE exams are available for early diagnosis and screening procedures. Availability of treatment modalities with curative intent and costs for prostate cancer related procedures varied between and within countries.ConclusionsPSA and DRE are available for detecting prostate cancer and may detect aggressive cancers early, leading to improved outcomes. However, PSA screening is also associated with overdiagnosis and over-treatment. National prostate cancer policies should consider health systems, evidence-based guidelines, population characteristics and healthcare financing to ensure access to clinically relevant and safe prostate cancer related care.

Prevalence and determinants of cervical cancer screening in five sub-Saharan African countries: A population-based study

BackgroundCervical cancer is the fourth most common cancer among women worldwide, with an estimate of 570,000 new cases and about 311,000 deaths annually. Low-resource countries, including those in sub-Saharan Africa, have the highest-burden with an estimate of 84 % of all cervical cancers. This study examines the prevalence and socio-demographic-economic factors associated with cervical cancer screening in sub-Saharan Africa. MethodsA weighted population-based cross-sectional study using Demographic and Health Surveys data. We used available data on cervical cancer screening between 2011 and 2018 from the Demographic and Health Surveys for five sub-Saharan African countries (Benin, Ivory Coast, Kenya, Namibia, and Zimbabwe). The study population included women of childbearing age, 21–49 years (n = 28,976). We fit a multivariable Poisson regression model to identify independent factors associated with cervical cancer screening. ResultsThe overall weighted prevalence of cervical cancer screening was 19.0 % (95 % CI: 18.5 %–19.5 %) ranging from 0.7 % in Benin to 45.9 % in Namibia. Independent determinants of cervical cancer screening were: older age (40−49 years) adjusted prevalence ratio (aPR) = 1.77 (95 % CI: 1.64, 1.90) compared with younger age (21−29 years), secondary/higher education (aPR = 1.51, 95 CI: 1.28–1.79) compared with no education, health insurance (aPR = 1.53, 95 % CI: 1.44–1.61) compared with no insurance, and highest socioeconomic status (aPR = 1.39, 95 % CI: 1.26–1.52) compared with lowest. ConclusionThe prevalence of cervical cancer screening is substantially low in sub-Saharan Africa countries and shows a high degree of between-country variation. Interventions aimed at increasing the uptake of cervical cancer screening in sub-Saharan Africa are critically needed.

Prevalence and determinants of breast cancer screening in four sub-Saharan African countries: a population-based study

ObjectivesBreast cancer is the most prevalent cancer and the second leading cause of cancer-related deaths among women after cervical cancer in much of sub-Saharan Africa. This study aims to examine...

Implementation and Effectiveness of community-based resources to increase cervical cancer screening uptake among women living in sub-Saharan Africa: A protocol for systematic review

# Background Sub-Saharan Africa (SSA) accounts for about 70% of the global burden of cervical cancer; this is due to several factors including lack of access to cervical cancer screening, low knowledge of cervical cancer and screening services, poor-functioning health systems, insufficient and poorly trained health workers, and the high burden of human immunodefiency virus (HIV) infection. To date, to the best of our knowledge, there has been no systematic review of the literature on the role of community-based resources such as community health workers and community-based organisations in increasing the uptake and or continuing participation of women in cervical cancer screening, in the setting of high HIV burden, in sub-Saharan Africa. # Methods We will systematically search selected databases and websites from 1980 to date for published and grey literature including citation and reference list tracking, on studies with a community focus carried out in sub-Saharan Africa, without language restrictions. Randomised controlled trials (RCTs), observational studies, and qualitative and mixed methods studies of interventions (carried out with and without comparison groups) reporting impact on participation in cervical cancer screening in sub-Saharan Africa will be identified and assessed for methodological quality by two independent reviewers. We will use narrative synthesis and/or meta-analysis depending on the study selection. # Results Findings will be summarised into abstracts for presentation at conferences and submission to peer-reviewed journals in the field for wide-ranging dissemination to patients, researchers, healthcare professionals and policy makers on cervical cancer in sub-Saharan Africa. # Conclusion The review will address the gap in evidence for effective and implementable community-based strategies that encourages uptake of cervical cancer screening among women living in sub-Saharan Africa. The findings will have the potential to inform future screening practice and research with the hope of reducing the burden of cervical cancer in the region. # PROSPERO registration number -- CRD42018102539.

Opportunities and challenges for introducing HPV testing for cervical cancer screening in sub-Saharan Africa

To protect women against cervical cancer, the World Health Organization recommends that women aged 30 to 49 years be screened with tests that detect human papillomavirus (HPV). If the countries that have the greatest burden of this disease—especially those in sub-Saharan Africa—are not to be left behind, we must understand the challenges they face and identify measures that can help them take full advantage now of innovations that are transforming screening services in wealthier countries. We reviewed policy documents and published literature related to Kenya, Tanzania, and Uganda, and met with key personnel from government and nongovernmental organizations.National policy makers understand the value of HPV testing in terms of its superior sensitivity and the programmatic advantages that could result from using self-collected samples. However, while these countries have national cervical cancer prevention strategies, and some have national departments or units for cervical cancer prevention, screening is rare, funding scarce, and quality low. Age guidelines are not strictly followed, with scarce resources being used to screen many women younger than the recommended ages.Published evidence of the benefits of HPV testing—including performance, safety, and cost-effectiveness—must be provided to ministry of health leaders, along with information on anticipated costs for training personnel, purchasing supplies, providing facility space, and maintaining test kits. Despite the obstacles, a joint effort on the part of global and national stakeholders to introduce molecular screening methods can bring better protection to the women who need it most.

Individual-level and community-level determinants of cervical cancer screening among Kenyan women: a multilevel analysis of a Nationwide survey

BackgroundStudies on the determinants of cervical cancer screening in sub-Saharan Africa have focused mostly on individual-level characteristics of cervical cancer screening. Therefore, in this study, we included both individual- and community-level indicators to examine the determinants of cervical cancer screening among Kenyan women.MethodsWe analyzed data from the 2014 Kenya Demographic and Health Surveys. Our analysis focused on 9016 married women of reproductive age (15–49 years). We conducted multilevel analyses using generalized linear mixed models with the log-binomial function to simultaneously analyze the association of individual- and community-level factors with cervical cancer screening.ResultsAbout 72.1% of women (n = 6498) knew about cervical cancer. Of these women, only 19.4% had undergone cervical cancer screening [58.24% Papanicolaou (Pap) test and 41.76% visual inspection]. Our multivariate analysis results indicated that the prevalence of cervical cancer screening was higher among women aged 35-49 years than women aged 15-24 years. The prevalence was also higher among women residing in the Central, Nyanza, and Nairobi regions than women residing in the Coastal region. Cervical cancer screening was more prevalent among women who had media exposure, had higher household wealth index, were employed, were insured, and had visit a health facility in 12 months than did their counterparts. The prevalence of Pap test history was 19% higher among women who had sexual autonomy than women who did not have sexual autonomy. The prevalence of Pap test history was also higher among communities comprised of higher proportions of women with sexual autonomy and higher education.ConclusionsPolicies should emphasize increasing gender equality, improving education at the community level, providing employment opportunities for women, and increasing universal health insurance coverage. These focal points can ensure equity in access to health care services and further increase the prevalence of cervical cancer screening in Kenya.

Cervical cancer risk and impact of Pap‐based screening in HIV‐positive women on antiretroviral therapy in Johannesburg, South Africa

Data on invasive cervical cancer (ICC) incidence in HIV-positive women and the effect of cervical cancer screening in sub-Saharan Africa are scarce. We estimated i) ICC incidence rates in women (≥18 years) who initiated antiretroviral therapy (ART) at the Themba Lethu Clinic (TLC) in Johannesburg, South Africa, between 2004 and 2011 and ii) the effect of a Pap-based screening program. We included 10,640 women; median age at ART initiation: 35 years [interquartile range (IQR) 30-42], median CD4 count at ART initiation: 113 cells/µL (IQR 46-184). During 27,257 person-years (pys), 138 women were diagnosed with ICC; overall incidence rate: 506/100,000 pys [95% confidence interval (CI) 428-598]. The ICC incidence rate was highest (615/100,000 pys) in women who initiated ART before cervical cancer screening became available in 04/2005 and was lowest (260/100,000 pys) in women who initiated ART from 01/2009 onward when the cervical cancer screening program and access to treatment of cervical lesions was expanded [adjusted hazard ratio (aHR) 0.42, 95% CI 0.20-0.87]. Advanced HIV/AIDS stage (4 versus 1, aHR 1.95, 95% CI 1.17-3.24) and middle age at ART initiation (36-45 versus 18-25 years, aHR 2.51, 95% CI 1.07-5.88) were risk factors for ICC. The ICC incidence rate substantially decreased with the implementation of a Pap-based screening program and improved access to treatment of cervical lesions. However, the risk of developing ICC after ART initiation remained high. To inform and improve ICC prevention and care for HIV-positive women in sub-Saharan Africa, implementation and monitoring of cervical cancer screening programs are essential.

Randomized trial evaluating self-sampling for HPV DNA based tests for cervical cancer screening in Nigeria

BackgroundCervical cancer incidence and mortality rates in Sub-Saharan Africa (SSA) remain high due to several factors including low levels of uptake of cervical cancer screening. Self-collection of cervicovaginal samples for HPV DNA testing may be an effective modality that can increase uptake of cervical cancer screening in SSA and hard to reach populations in developed countries. We investigated whether self-collection of cervicovaginal samples for HPV DNA tests would be associated with increased uptake of screening compared with clinic based collection of samples. Furthermore, we compared the quality of samples collected by both approaches for use in HPV genotyping.MethodsWe conducted a community based randomized trial in a semi-urban district of Abuja, Nigeria with 400 women, aged 30 to 65 years randomized to either hospital-collection or self-collection of cervicovaginal samples. We compared cervical cancer screening uptake among the 2 groups and evaluated the concentration of human DNA in the samples by measuring RNase P gene levels using qPCR. High-risk HPV DNA detection and typing was done using the GP5+/6+ Luminex system.ResultsMost participants in the self-collection arm (93%, 185/200) submitted their samples while only 56% (113/200) of those invited to the hospital for sample collection attended and were screened during the study period (p value < 0.001). Human genomic DNA was detected in all but five (1.7%) participants, all of whom were in the self-collection arm. The prevalence of high-risk HPV in the study population was 10% with types 35, 52 and 18 being the commonest.ConclusionsOur study shows that self-sampling significantly increased uptake of HPV DNA based test for cervical cancer screening in this population and the samples collected were adequate for HPV detection and genotyping. Cervical cancer screening programs that incorporate self-sampling and HPV DNA tests are feasible and may significantly improve uptake of cervical cancer screening in SSA.

Performance of alternative strategies for primary cervical cancer screening in sub-Saharan Africa: systematic review and meta-analysis of diagnostic test accuracy studies

Objective To assess and compare the accuracy of visual inspection with acetic acid (VIA), visual inspection with Lugol’s iodine (VILI), and human papillomavirus (HPV) testing as alternative standalone methods for...