Health for All: Screening for Cervical Cancer in the Amazon

Ensuring that no woman dies from cervical cancer is the goal of a programme that brings rapid, low-cost HPV testing to remote communities in the Amazon.

Silvia de Sanjosé is a researcher at ISGlobal and coordinator of the PAVE (HPV and Automated Visual Assessment) consortium, which promotes a programme to improve cervical cancer control in low-income populations. Here, she shares her notes from a campaign on the banks of the Amazon.

Journey up the Amazon

We set off from Belém, in the state of Pará, and travel westwards along the Amazon. Our destination is Breves, a community with an uncertain population—somewhere between 50,000 and 100,000. Today, we are launching the second cervical cancer screening campaign on the banks of the Amazon. The first took place two months ago in the remote town of Sao Gabriel and was a success in terms of participation.

I am accompanied by Federica Inturrisi, an epidemiologist and expert in the evaluation of HPV detection technologies, and 27 professionals from the MARCO project team of the Fiocruz Foundation. They have boarded in Brasília, bringing all the necessary equipment for a campaign focused on the early detection of precancerous cervical lesions.

The project uses vaginal samples collected by women themselves to detect HPV, selects those who test positive, performs biopsies and treats those who need it.

The project will use vaginal samples collected by women themselves to detect HPV, select those who test positive, perform biopsies and treat those who need it. This work will be carried out by two gynaecologists with the help of four nurses, three lab technicians who will set up a mobile lab, and recruitment staff. Our aim is to reach 500 women. The transport of personnel and materials is supported by the Pará Regional Armed Forces, which assist in humanitarian operations. It takes two days to get from Brasília to Breves.

Women who have been waiting for months

The heat and humidity are intense. The women arrive. Most of them can read and write, and they ask a few questions. They are given information about the project and shown how to take a sample. Many bring their babies or young children. After two to three hours, the HPV test results are ready and those who test positive are called in for triage and treatment. Those who test negative receive a text message.

The triage visit includes a gynaecological examination. Women with an obvious lesion or high-risk HPV infection will undergo thermal ablation. This procedure takes no more than 40 seconds, is very well tolerated and provides immediate treatment of precancerous lesions. Women leave the consultation feeling reassured. Many have waited months for the results of their last cervical smear test or a follow-up to an abnormal Pap test.

For many, the main concern is the origin of this sexually transmitted infection and the impact this information might have on their partner. In counselling, we try to emphasise the opportunity we are offering.

Thirteen hours by boat to vaccinate their daughter

On the first day, we saw 136 women. One woman I saw had travelled 13 hours in a small boat to get her daughter vaccinated against HPV. Many women also come from homes along the river, hours away from Breves. Triage visits start at 1pm, once all the lab results are in. We finish around 10pm - 12 hours straight of consultations - but all the women who tested positive have returned! Only one had to leave because her boat couldn't wait.

One woman travelled 13 hours by boat to get her daughter vaccinated against HPV

The mosquitoes arrive every afternoon. Mosquito repellent helps, but not always. Every day it rains heavily for a few minutes. Everything stops, but only briefly.

Word of mouth leads to increased participation

As the week progresses, word spreads and more women come forward for screening. We only have two gynaecologists who have to examine 25% of the women because of their HPV-positive results. Brazil does not currently allow nurses to triage or take biopsies - this will be our bottleneck.

Our work is featured in the local media, and the municipality and health secretary are pleased with the success of this intervention, which is entirely managed by the team led by Ana Ribeiro and Tania Raiol from Brasília. Both work closely with Ana Cecilia Rodríguez and Mark Schiffman, epidemiologists at the US National Cancer Institute. They have been working for years to develop solutions to reduce the impact of HPV in populations with limited access to preventive health care.

The challenge of eliminating advanced cervical cancer

Today, MCS, a 34-year-old mother of three, arrives with an advanced lesion discovered three years ago. She has been waiting to be called in for treatment. A gynaecological examination suggests the possibility of cancer. HPV 16 is the cause.

Later, KFA, 44 years old and mother of 13, arrives with some worrying symptoms, although she is in relatively good health. The examination shows that her cancer has spread throughout her cervix. HPV 16 is present. It is devastating.

Our goal is to make sure we never see cases like this again. Instead, we want to detect precancerous lesions early - lesions that can be treated quickly and effectively, sparing women the difficult journey once cancer has developed

Our goal is to make sure we never see cases like this again. Instead, we want to detect precancerous lesions early - lesions that can be treated quickly and effectively, sparing women the difficult journey once cancer has developed.

When we come across these heartbreaking cases, it lowers the morale of the team. But we are buoyed by the knowledge that many more women are waiting to be screened. In five days we have screened over 800 women: 186 have had a colposcopy and 98% of those who need treatment have received it. The team will return in six months to assess the success of the treatment.

Research yields results

Once again, we confirm that decades of HPV research allow us to predict and estimate the risk of cervical pre-cancer and cancer with a high degree of accuracy. The risk is strongly linked to the different types of HPV. In this study, we were able to predict with remarkable accuracy who would have a lesion based on their HPV results alone.

In the coming weeks, artificial intelligence will be incorporated into the fieldwork to assess cervical images to further refine this predictive ability. Preliminary results from the PAVE consortium are very promising and are on track for publication.

The risk is strongly linked to the different types of HPV. In this study, we were able to predict with remarkable accuracy who would have a lesion based on their HPV results alone

We have exceeded the expected number of women screened, despite having to limit participation due to demand. Organising these campaigns in partnership with Ministries of Health is a rapid, cost-effective strategy that can save the lives of many women who are often overlooked.

Our hope is that their daughters will grow up vaccinated, with a drastically reduced risk of cervical cancer - so much so that these campaigns will no longer be needed in the future.

As I return home, grateful to have been part of this campaign, I reflect on my own privileges. I leave with a renewed sense of purpose, never forgetting the Amazon and all that this vast green garden holds.