Implementation of a Cervical Cancer Tumor Board to optimize patient care and follow-up at a rural hospital in Malawi

doi:10.21203/rs.3.rs-3313259/v1

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Research Article

Implementation of a Cervical Cancer Tumor Board to optimize patient care and follow-up at a rural hospital in Malawi

https://doi.org/10.21203/rs.3.rs-3313259/v1

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Cervical cancer is Malawi's most diagnosed and highest mortality cancer. Due to a lack of screening, it is often diagnosed at an advanced stage. It has poor survival outcomes because treatment is not always available, patients are not quickly engaged in care and follow-up can be challenging for patients, especially those living far from a secondary facility. We set up a multidisciplinary team-based cervical cancer tumor board (CCTB) to better capture and care for clients at risk for cervical cancer and those with a new diagnosis. In February 2019, we initiated a monthly cervical cancer CCTB to enroll, review and discuss management for clients with suspected cervical cancer lesions. Specifically, we developed a cervical cancer registry to log suspects at Neno District Hospital. Our CCTB team members included cervical cancer screening providers, obstetrics and gynecology clinicians, and palliative care, laboratory, and community health workers representative. Any client with findings that required confirmation of cervical cancer diagnosis through a biopsy following cervical cancer screening was enrolled. Once enrolled, patients were followed continuously for final pathology results, treatment planning, and outcomes including referrals for surgeries and death. Between 1 February 2019, and 30 April 2021, an estimated 4,822 Visual Inspections with Acetic Acid (VIAs) were performed in the district. We enrolled 72 clients from those initial screenings with suspected cervical cancer. We found a high linkage to care for clients of 97%. All women enrolled in the CCTB had their results for biopsies available (100%). Total loss to care was very minimal at 2% for premalignant lesions. Out of the clients enrolled in CCTB, 39.8% (n = 37) had cervical cancer and among them, 73.0% were successfully staged.

Cervical cancer-focused CCTB is an effective way to follow clients with suspected and diagnosed cervical cancer to ensure appropriate treatment and subsequent follow-up. We demonstrated that CCTB could be successfully implemented in rural Malawi at the district hospital level.

Tumor Board

Cervical Cancer

Linkage to care

Premalignant lesions

Screening

Malawi

According to World Health Organisation (WHO), cervical cancer is the second most common cancer globally and the leading cause of cancer deaths among women [1]. In 2018 alone, about 510,000 women and 311,000 women were diagnosed with cervical cancer and died from the disease respectively [2]. Low and middle-income countries (LMICs) are disproportionately affected by the disease, with approximately 90% of the deaths occurring in LMICs [3, 4].

In south-eastern Africa, Malawi has the highest age-standardized incidence rate for cervical cancer, estimated at 72.9 cases per 100,000 women [5]. Among several studies conducted in Malawi, cervical cancer is the most commonly diagnosed cancer, accounting for 50% of all cancers [6–9]. Cervical cancer mortality in Malawi is also the highest globally, estimated at 49.8 per 100,000 women [4]. The high mortality of the disease, most commonly associated with late diagnosis, was highlighted in a recent study at Queen Elizabeth Central Hospital where 56% of patients were diagnosed with advanced-stage cancer during their first screening visit [10]. Reasons for late diagnosis and poor survival have been attributed to poor linkage to care for cervical cancer suspects, shortage of staff, lack of essential equipment and supplies, lack of supervision, and the use of male service providers [11].

Studies have shown that cervical cancer mortality can be achieved by timely and appropriate screening, treatment, and follow-up of eligible women [5, 8, 10, 12]. As a prevention strategy, cervical cancer screening with same-day treatment for pre-malignant lesions helps to improve the uptake of screening, ensures early case detection and treatment, and provides an opportunity for long-term follow-up. For LMICs, visual inspection of the cervix using acetic acid (VIA) by trained healthcare providers, followed by same-day treatment with cryotherapy or thermo-coagulation has been a cost-effective strategy for cervical cancer prevention [13]. Many studies have demonstrated improved case yield and good outcomes when using VIA and cryotherapy/thermo-coagulation as a secondary prevention method for cervical cancer [14–16].

Based on this screening strategy, Malawi has been implementing a cervical cancer control program using VIA and cryotherapy/thermo-coagulation for pre-malignant cervical lesions as a method of choice since 2004 [17–19]. In the current program, VIA and treatment for pre-malignant lesions have been provided as part of an integrated maternal and child health program, and sometimes within HIV and STI clinics, and cryotherapy or thermo-coagulation has been provided by the same provider. In many facilities, nurses who are the most common cadre of healthcare workers in Malawi provide these services [20].

Despite improvements in uptake of VIA and treatment with cryotherapy or thermo-coagulation in Malawi for pre-malignant lesions, lack of proper systems, referral pathways, and follow-up for women with VIA-positive lesions of more than 75% or women with lesions suspicious of cervical cancer (known as a large cervical lesion) remain a major challenge in Malawi [21]. Linking this group to appropriate follow-up and care is essential to reducing cervical cancer morbidity and mortality, as these women can be managed appropriately and timely [22, 23].

Several barriers to linkage to care for women with large cervical lesions after screening have been documented. Within the cervical cancer screening clinics both primary and secondary levels of care, women with large cervical lesions are referred for follow-up outside the clinics due to a lack of expertise in the management of these cases at the local level. Due to the lack of pathology services at the district hospital level in Malawi, women with large cervical lesions are often referred to tertiary hospitals for follow-up and management, a process that has been shown to delay the diagnosis of cervical cancer [24]. The delays are further worsened by the persistent staff shortages and lack of organized systems for identifying and tracking patients with large cervical lesions. More often, there is a communication breakdown between referring and referral facilities. As shown in other studies, there is a lack of community-based follow-up of women with large cervical lesions after the screening [25, 26]. Other community-level barriers to follow-up include lack of male partner involvement, long distances to referral facilities, lack of knowledge on cervical cancer and screening services, misperceptions about susceptibility to cervical cancer, and benefits of screening [12, 27, 28]. The COVID-19 pandemic has exacerbated the problem as governments in approximately 42% of countries worldwide completely or partially suspended cervical cancer screening services during the first wave of the pandemic [29].

Challenges with linkage to care for women with large cervical lesions after the screening were common in our setting in Neno district, a rural district in southern Malawi. Despite the ready availability of VIA and treatment with cryotherapy or thermo-coagulation, large gaps existed in the management of women with large cervical lesions after the screening. Before 2019, no follow-up data existed on patients diagnosed with large cervical lesions after the screening. No facility or community-level system to ensure follow-up of patients with large cervical lesions existed before 2019. For example, we did not know where patients were referred to after being diagnosed with a large cervical lesion, whether appropriate healthcare workers saw patients to determine the next treatment steps, whether these patients had cervical cancer biopsy taken, whether the patients received a proper diagnosis and whether patients were appropriately followed up.

In this paper, we describe a multidisciplinary cervical cancer tumor board aimed at improving the linkage and optimization of care for women diagnosed with large cervical lesions after the screening. Tumor boards (CCTBs) have been identified as key interventions to improve the care processes for clients with various cancers including cancer of the cervix [27, 28]. A tumor board is described as a committee of key staff members conducting case reviews and deciding on challenging cancer cases to determine the best care options for clients [27]. Some studies have demonstrated that CCTBs could improve the quality of life for cancer patients and those with lesions suspicious of cancer through notable improvements in retention and resulting in improved linkages to care pathways [17, 28, 30, 31]. After describing the role of the tumor board, we will proceed to describe a cohort of women with a large cervical lesion that was followed up between February 1, 2019, and April 30, 2021. Specifically, we will describe the proportion of women with a large cervical lesion who were enrolled in the CCTB and underwent cervical biopsy. Patients who had a biopsy taken will describe the turnaround time for biopsies, diagnoses after biopsy, the treatment, follow-up, and clinical outcomes. To our knowledge, this is the first rural district in Malawi to address challenges with linkage to care and follow-up among women with large cervical lesions after cervical cancer screening.

Setting and study design

This is a descriptive study describing the improvement in linkage to care and follow-up for women with large cervical lesions using a CCTB in Neno District, Malawi. Neno is a rural, impoverished district with an estimated population of 153,132 as of 2023 [32, 33]. The district is serviced by two hospitals (one district hospital and 1 community hospital) and 12 primary health centers [34].

Cervical cancer program in Neno District

Neno District started offering free cervical cancer screening services for all women aged between 25 and 49 years in 2010 [35]. Initially, the district was screening for cervical cancer using VIA and treating pre-malignant lesions using cryotherapy, before adding the treatment of pre-malignant lesions using thermo-coagulation in 2018. By 2020, all 14 health facilities were offering cervical cancer screening services with eight facilities offering VIA and cryotherapy/thermo-coagulation while the remainder of the facilities offered VIA only. In facilities offering VIA only, VIA-positive clients were referred to facilities with cryotherapy/thermocoagulation. Additionally, all eligible women who were being managed for HIV or non-communicable diseases in the integrated chronic care clinic were offered VIA and treatment of pre-malignant lesions on routine clinic appointments [34].

To support diagnosis and follow-up, the district offers free pathology services to all clients that require biopsies supported by a non-governmental organization called Partners In Health (PIH). Biopsy samples are sent to a private pathology laboratory about 2 hours away in the city of Blantyre. Additionally, the district has a weekly gynecology clinic run by clinical officers and supported by a physician at the district hospital.

According to Malawi cervical cancer national guidelines, VIA and cryotherapy/thermo-coagulation, and follow-up for VIA-positive women with cervical lesions up to 75% of the cervix is done by nurses. Women with cervical lesions over 75% of the cervix, however, are referred to a clinician for follow-up. For cervical lesions up to 75%, the program is managed by trained and dedicated nurses, with dedicated tools and a follow-up system [20]. Our efforts to increase VIA and cryotherapy/thermo-coagulation for cervical lesions of less than 75%, including integrating cervical cancer with HIV and NCD care, led to an increase in the uptake of VIA and treatment with cryotherapy/thermo-coagulation and this has been previously described. However, in women with lesions covering more than 75% of the cervix, lesions that the probe cannot easily fit and lesions suspicious of cervical cancer were supposed to be followed up by clinicians. For these women, no tools were available for referral, enrollment, and follow-up. However, this group of women is at risk of mortality, as late diagnoses are associated with poor outcomes [36].

Tumor board program in Neno District

Despite the success in the uptake of VIA and follow-up for lesions covering up to 75% of the cervix in Neno District, very limited information was available on follow-up and outcomes for patients with large cervical lesions. Specific challenges included a lack of registers to document and follow up with these women, lack of clinical protocols for management of these patients, limited staff to manage these patients, and lack of systems for following up with women when they are lost to follow up. Additionally, communication among staff managing these clients was not happening most of the time. Effectively managing these patients required communication between nurses who referred these patients, clinicians who will collect the biopsies, laboratory technicians who sent the samples for pathology, clinicians who received the results of pathology, clinicians who will give the results to the patients, and clinicians who will make follow up plan. As such, our experience showed a lack of follow-up for this category of patients by medical practitioners, LTFU by patients, and late diagnosis for cervical cancer of patients with large lesions.

To address the challenges highlighted, a CCTB was formulated with the District Ministry of Health (MoH) leadership. The aim was to identify and follow up with clients with large cervical lesions and ensure appropriate management is provided by healthcare workers. As such, CCTB was multidisciplinary (Table 1) including trained cervical cancer nurses, obstetrics and gynecology clinicians, HEAL fellows and representatives from the CHWs program, laboratory staff, and palliative care (Table 1).

Table 1

Tumor board team composition
Cadre	Number of people	Roles
Trained cervical cancer nurse provider	2	Bring information on patients who were referred to the tumor board and update the electronic register
Obstetrics and gynecology clinician	2	Responsible for arranging a biopsy, clinical follow-up, and management of the patient
HEAL fellows	2	Provide mentorship, guidance, and support to the tumor board team
Laboratory Technician	1	Bring hard copy biopsy results in fodder. These results were also sent to Neno from a private laboratory in Blantyre by email.
Palliative care representative	1	Bring a palliative care register and note clients requiring palliative care support
CHW supervisor	1	Record and track all patients from their households who needed to report to the district hospital to collect their biopsy results, to be done LEEP or Hysterectomy.
Notes: Health Equity, Action, and Leadership (HEAL) fellows are United States of America (USA) based obstetrics and gynecology specialists that spend up to 22 months in Neno since 2016.

Initially, the CCTB team conducted baseline data and reviewed over 5,000 patients to identify challenges and make solutions on how to follow up with women with large cervical lesions. This was followed by the creation of CCTB terms of reference, the CCTB electronic register to record women followed up in CCTB, the schedule of CCTB meetings, and more importantly, the clinical pathway for women with large cervical lesions. All women with large cervical lesions were referred to the gynecology clinic for a biopsy and enrollment into the tumor board for further follow-up (Fig. 1).

Figure 1: Referral Pathway for Visual Inspection with Acetic Acid

After collecting the biopsy, samples were sent to the Neno District Hospital laboratory which sent the samples to the pathology laboratory every Wednesday, or transport was available on any other day of the week. The pathology results were communicated to CCTB via a palliative care clinician who received the results via email from the pathology lab. The clinical follow-up of women depended on the outcome of the biopsies: repeat biopsy for non-diagnostic samples, pre-malignant management depending on CIN staging, staging and follow-up for cervical cancer, and gynecological clinic follow-up for all other results. (Fig. 2).

Figure 2: Referral Pathway for Cervical Carcinoma on Biopsy

The team developed an electronic register to record all clients enrolled in the CCTB for easy follow-up, and the register was updated during monthly meetings. During the register review, the CCTB team reviewed patients with biopsy results, and action items were shared with team members to follow up before the next meeting. For new biopsy results or if patients missed their appointment, patients were followed up using the community health worker program to ensure a visit to the gynecological clinic. Follow-up with a referral hospital was also planned if a patient was referred to a tertiary facility. If a woman was unable to come to the gynecological clinic or unable to go to a tertiary facility, social support, mainly in form of transport fare support, was provided by PIH. A WhatsApp group was created to ease communication among CCTB members.

Inclusion and exclusion criteria.

In this study, we included all women that were referred to the CCTB after VIA between February 1, 2019, to April 30, 2021. This included 1) VIA-positive women with cervical lesions larger than 75%, 2) VIA-positive women with a lesion that the cryotherapy or thermo-coagulation probe cannot easily fit the lesion 3) women with a lesion suspicious of cervical cancer. We called women fitting these three criteria women with large cervical lesions. We followed the national protocols on cervical and the identification of these lesions, and these are explained elsewhere.³³

Data Management and Analysis

We used the cervical cancer suspect register in the facilities and an electronic CCTB register to retrieve patients included in the study. Table 2 summarizes the variables that were used in the study. Data cleaning and descriptive analysis on outcomes were performed in Microsoft Excel and Stata version 15 respectively.

Table 2

Summary of study variables
Variable	Definition
Patients enrolled in tumor board (yes/no)	If women with large cervical lesions after cervical cancer screening were successfully enrolled in the CCTB. Women with large lesions were identified based on national guidelines and included: 1) VIA + with a lesion covering more than 75% of the cervix 2) Lesions where the cryotherapy tip cannot reach or extends 2 mm beyond the cryotherapy probe 3) Lesions suspicious of cervical cancer
Diagnostic yield	Define whether the biopsy had meaningful results. Results included diagnostic and non-diagnostic results
Biopsy results	These results followed the national guidelines for classifying cervical lesions and included the following outcomes: • Cervical intraepithelial neoplasia (CIN): CIN1, CIN2, and CIN3 • Invasive squamous cell carcinoma • Cervicitis • Cervical warts • Schistosomiasis • No dysplasia or normal
Treatment for pre-malignant lesion	These depended on the best practice and clinical skills of the team during the tumor board. Options included: 1) LEEP for CIN and CIN2 and some CIN3 in the Neno district 2) Surgical resection at the tertiary facility for some cases of CIN3 or in cases of incomplete resection after LEEP
Cervical cancer staging	These were defined based on (International Federation of Gynaecology and Obstetrics) FIGO guidelines
Patient outcomes	These defined the final pathway or outcome for the patients enrolled in CCTB which included death, palliative care, and referral to Queen Elizabeth Central hospital, and those whose outcome was unknown
Lost to follow-up (LTFU)	These were women who could not be tracked because they came from other districts outside Neno.

Ethical review

All data used in the study were collected as part of a retrospective routine clinical with the use of the anonymized dataset to conduct data cleaning and analysis. Ethical permission was obtained from the National Health Services Research Committee protocol number 1209.

Baseline characteristics

Between February 1, 2019, and April 30, 2021, 4,822 VIAs were conducted at Neno District Hospital (Fig. 3).

Figure 3: Outcomes and follow up of Clients enrolled in Tumor Board

Among all VIAs, 2.0% (n = 95) of the women had large cervical lesions (VIA positive lesions over 75% or lesions where the cryotherapy tip cannot reach or extends 2 mm beyond the cryotherapy probe or lesion suspicious of cervical cancer) and were referred to CCTB. Two women were LTFU before assessment for CCTB. The median age for women enrolled in CCTB was 46 years (IQR 41.0-55.5 years).

All women enrolled in CCTB had a cervical biopsy was taken (n = 93, 100%) (Table 3). The turnaround time for cervical biopsies was 12 days. The diagnostic yield was very high, 98.2% of the samples were diagnostic. Only two samples were initially non-diagnostic but the results were diagnostic after repeating the biopsy (Fig. 3).

Table 3

Biopsy results for patients followed up in tumor board (n = 93)
Biopsy results	N	%
Cervical cancer
Invasive squamous cell carcinoma Adenocarcinoma	36 1	38.7 1.1
Pre-malignant lesions
CIN 1	1	1.1
CIN 2	6	6.5
CIN 3	17	18.3
Cervicitis	14	15.0
Benign endocervical polyp	4	4.3
Cervical warts	3	3.2
Schistosomiasis	2	2.2
No dysplasia	9	9.6
Notes: CIN Cervical Intraepithelial Neoplasia

Outcomes for premalignant lesions

Among women enrolled in CCTB, 25.8% (n = 24) had pre-malignant lesions; one with CIN1, six with CIN2, and 17 with CIN3 (Table 4). Among the 24 women with the pre-malignant lesion, 19 were scheduled for LEEP at the district hospital. Among the 19 women scheduled for LEEP, 16 successfully received LEEP and 3 were LTFU. The average time from diagnosis to LEEP was 30 days. All 16 patients that had LEEP done had their biopsy repeated and 75% (n = 12) had complete resection (Fig. 3). Women with incomplete resection were referred to the nearest referral facility where surgical resection was successfully performed.

Table 4

Outcomes for women with premalignant lesions
	Proposed plan (n = 24)-n	The proportion who received care according to plan (n = 19)-n, %
CIN 1
LEEP	1	0 (0.0%)
CIN 2
LEEP	6	4, 66.7%
CIN3
LEEP	12	10, 83.3%
Referral to a tertiary hospital for surgical resection	5	5,100%

Notes: CIN Cervical Intraepithelial neoplasia, LEEP Loop electrosurgical excision of the cervix

Cervical cancer staging and outcomes

Four out of ten women (39.8%, n = 37) enrolled in CCTB had cervical cancer (Table 5). Among women with cervical cancer, only 73.0% (n = 27) with cancer were successfully staged. Of those staged, two-thirds (66.7%, n = 18) were in stage 2B and above. Based on the clinical assessment, 60% (n = 16) of the women with cervical cancer were immediately enrolled in palliative care, and 37% (n = 10) were referred to a tertiary hospital for further evaluation.

Table 5

Cervical cancer staging
	Invasive squamous cell carcinoma (n = 37)
Staging done-
Yes	27 (73.0%)
No	4 (10.8%)
Not known	6 (16.2%)
Staging groups-n = 27
1B1	5 (18.5%)
1B2	4 (14.8%)
2B	7 (25.9%)
3A	7(25.9%)
3B	4 (14.8%)
Final outcomes-n = 27
Death	1 (3.7%)
Palliative care	16 (59.3%)
Refer to tertiary Hospital	10 (37.0%)

In this 2-year review of cervical cancer patients, we show a high linkage to care and retention of clients (97%) for women with pre-malignant lesions following the implementation of a district hospital-based tumor board. These results suggest that CCTBs could be very useful as they are consistent with other studies conducted elsewhere that similarly suggest the importance and huge need of having CCTBs implemented as part of oncology services, particularly in rural settings to expand the yield [30, 31]. Even though the tumor board members were from one district hospital, the intervention covered the whole district since it was a referral facility for 13 other facilities which were under its catchment area. To our knowledge, no tumor board has ever been implemented at any rural health facility in Malawi. This is the first paper to describe linkage to care detailing pathways for women with lesions suspicious of cervical cancer from household and community levels to secondary and tertiary levels in a developing country. This study adds very useful and unique knowledge on the management and linkage to care for women with premalignant cervical lesions, particularly in rural and low-income settings.

All the women enrolled in the CCTB (100%) had their biopsies taken and the results were available within 12 days which allowed for all results were available for all women followed up in CCTB at the next meeting. Having pathology results is very key in the management of all cancer patients with other studies showing long turnaround times for pathology results negatively affect prompt decision-making in managing cancer patients contributing to late diagnosis and treatment [37]. This facilitated decision-making by the CCTB members and provided ample time for the community health workers to trace the clients back to care. Turnaround time for our CCTB biopsy results was lower than other facilities in the urban settings in Malawi with one study finding an average range of 18 to 43 days [38].

Overall, the total loss to care across the care cascade of CCTB was very minimal. Strong tracing, follow up and linkage to care programs contributed to clients who could not be traced back to care had moved to other places beyond the jurisdiction of the CCTB. Throughout the implementation of the CCTB in Neno District, we experienced a 2% loss to follow-up for clients with premalignant lesions who were supposed to undergo a biopsy according to the Malawian Cervical Cancer Prevention (CECAP) guidelines. However, 84.2% of clients who were scheduled for LEEP had the procedure done at Neno District Hospital since we already had adequately skilled workforce to perform this unique procedure. This capacity is not available at all district hospitals in Malawi, but we show that it is possible with equipment and competent staff. Of all the 16 clients who were done LEEP, 75% (n = 12) had successful resections from the repeat biopsy while 3 (18.75%) had incomplete resections which required another review at the nearest referral where a successful surgical procedure was done. This indicates the requirement for competent teams in cervical cancer management at the district hospital setting and the need for a careful review of referral pathways to prevent the progression of premalignant lesions into cancerous lesions as suggested in other systematic reviews [39, 40]. More importantly, we need oncology services at the district hospital level to minimize LTFU.

We had almost one-third of clients not staged. Three-quarters (72.9%) of clients with confirmed malignant lesions had staging and with over half (59.25%) with a late diagnosis and were enrolled in palliative care without the ability for curative treatment. just like another study on late breast cancer diagnosis done in Tanzania found [41]. This might be attributed to the late identification of clients due to low overall screening in the district (only 11% of women 15–49 years by March 2022), leading to late diagnosis followed by late enrollment into the tumor board.

Key enablers to our CCTB intervention included the establishment of a multi-disciplinary team which included representatives from all departments at the district hospital level who played a direct role in conducting VIA, obtaining a biopsy from the cervix, sending and receiving biopsy results, providing palliative care and community health workers who traced clients at the household level. The composition is similar to CCTBs in another study elsewhere where a multidisciplinary approach was assembled which included the community team [31].

A cervical cancer-focused CCTB is a low-cost and effective way to follow clients with suspected and diagnosed cervical cancer to ensure that treatment and subsequent follow-up are appropriate. We demonstrated that a cervical cancer tumor board can be successfully implemented in rural Malawi at the district hospital level. This model, if adopted at district hospitals in Malawi, may help reduce cervical cancer morbidity and mortality by improving the follow-up of patients with large cervical lesions after the screening. Other areas for further research include exploring other factors which lead to late diagnosis of cervical cancer and late staging of the same associated with linkage to care.

Ethics approval and consent to participate

This study was approved by the Neno District Health Research Committee and was approved by Malawi National Health Science Research Committee Protocol No 20/10/1216. We also obtained written informed consent from all participants, who either signed or used their fingerprints in case they were illiterate. Participants were free to withdraw from the study at any point. We assigned unique numbers as identifiers and securely stored data on a password-protected computer.

Consent for publication

All participants consent to have the data or analysis from the same can be published

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests"

Funding

The study received funding from Wagner Foundation through collaborative work with Partners In Health / Abwenzi Pa Za Umoyo. The funders had no role in study design, data collection and analysis, the decision to publish, or the preparation of the manuscript.

Authors' contributions

Isaac Mphande, Conceptualization, Methodology, writing, draft and original article writing, Ruth Chiphaka, Data verification, program implementation, editing, Sitalire Kapira, Draft review, data verification, program implementation, Margret Prior, Conceptualization, program implementation, Andrea Walker, Conceptualization, draft review and editing, Hilda Mbalati, Program implementation, Emilia Connolly, Moses Banda Aron, Methodology, Draft editing. Chiyembekezo Kachimanga, Supervisor, methodology, draft and final reviewer, data analysis.

Acknowledgement

We would like to thank the HEAL fellows for helping to initiate the tumor board and working on the registry for logging clients. We would like to extend our gratitude to MOH staff from Neno District Hospital and PIH staff and support staff for supporting the tumor board operations by helping clients to get quality care. We thank Dr. Luis Gadama from Kamuzu University of Health Sciences who trained our clinical officers and physicians in performing radical hysterectomies. This work has been made possible with financial support from the Wagner Foundation. The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.

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Implementation of a Cervical Cancer Tumor Board to optimize patient care and follow-up at a rural hospital in Malawi

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Abstract

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Introduction

Methods

Setting and study design

Cervical cancer program in Neno District

Tumor board program in Neno District

Data Management and Analysis

Ethical review

Results

Baseline characteristics

Outcomes for premalignant lesions

Notes: CIN Cervical Intraepithelial neoplasia, LEEP Loop electrosurgical excision of the cervix

Cervical cancer staging and outcomes

Discussion

Conclusion

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors' contributions

Acknowledgement

References

Additional Declarations

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