Lo que piensan las mujeres: Conocimientos y percepciones sobre cáncer de cuello de útero y realización de PAP

En la Argentina la mortalidad por cáncer de cuello de útero no ha tenido descensos significativos en los últimos cuarenta años (Arrossi et al, 2003) y la distribución de la carga del cáncer de cuello de útero es extremadamente desigual: las tasas de mortalidad de las provincias de las regiones Noreste y Noroeste (alrededor de 15/100.000) son entre tres y cuatro veces más altas que la de la Ciudad de Buenos Aires (4/100.000) (Arrossi et al, 2008). Uno de los principales problemas en estas regiones es la baja cobertura del tamizaje: según la Encuesta Nacional de Factores de Riesgo del año 2009, en las regiones Noreste y Noroeste, sólo el 46%de las mujeres entre 35 y 64  años  sin cobertura de salud se había realizado un PAP en los dos años anteriores a la encuesta (MSAL, 2009, mientras que en otras regiones, la cobertura es mayor. Por ejemplo, en las regiones Sur y Centro, la misma supera el 60%. A pesar de la baja cobertura del tamizaje y tratamiento que presentan las regiones de Argentina más afectadas por la enfermedad, la evidencia acerca de la percepción y el conocimiento que tienen las mujeres de estas áreas sobre la prevención y tratamiento del cáncer de cuello de útero es prácticamente inexistente. En ese contexto, se llevó a cabo la presente investigación formativa cuyo objetivo es analizar el conocimiento y las percepciones de mujeres de cuatro de las provincias argentinas con mayor mortalidad por esta causa (Jujuy, Misiones, Salta y Chaco) y la Provincia de Buenos Aires acerca del cáncer de cuello de útero, sus causas y métodos de prevención y tratamiento, e identificar las barreras de acceso a los servicios de tamizaje.  El propósito final del trabajo es contar con información que permita el diseño e implementación de estrategias de aumento de la cobertura del tamizaje teniendo en cuenta la perspectiva de las mujeres. Estas provincias, por su elevada tasa de mortalidad por cáncer de cuello de útero, fueron identificadas como prioritarias para las acciones  del Programa Nacional de Prevención de Cáncer Cérvico-uterino.Fil: Zamberlin, Nina. Ministerio de Salud de la Nación; ArgentinaFil: Thouyaret, Laura. Ministerio de Salud de la Nación; ArgentinaFil: Arrossi, Silvina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Centro de Estudios de Estado y Sociedad; Argentin

Changing the paradigm of cervical cancer prevention through introduction of HPV-testing: evaluation of the implementation process of the Jujuy Demonstration Project in Argentina

Introduction: The Jujuy Demonstration Project (JDP) was a project carried out over the course of 4 years (2011-2014) to develop, implement and evaluate the programmatic components of a Human Papilloma Virus (HPV)-based screening programme in Argentina. The aim of this paper is to present a qualitative evaluation of the context and implementation process of the JDP. Methods: We used an adaptation of the Health System Framework (HSF), which includes interconnected contextual factors that are considered key drivers for successful health interventions. We reviewed secondary documents, which included scientific reports, norms and regulations, information sheets, power point presentations and manuals and recommendations published by the National Programme for Cervical Cancer Prevention. We also carried out semi-structured interviews with key informants to explore their views about technology acceptability. Results: Key components of the JDP implementation process were: a high level of political support and consensus among stakeholders, the demonstrated effectiveness of the technology and its acceptability by health authorities and providers, the funding of tests and diagnosis/treatment services, the implementation of an information system for monitoring and evaluation and the reorganisation of the network of screening, diagnosis and treatment services. Conclusion: This analysis examines the policy context in which the JDP was implemented and the system components that were key for the demonstrated effectiveness of the strategy. Such analyses provide useful insights into core components of HPV testing implementation that are needed to guarantee its potential effectiveness to reduce cervical cancer incidence and mortality.Fil: Arrossi, Silvina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Centro de Estudios de Estado y Sociedad; ArgentinaFil: Paolino, Melisa Delia. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Ramos Mejía"; ArgentinaFil: Laudi, Rosa Maria del Valle. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Ramos Mejía"; ArgentinaFil: Thouyaret, Laura. Ministerio de Salud. Instituto Nacional del Cáncer; Argentin

Adherence to triage among women with HPV-positive self-collection: A study in a middle-low income population in Argentina

Introduction: Screening for cervical cancer (CC) prevention has substantially changed with the introduction of human papillomavirus (HPV) tests. This technology compared to cytology has increased the detection of pre-malignant and malignant cervical lesions in real-world programmes in different settings. Very importantly, through self-collection, HPV testing can reduce barriers to screening and increase coverage. However, when using HPV self-collection, triage tests are a key step in the CC prevention process, and high adherence to triage has been difficult to obtain in low-middle income settings. The aim of this study was to measure adherence to triage among women with HPV+ self-collection and analysed factors associated with this adherence in a middle-low resource setting in Argentina. We also evaluated key indicators related to the implementation of the HPV self-collection strategy. Methods: We analysed data on screening/triage/diagnosis/treatment from women aged 30+ who performed self-collection between 2015 and 2017 (n = 15,763), in the public health system in Tucuman, Argentina. We analysed secondary data from the national screening information system. The primary outcomes were: 1) adherence to cytology triage within the recommended timeframe (120 days) and 2) overall adherence to cytology triage including data at 18 months after screening. Multivariable regression was used to examine the association between age group, year of the screening test, record of the previous Pap-based screening and health insurance status with adherence to triage test as a primary outcome. We reported odds ratios, 95% confidence intervals and p-value of 0.05, which was considered the threshold for p-values). Results: We analysed data of 2,389 HPV+ women. The overall adherence to triage at 18 months was 42.9%. The percentage of women completing cytology triage within the recommended timeframe of 120 days was lower (25.2%). Women with the record of a previous Pap-based screening had 1.86 times the odds of having a triage compared to women without a record of a previous Pap-based screening (95% CI: 1.64-2.64, p <0.001). Furthermore, the probability of having triage at the recommended timeframe was higher among women who were older and women with public health insurance. Conclusions: Our results showed that adherence to triage in the recommended timeframe was low. In addition, the probability of having triage at the recommended timeframe was higher among women with a record of a previous Pap-based screening, a proxy of the use of health services. Our results showed that adherence to triage in the context of the HPV-self-collection strategy is challenging. The implementation of alternative approaches that might facilitate adherence to triage should be further investigated.Fil: Paolino, Melisa Delia. Centro de Estudio de Estado y Sociedad; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Gago, Juan. University Of New York. School Of Medicine.; Estados UnidosFil: Le Pera, Anabella Hebe. Centro de Estudio de Estado y Sociedad; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Cinto, Oscar. Provincia de Tucuman. Ministerio de Salud; ArgentinaFil: Thouyaret, Laura. Ministerio de Salud. Instituto Nacional del Cáncer; ArgentinaFil: Arrossi, Silvina. Centro de Estudio de Estado y Sociedad; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Eff ect of self-collection of HPV DNA off ered by community health workers at home visits on uptake of screening for cervical cancer (the EMA study): a population-based cluster-randomised trial

Background Control of cervical cancer in developing countries has been hampered by a failure to achieve high screening uptake. HPV DNA self-collection could increase screening coverage, but implementation of this technology is diffi cult in countries of middle and low income. We investigated whether off ering HPV DNA self-collection during routine home visits by community health workers could increase cervical screening. Methods We did a population-based cluster-randomised trial in the province of Jujuy, Argentina, between July 1, 2012, and Dec 31, 2012. Community health workers were eligible for the study if they scored highly on a performance score, and women aged 30 years or older were eligible for enrolment by the community health worker. 200 community health workers were randomly allocated in a 1:1 ratio to either the intervention group (off ered women the chance to self-collect a sample for cervical screening during a home visit) or the control group (advised women to attend a health clinic for cervical screening). The primary outcome was screening uptake, measured as the proportion of women having any HPV screening test within 6 months of the community health worker visit. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02095561. Findings 100 community health workers were randomly allocated to the intervention group and 100 were assigned to the control group; nine did not take part. 191 participating community health workers (94 in the intervention group and 97 in the control group) initially contacted 7650 women; of 3632 women contacted by community health workers in the intervention group, 3049 agreed to participate; of 4018 women contacted by community health workers in the control group, 2964 agreed to participate. 2618 (86%) of 3049 women in the intervention group had any HPV test within 6 months of the community health worker visit, compared with 599 (20%) of 2964 in the control group (risk ratio 4·02, 95% CI 3·44–4·71). Interpretation Off ering self-collection of samples for HPV testing by community health workers during home visits resulted in a four-fold increase in screening uptake, showing that this strategy is eff ective to improve cervical screening coverage. This intervention reduces women’s barriers to screening and results in a substantial and rapid increase in coverage. Our fi ndings suggest that HPV testing could be extended throughout Argentina and in other countries to increase cervical screening coverage

Programmatic human papillomavirus testing in cervical cancer prevention in the Jujuy Demonstration Project in Argentina: a population-based, before-and-after retrospective cohort study

Background: Human papillomavirus (HPV) testing for cervical cancer prevention was introduced in Argentina through the Jujuy Demonstration Project (2011-14). The programme tested women aged 30 years and older attending the public health system with clinician-collected HPV tests. HPV self-collection was introduced as a programmatic strategy in 2014. We aimed to evaluate the effectiveness of programmatic HPV testing to detect cervical intraepithelial neoplasia (CIN) of grade 2 or worse (CIN2+) in comparison with cytology-based screening. Methods: We did a population-based, before-and-after retrospective cohort study using data from the National Cervical Cancer Prevention Program for the Jujuy province in northwest Argentina. We obtained data for the cytology-based screening period from Jan 1, 2010, until Dec 31, 2011, and for the HPV-based screening period from Jan 1, 2012, until Dec 31, 2014. The primary outcome was detection of histologically diagnosed CIN2+ among women aged 30 years and older. To assess the outcomes in all individuals included in the study, we used multivariable logistic regression and propensity score matching. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was used for the before-and-after analysis of programmatic dimensions. Findings: Of the 29 631 women who underwent cytology-based screening in 2010?11, CIN2+ was detected in 236 (0·8%) individuals. Of the 49 565 women HPV tested in 2012?14 (clinician-collected tests, n=44 700; self-collection tests, n=4865), 693 (1·4%; 658 clinician-collected tests; 35 self-collection tests) were found to have CIN2+ after the first round of screening. Compared with cytology-based screening, the odds ratio of being diagnosed with a CIN2+ lesion was 2·34 (95% CI 2·01?2·73; p<0·0010) with clinician-collected tests, and 1·08 (0·74?1·52; p=0·68) when screened with self-collection tests, after controlling for age and health insurance status. Screening coverage was similar in both periods (52·7% vs 53·2%); improvements of programmatic indicators were observed in the HPV testing period in relation to laboratory centralisation, lower overscreening (6·6% vs 0·0%), higher adherance to age recommendations (79·3% vs 98·8%), and a decrease of inadequate samples (3·6% vs 0·2%). Interpretation: HPV testing in middle-income settings increases detection of CIN2+ lesions and allows for improvement of programmatic indicators. Evidence suggests that the introduction of HPV testing will accelerate the reduction of cervical cancer burden. Funding: Argentinian National Cancer Institute and National Council of Scientific and Technologic Research.Fil: Arrossi, Silvina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Centro de Estudios de Estado y Sociedad; ArgentinaFil: Paolino, Melisa Delia. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Centro de Estudios de Estado y Sociedad; ArgentinaFil: Laudi, Rosa. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Ramos Mejía"; ArgentinaFil: Gago, Juan Ezequiel. Centro de Estudios de Estado y Sociedad; Argentina. Ministerio de Salud. Instituto Nacional del Cáncer; ArgentinaFil: Campanera, Alicia. Ministerio de Salud de la Provincia de Jujuy; ArgentinaFil: Marín, Oscar. Hospital Pablo Soria; ArgentinaFil: Falcón, Cristina. Hospital Pablo Soria; ArgentinaFil: Serra, Verónica. Ministerio de Salud de la Provincia de Jujuy; ArgentinaFil: Herrero, Rolando. No especifíca;Fil: Thouyaret, Laura. Ministerio de Salud. Instituto Nacional del Cáncer; Argentin

Lo que piensan las mujeres: conocimientos y percepciones sobre cáncer de cuello de útero y realización del Pap

Área de Salud, Economía y Socieda

Prevención del cáncer cervicouterino: recomendaciones para el tamizaje, seguimiento y tratamiento de mujeres en el marco de programas de tamizaje basados en el test de VPH: actualización 2015

Este documento tiene por objetivo unificar los criterios de acción para el tamizaje, seguimiento y tratamiento de mujeres para la prevención del CCU (cáncer cérvico-uterino), en el marco de la incorporación de la prueba de VPH (Virus de Papiloma Humano) como tamizaje primario en la ArgentinaÁrea de Salud, Economía y Socieda

La comunicación en una estrategia integral para mejorar la participación de las mujeres en los programas de tamizaje de cáncer cérvico-uterino: la experiencia del Programa Nacional de Prevención de Cáncer Cérvico-uterino

Área de Salud, Economía y Socieda

Rotafolio: test de VPH y prevención del cáncer de cuello de utero: material de apoyo para el equipo de salud

Área de Salud, Economía y Socieda

Changing the paradigm of cervical cancer prevention through introduction of HPV-testing: evaluation of the implementation process of the Jujuy Demonstration Project in Argentina

Fil: Arrossi, Silvina. CEDES. Centro de Estudio de Estado y Sociedad. Área de Salud, Economía y Sociedad. Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET); ArgentinaFil: Paolino, Melisa. CEDES. Centro de Estudio de Estado y Sociedad. Área de Salud, Economía y Sociedad. Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET); ArgentinaFil: Laudi, Rosa. Hospital Ramos Mejía; ArgentinaFil: Thouyaret, Laura. Programa Nacional de Prevención de Cáncer Cervicouterino. Instituto Nacional del Cáncer; ArgentinaIntroduction: The Jujuy Demonstration Project (JDP) was a project carried out over the course of 4 years (2011–2014) to develop, implement and evaluate the programmatic components of a Human Papilloma Virus (HPV)-based screening programme in Argentina. The aim of this paper is to present a qualitative evaluation of the context and implementation process of the JDP. Methods: We used an adaptation of the Health System Framework (HSF), which includes interconnected contextual factors that are considered key drivers for successful health interventions. We reviewed secondary documents, which included scientific reports, norms and regulations, information sheets, power point presentations and manuals and recommendations published by the National Programme for Cervical Cancer Prevention. We also carried out semi-structured interviews with key informants to explore their views about technology acceptability. Results: Key components of the JDP implementation process were: a high level of political support and consensus among stakeholders, the demonstrated effectiveness of the technology and its acceptability by health authorities and providers, the funding of tests and diagnosis/treatment services, the implementation of an information system for monitoring and evaluation and the reorganisation of the network of screening, diagnosis and treatment services. Conclusion: This analysis examines the policy context in which the JDP was implemented and the system components that were key for the demonstrated effectiveness of the strategy. Such analyses provide useful insights into core components of HPV testing implementation that are needed to guarantee its potential effectiveness to reduce cervical cancer incidence and mortalit