Backed by a $5.1-million grant from the United States Agency for International Development (USAID) and the U.S. National Academies of Science, Engineering and Medicine (National Academies), University of North Carolina at Chapel Hill and University of Malawi College of Medicine physicians and scientists will launch a multi-pronged effort to combat cervical cancer in Malawi, a country in sub-Saharan Africa where cervical cancer is the leading cause of cancer death among women.
The project team includes:
USAID and the National Academies are funding a total of $12 million for two new programs to prevent cervical cancer in sub-Saharan Africa, including the project in Malawi and one in Mozambique.
“Women who aren’t screened and treated for cervical cancer have a higher risk of dying of this preventable disease,” Dr. Smith said. “We need to do all we can to increase cervical screening rates globally. We’re testing a self-sampling technology that should increase screening coverage dramatically, but we have unanswered questions about cost and implementation within existing health care systems. Study findings will inform future policy and implementation, not only for self-collection tests in Malawi, but in other countries.”
[Photo: Dr. Jennifer S. Smith]
Screening women enables medical providers to detect and treat precancerous changes before they develop into cervical cancer, Dr. Tang noted.
“Because women in Malawi weren’t being screened,” Dr. Tang said, “they were getting diagnosed very late. A late cervical cancer diagnosis is usually a death sentence in Malawi. That is why we’re trying to screen as many women as possible using a highly sensitive test, and to treat the women with evidence of precancerous lesions the same day.”
According to the World Health Organization (WHO), the majority of cervical cancer deaths occur in low- and middle-income countries. The disease is linked to the sexual transmission of human papillomavirus (HPV).
Malawi has the second-highest cervical cancer rate of any country in the world, according to 2018 estimates from the HPV Information Centre. Dr. Gopal noted that the high rate of cervical cancer parallels high rates of HPV and HIV and low rates of population-level screening and vaccination.
In 2004, the Malawi Cervical Cancer Control Program set a target to screen 80 percent of eligible women for cervical cancer. By 2015, less than one-third of eligible women had completed the screening, according to program data.
“Progress is being made, but there is a tremendous amount still to do to stem the cervical cancer epidemic,” Dr. Gopal said. “We need to understand how most efficiently to deliver the preventive services to the highest number of women, and avert these unnecessary cancer deaths.”
With the new funds, UNC-Chapel Hill and the Malawi College of Medicine will evaluate the feasibility and cost-effectiveness of integrating self-collection HPV testing into voluntary family planning clinics and community-based sites in Malawi. The researchers also are planning to investigate the effectiveness of treating precancerous lesions, using a method known as thermocoagulation, in a “screen-and-treat” strategy.
“We couldn’t be more proud of this team of U.S.- and Africa-trained investigators receiving such a large award to better understand the global burden of cervical cancer,” said Dr. Myron Cohen, director of the UNC Institute for Global Health and Infectious Diseases, which was awarded the grant. “UNC faculty and staff from across the campus have worked hard over the past 25 years to build a self-sustaining model of clinical care, research and training in Malawi for health professionals from the United States and in-country to succeed and improve health for all. This grant exemplifies this mission.”
Dr. Cohen also is professor of epidemiology at the UNC Gillings School, Yeargan-Bate Eminent Distinguished Professor of Medicine, Microbiology and Immunology in the UNC School of Medicine and associate vice chancellor for global health at UNC-Chapel Hill.
Recent technological advances have made the project possible, Dr. Tang said. HPV testing now can be completed rapidly to determine whether a woman has a strain of the virus that is high-risk for causing cervical cancer. With the results, providers can determine which women might need same-day treatment of precancerous cervical lesions. Thermocoagulation involves using a portable, battery-operated device that can be used easily in settings with limited resources, she said.
“Transportation is one of the biggest barriers to treatment for women in Malawi, along with cost,” she said. “We’re trying to save women from having to come to the clinic multiple times, spending money and time they don’t have. As soon as we find a problem, we are treating it immediately.”
UNC physicians and researchers have collaborated with Malawian health leaders since 1990 to provide clinical care and research for HIV and other sexually transmitted diseases. This partnership led to the establishment of the UNC Project-Malawi site in Lilongwe.
As prevention and treatment interventions have improved the survival rates of people living with HIV in Malawi, cancer has emerged as a growing health problem in the country. In 2014, the Malawi Cancer Consortium was launched with funding from the National Cancer Institute to help fight cancer, particularly HIV-associated cancers.
Last year, Malawian leaders traveled to UNC-Chapel Hill to meet with UNC administrators, physicians and scientists to prepare for the opening of Malawi’s first dedicated cancer center, which is expected to be built this year adjacent to UNC Project-Malawi.
The newly funded cervical cancer project builds on the results of a pilot study led by co-principal investigator Dr. Lameck Chinula.
During the pilot study, more than 400 rural women were screened for cervical cancer using a community-based screening approach, and then, if they were found to have precancerous lesions, were treated with thermocoagulation.
“We would like to see providers maximize any contacts they have with women and use the most efficient, culturally-sensitive screening test available to identify patients needing treatment for cervical pre-cancer,” Dr. Chinula said. “By allowing women to self-collect specimens for HPV testing, we hope to empower and increase the number of women screened. As a clinician-researcher who has had to deliver the bad news of an incurable cervical cancer diagnosis in Malawi, I can look to the future with hope that a day will come when these diagnoses will be a rare occurrence.”
According to the USAID, this is the first time the agency has funded programs to prevent cervical cancer in the context of broader women’s health, other than under the President’s Emergency Plan for AIDS Relief (PEPFAR). These new programs in Malawi and Mozambique will coordinate closely with PEPFAR investments in both countries.