Reducing the toll of cervical cancer around the world

Cervical cancer is the fourth most common cancer among women worldwide and was responsible for approximately 266,000 deaths in 2012, according to the World Health Organization. In contrast, it’s relatively rare in the United States. The American Cancer Society estimates that only 12,990 cases will be diagnosed this year, ranking it 11th among cancers affecting U.S. women.

Since the 1950s, U.S. cervical cancer rates have fallen by 70% thanks to the Papanicolaou (Pap) test and national screening programs, says Kathleen Schmeler, M.D., associate professor of Gynecologic Oncology and Reproductive Medicine.

“Cervical cancer is now a preventable disease, but it remains a leading killer of women in low- and middle-income countries and underserved regions of the U.S.,” says Schmeler. “Unfortunately, women in these areas lack access to screening programs and trained providers.”

To address these dramatic disparities, MD Anderson is using Project ECHO (Extension for Community Healthcare Outcomes), a tele-mentoring program developed at the University of New Mexico in 2003. The project, now used by a number of academic medical centers, uses Skype-like video conferencing during which academic physicians train health care providers in underserved areas how to manage and prevent multiple diseases.

MD Anderson faculty in Houston are using the technology to train providers in underserved areas how to prevent and manage cervical cancer. Regularly held hourly sessions take place during which patient cases are discussed and training sessions are presented.

These efforts, led by Schmeler and Ellen Baker, M.D., who serves as Project ECHO’s director, and Melissa Lopez, Project ECHO’s program manager, are the focus of a special article published this week in the Journal of Global Oncology.

“ECHO is a simple, low-cost, evidence-based model that is used to improve patient care and outcomes as well as provider knowledge, self-efficacy and satisfaction through regular tele-mentoring sessions,” says Lopez.

The first ECHO program at MD Anderson was launched in 2014, and focused on improving cervical cancer prevention services in the Texas’ Rio Grande Valley, an underserved region along the Texas-Mexico border. This area’s cervical cancer rates are up to 30% higher than the rest of the state.

Through Project ECHO, MD Anderson faculty train community health workers on how to educate women about the importance of cervical cancer screening and vaccination for the human papillomavirus (HPV). Providers in underserved areas, including physicians, nurse practitioners, physician assistants and midwives, are taught to manage abnormal screening results including performing colposcopy, cervical biopsies and loop electrosurgical excision procedures (LEEP) to prevent cervical cancer.

This particular ECHO initiative is run in collaboration with the University of Texas Medical Branch in Galveston, the University of Texas Health Science Center School Of Public Health’s Brownsville Regional Campus, and Su Clinica Familiar, a Federally Qualified Health Center in the Rio Grande Valley.

“Our first ECHO clinic was so successful that we’ve now developed other clinics related to cervical cancer in different regions, with different needs, held in different languages,” says Baker.

In 2015, an ECHO program for cervical cancer prevention and management was established for providers in Latin American countries, including Mexico, El Salvador, Guatemala, Colombia, Bolivia, Paraguay, Ecuador, Peru, Uruguay, Chile and Brazil. In collaboration with UT Medical Branch in Galveston and the Universidad de La República in Uruguay, gynecologic oncologists from MD Anderson share prevention and treatment experience to meet the diverse needs in these countries.

In some African countries, the number of trained providers relative to population size is extremely low. For example, Mozambique has only 1% the amount of the doctors per capita compared to the U.S., explains Baker, and few of these physicians have special training in managing cancer. To train African providers how to prevent and treat breast and cervical cancer, MD Anderson established partnerships in Mozambique and Zambia.

The Mozambique ECHO program is a multi-center partnership between MD Anderson, the Hospital Central de Maputo in Mozambique, and three MD Anderson Sister Institutions in Brazil – Barretos Cancer Hospital, Hospital Israelita Albert Einstein and AC Camargo. In Zambia, the cancer center collaborates with physicians and nurses at the Cancer Diseases Hospital in Lusaka, via monthly ECHO sessions.

“Providers have reported that ECHO clinics improved their knowledge and ability to deliver high quality care,” says Schmeler. “What has been somewhat surprising, and very rewarding, is the growth of strong relationships among providers and faculty participating in ECHO.  This has allowed the development of additional collaborative research and training projects.”

Through those relationships, Schmeler hopes to broaden the current ECHO programs within Texas, Latin America and Africa as well as expand new partnerships addressing other needed areas. And MD Anderson is increasingly using the ECHO model to focus on other aspects of cancer prevention and management, including tobacco cessation, survivorship and palliative care.