Training and Education

See and Treat

- Indonesia

- South Africa

- Surinam

Science and Research

Reports from the field

Surinam

A new cervical cancer screening project was launched in January 2005 in (Nieuw) Nickerie, a district in the western part of Surinam (see illustration, map of Surinam). The project is part of the Female Cancer Programme (FcP) from the "Leiden University Medical Center" (LUMC), and is funded by Nationale Postcode Loterij. The Female Cancer Program is in cooperation with the Surinam Planned Parenthood Association, the Lobi Foundation.

Surinam, with its population of approximately 490.000 people, is one of the high-risk countries for cervical cancer with a lifetime risk of 1/35. The population is a diversity of ethnical background. Hindustani (also known locally as "East Indians"; their ancestors emigrated from northern India in the latter part of the 19th century) are counted for 37% of the population, Creole (mixed white and black) 31%, Javanese 15%, "Maroons" (their African ancestors were brought to the country in the 17th and 18th centuries as slaves and escaped to the interior) 10%, Amerindian 2%, Chinese 2%, Caucasians 1% and others 2%.

A cytological screening project carried out between 1998 and 2001 found a meager 1.3% prevalence of pre-malignant lesions in a high-risk population of about 32.000 women. Of all women with abnormal Pap smears only 30% completed treatment. Many patients were lost to follow-up because of logistical barriers. Effectiveness of Pap smear screening in developing countries is limited because of long delays between smear collection and delivery of screening results. In addition, lost to follow-up often results in delayed treatment and advanced disease.

The lessons learned from the disappointing outcomes of the national screening effort have led to an alternative approach. This new approach intends to improve cervical cancer services for women in the interior using a "See and Treat" approach. The uterine cervix is examined with Acetic Acid (Visual Inspection with Acetic Acid: VIA) to detect white lesions, which are characteristic for pre-malignant cervical disease. Immediate - on the spot -treatment is offered by means of cryotherapy.

All screening and treatment activities take place at the primary care level. Cases suspicious for invasive disease are referred to a gynaecologist in the district hospital or in the capital city. In addition to visual inspection, Pap smears were also made for all women for comparison of screening results. Pap smears were not examined on the spot but were taken to the capital for examination. Women are informed about the risk of cervical cancer and of the methods to prevent this disease. The Surinam Planned Parenthood Association is responsible for the implementation of the project. Two trained medical doctors examine and treat patients who participate in this project. Screening and on the spot treatment were free of charge.

In the district of Nickerie (1.), an agricultural area (rice, bananas etc.) with a population mainly consisting out of Hindustani and Javanese people, 1500 participant attended this project. At the end of the screening phase of the project in Nickerie, roughly 16% pre-malignant cases were detected with the visual inspection method compared to approximately 1.3% with the Pap smear. No patients who were eligible for immediate treatment were lost to follow-up; 95% of lesions detected with VIA were successfully treated.

The results of this project show that screening with visual inspection followed by immediate treatment detects more pre-malignant lesions than conventional Pap smears, and almost no cases were lost to follow-up. The nearby future goals in this project are to screen in eastern part of Surinam, an area (2. Moengo and surroundings) with women relatively remote for cervical screening in health care facilities for examining cost-effect analysis and implementation in national health care services (training, courses for local health care contributors etc.). To be a successful, cervical cancer prevention services must be acceptable and accessible to women, while also being cost-effective and sustainable. Even with a perfect screening test, no program is successful if women do not come for screening, if quality of care is poor, or if effective information systems are not in place to allow adequate follow-up care.

The FcP team in Surinam received a price for this See & Treat program of the International Planned Parenthood Federation

"On the spot" education for local population about cervical cancer & FcP and Lobi Foundation, a good partnership in the fight against cervical cancer in Surinam