Mapping Evidence on Management of Cervical Cancer in Sub-Saharan Africa: Scoping Review Protocol

doi:10.21203/rs.3.rs-23265/v1

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Mapping Evidence on Management of Cervical Cancer in Sub-Saharan Africa: Scoping Review Protocol

https://doi.org/10.21203/rs.3.rs-23265/v1

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Background

Cancer is a non-communicable disease, and is the number two leading cause of death globally. Among all cancers, cervical cancer is the number one killer of women in Low-Income countries (LICs). Cervical cancer is a well understood preventable cancer. The rates of cervical cancer are very varied and inversely proportional to effectiveness of disease management policies. Management of cervical cancer includes: prevention, screening, diagnosis and treatment. The main objective of this scoping review is to map evidence on cervical cancer management in sub-Saharan Africa (SSA) to understand the coverage of cervical cancer prevention and treatment services and provide an opportunity to generate knowledge on risk factors, attitudes and practices extendable globally.

Methods and analysis

This review will be guided by Arksey and O’Malley’s framework recommended for conducting scoping review studies. The Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews (PRISMA-Scr) checklist will also be completed to ensure that the review adheres to sound methodological rigour acceptable for scoping review studies. The following electronic databases will be search for potentially eligible articles: PubMed, Ebsco Host, Scopus and Cochrane Database of Systematic Reviews. Study screening procedures recommended by Higgins and Deeks will be followed.

Discussion

Cervical cancer can become a disease of the past with a proper control strategy in place. It is therefore imperative to map available evidence on management of cervical cancer to inform policy and advocacy action. More knowledge on the status quo will guide policy makers in ensuring cancer management guiding policies are formulated/updated/ revised accordingly.

Scoping review registration: Not registered with PROSPERO (not needed).

Protocol and registration: This scoping review was not registered.

Health Economics & Outcomes Research

cervical cancer management

control

prevention

screening

diagnosis

HPV vaccine

treatment

surgery

chemotherapy

radiotherapy

Sub-Saharan Africa

Approximately 527 600 new CC cases, 265 700 deaths were recorded worldwide in 2012 (4). In SSA, CC is the leading cause of cancer deaths among females(5). t is estimated that 90% of CC deaths occurred in developing countries, 25% in India (67 500), 60 100 deaths in Africa, 144 400 in Asia and 28 600 in the Caribbean Bay and Latin America (6). Variations in CC rates are due to difference in availability of screening that provide for the detection and treatment of precancerous lesions as well as HPV infection prevalence(7). HPV infection prevalence is highest in Africa (21%), Latin America and the Caribbean (16%), Asia (9%) and North America (5%) (6). In some Western countries CC rates decreased by 65% (6). In Norway, CC incidence decreased from 18.7 per 100 000 in 1970 to 9.6 per 100 000 in 2011 due to well established screening programs (6). In USA, the overall cancer death rate dropped by 27% from 1991 to 2016 whilst in developing countries mortality rates were 2-fold higher for CC over the same period (8). In USA CC was the leading cause of cancer death among women in 1930, the death rate was 36 /100 000, dropped to 5.6 in 1975 and to 2.3 in 2015 due to the development and implementation of PAP test, improved treatment of CC and HPV vaccination with an uptake rate of 47.5% in 2016 (4). In SSA the greatest threat to CC management is unavailability of vaccines, information, treatment and monitoring. CC is a neglected area of women’s health in LICs (3).

Low-Income Countries recognise the importance of HPV vaccination but getting the resources for the vaccine has been a challenge. Two vaccines, Gardasil and Cervarix are available for protection against two types of HPV that cause approximately 70% of CC cases (6). The major barrier to the use of the vaccines is their high cost (9). On the other hand, HPV vaccines do not protect against already existing infections and do not protect against all the types of HPV that cause CC (10), therefore screening is a critical component of CC management. Pap test is the most common screening tool for CC in developed countries, while in LICs it is generally inaccessible or met with resistance due to misinformation or poor attitudes (11). Imperative to note here that, a single round HPV testing can reduce the number of CC deaths by about 50% (6).

Cervical cancer is the mostly screened cancer worldwide(12). Cervical cytology screening programs using Papanicolaou every 3 to 4 years reduced CC incidence and mortality by approximately 80% in developed countries like North America, Europe, New Zealand, Japan and Australia (13). Screening tests like liquid-based cytology, conventional cytology, HPV testing, visual inspection with acetic acid (VIA), visual inspection with Lugol’s iodine (VILI) can detect CIN, if done with quality assurance(14).

Worldwide, 740 women die every day due to CC (15). In Uganda, 5-year age-adjusted standardized survival is as low as 19.8 years (16). HIV-positive people are a high-risk group for HPV infections (17), yet SSA account for over 70% of global HIV/AIDS burden(18).

HPV testing superiority in reducing mortality from CC was published in 2009 (19), while Australia and Netherlands were the first countries to implement HPV-based screening in their national programs in 2006 (19).

Cervical cancer control is defined as activities to reduce the CC burden through dissemination and implementation of evidence-based interventions (20). The interventions include prevention, early detection (screening and diagnosis) and treatment (20). Improvements in CC screening, involve addressing systems challenges and changing policies of public health structural interventions which alter structural context for health and are often politicised (21). Women are more likely to seek help when the disease is already at advanced stages (22). Any screening test will have an impact only if it is introduced in a well-planned implemented screening programme (23). Approximately, 90% of deaths occur in LICs (19), but it is technically possible to control CC globally.

Prevention of suffering and death from CC is a human rights issue and CC should be given a top priority on the public health agenda. Incidence, survival and death rates can be used to measure progress in CC control with death rates being the best indicator.

Scoping review The proposed scoping review will be conducted in accordance with Arksey and O’Malley’s (2005) scoping review framework. (24) indicates that the following steps should be undertaken when conducting scoping reviews: (a) identifying the research question; (b) identifying relevant studies; (c) selecting studies; (d) charting the data and (e) collating, summarising and reporting the results. The review will also follow the steps and guidelines outlined in the PRISMA-Extension for Scoping Reviews (PRISMA-ScR) checklist (25) .

Identifying the research question

The proposed hypothesis for this review is: CC management needs improvement in SSA. The main research question is: What evidence is there on CC management in SSA? The sub research questions include:

What is the usage/coverage of HPV vaccine in SSA?
What are barriers to CC screening uptake in SSA?
At what stage of CC are most diagnoses made?
Which drugs are being used for chemotherapy in CC treatment in SSA?
What is the status of radiotherapy in CC management in SSA?

The aim of this review is to map evidence on CC management in SSA. The objectives of the study are:

To explore on the coverage/usage of HPV vaccine in SSA;
To determine the barriers to CC screening uptake in SSA;
To find out the stages at which most CC is diagnosed in SSA;
To establish the status of radiotherapy in CC management in SSA and
To determine the drugs that are being used in CC treatment.

Identifying relevant studies

An initial search was performed to determine whether a previous review addressing this topic in SSA was conducted or was in progress. There were no complete or in-process reviews focusing on the coverage of cervical cancer prevention and treatment services in SSA. Based on the review question, the search strategy was developed by identifying the key concepts using the PICO (Problem/Intervention/Comparison/Outcome) approach (26) and further developing the search strategy using controlled vocabulary such as MeSH (Medical Subject Headings) terms. Papers published on CC management will be reviewed for each of the following topics: CC prevention, detection (screening and diagnosis) and treatment. A healthcare librarian from the University of Zimbabwe was consulted for the search strategy of electronic databases. The following key search words will be used: CC management or CC control; CC screening or VIAC or PAP smear or HPV testing; CC prevention or HPV vaccine’s; CC surgery; CC treatment or chemotherapy; CC radiotherapy. African country names and truncated terms such as ‘east* Africa’ will also be used to ensure that articles indexed using African country specific names or regional terms are retrieved.The operator ‘or’ will be used to combine synonyms; and the operator ‘and’ to filter to results which contain all the required terms. Peer Review of Electronic Search Strategies (PRESS) Checklist is used for the search strategy. The databases to be searched include: PubMed, Ebsco Host, Scopus and Cochrane Database of Systematic Review.

Study selection

Two independent reviewers will conduct abstracts and full article screening. The literature will include published peer-reviewed journal articles with evidence of empirical design utilising either qualitative, quantitative or mixed method research approach addressing the research questions. The screening procedure will be guided by Higgins and Deeks’ framework (27). All articles identified to be potentially eligible for inclusion in this review will be obtained in full texts. These articles will be then be exported to reference management software, EndNote version X7. Duplicates will then be removed before further screenings (abstract and full article) are conducted. The PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) flow chart will be used to display screening results of studies (28) (Fig. 1).

Eligibility criteria

Inclusion criteria

The inclusion criterion was guided by the following principles to determine articles relevant for this review:

Studies presenting evidence on cervical cancer
Studies presenting evidence conducted in SSA
No limits will be applied for publication date of included studies.
All study designs will be considered

Exclusion criteria

Studies that do not focus on humans, as well as those written in languages other than English will be excluded. Non-empirical material like book chapters, opinion papers, commentaries and editorials will also not be included.

Data extraction and charting

A data collection instrument (Table 1) was developed to confirm study characteristics as well as relevance. Data will be extracted by the principal investigator. The data extraction form will include the following elements: author(s), year of publication, title of study, country, study aim(s) or research question, study design, study setting (urban/rural), study population, sample size, key findings that relate to the review question, study limitations and implications and interpretations and conclusions from the authors. Data will be entered into Access and qualitative data will be uploaded in NVivo, a computer assisted qualitative data analysis software.

Data analysis

A narrative synthesis will be used, with data synthesised and interpreted using sifting, charting and sorting based on themes, key issues and type of study. Citation tracking will be done using Reference Manager Software in Endnote version X7. Data analysis and tabulation of the findings will be done using Review Manager (RevMan) (29). The narrative synthesis approach (30) will help summarise and identify patterns across studies using tabulations, clustering, textual descriptions, conceptual triangulation (concept mapping) and thematic analysis. Textual data summary will be tabulated from qualitative, mixed methods and quantitative studies. Descriptive statistics will also be used to quantify studies based on the patterns identified. Directed content analysis methods will be used on abstracted data to identify patterns or themes that characterise factors that affect CC management.

Quality control and assessment

Studies that will be published between the research and report writing will be obtained by subscribing to updates to databases using the search domains used during literature search. Data will be extracted by principal investigator and accuracy will be checked by a second reviewer. Studies with uncertainties about their inclusion will be discussed with a third reviewer.

The quality of evidence will be assessed based on guidance in National Institute for Health and Care Excellence single technology appraisal Specification for Manufacturer/Sponsor Submission of Evidence adapted from the Centre for Reviews and Dissemination’s guidance for undertaking reviews in health care (30). Mixed Method Quality Appraisal Tool will be used for quality assurance (13), with aspects like: published in a peer reviewed journal and evidence of sample size calculation will be used to assess quality of included studies. Dissemination of the results will include publications in journals and presentations at health conferences.

Cervical cancer deaths and incidence rates are still high in SSA(31).The rate of control achieved depends on prevention (vaccination and screening) policies. Vaccination of girls has a long term effect on cancer rates because of the long period (1–40 years) (19) from HPV infection to invasive CC, hence control will remain crucial for a long time into the future.

Global research has shown that among the ways to prevent CC, CC screening and follow-up has the greatest or second greatest impact after vaccination, hence lives can be saved by comprehensive application of available evidence-based interventions to all females who could be affected by CC. The results of the scoping review will be used to inform health policy and knowledge to end users regarding strategies that can be used to facilitate CC control. The review will be used to identify research gaps that need to be addressed in CC management. Furthermore, this review will provide a complete and reliable picture of how CC control is being managed in the region, the challenges and opportunities of CC management will be highlighted (32). The results of this review may likely contribute to women’s understanding of the relationship between HPV and CC for them to make appropriate, evidence-based decisions on available prevention strategies (33). This scoping review will contribute in informing guidelines regarding CC control and management.

The outlook for CC control is bright since the knowledge of what to do is there and the tools to do prophylactic interventions which include, vaccination of the girls, screening and preventive treatment for adult women are well known. Treatment of precancerous lesions is of low cost compared to cost of invasive cancer treatment (which is not readily accessible to many women) (34). It is detrimental to fail to use tools and knowledge for HPV vaccination, screening, and preventive treatment that have saved lives in HICs. Communities need to act urgently to save women and girls from this monster called CC .Cervical cancer is a well-known and preventable cancer and the rates of CC are very varied and are inversely proportional to effectiveness of prevention policies. We could not find mapped evidence on CC management processes to explain the increasing CC deaths and incidence.

Cervical Cancer

CIN

Cervical intraepithelial neoplasia

HICs

High Income Countries

HPV

Human Papilloma Virus

LICs

Low Income Countries

LMICs

Low and Middle Income Countries

MeSH

Medical Subject Headings

PAP

Papanicolaou

PICO

Problem/Intervention/Comparison/Outcome

PRESS

Peer Review of Electronic Search Strategies

PRISMA

Preferred Reporting Items for Systematic Review and Meta-Analysis

PROSPERO

International prospective register of systematic reviews;

RevMan

Review Manager

SSA

Sub-Saharan Africa

VIAC

Visual Inspection with Acetic Acid and Camera

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and materials

All data generated or analyzed during this study will be included in the published systematic review article.

Competing interests

The authors declare that they have no competing interests.

Funding

Funding for the scoping review was is applicable, however, the full study for for primary data is funded by the University of KwaZulu-Natal College of health sciences Doctoral research Scholarship grant.

Authors’ contributions

PM conceptualized the study under the supervision of TG, NT and SM and designed data collection methods. PM and MH will review the papers for inclusion in the review with disagreements resolved by TG. All authors contributed to the writing and review of the final manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to thank the University of KwaZulu-Natal (UKZN) for funding the full study. Standard disclaimer applies.

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Due to technical limitations, Table 1 is provided in the Supplementary Files section.

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Editorial decision: Major revision
25 Feb, 2021
Review #1 received at journal
11 Feb, 2021
Reviewer #1 agreed at journal
30 Dec, 2020
Reviewers invited by journal
29 Dec, 2020
Editor assigned by journal
22 Apr, 2020
Editor invited by journal
21 Apr, 2020
First submitted to journal
17 Apr, 2020
Submission checks completed at journal
17 Apr, 2020

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Mapping Evidence on Management of Cervical Cancer in Sub-Saharan Africa: Scoping Review Protocol

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Abstract

Background

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