As a medical student in Bangkok, Khunying Kobchitt “Kobbie” Limpaphayom saw firsthand the devastating impact of cervical cancer on Thai women and their families—a woman about 40 years of age arrived for a doctor’s appointment with blood running down her leg and a foul odor pervading her body.
“She carried one small child and her husband followed her with two other young children,” recalls Limpaphayom, a former president of the Royal Thai College of Obstetricians and Gynaecologistsand member of the medical faculty at Thailand’s prestigious Chulalongkorn University. “When my professor told her that she had advanced cancer of her cervix, could not have any surgery, not even radiation, the woman started to cry, then her husband and all her children.”
That encounter early in Limpaphayom’s career left her profoundly aware of the need to give Thai women access to early screening for this highly preventable and treatable form of cancer. Jhpiego, a pioneer in cervical cancer prevention, made that possible. The low-cost, effective screen-and-treat approach introduced by Jhpiego in Thailand a decade ago (with Limphaphayom leading its team) has benefited more than 600,000 women. The Government of Thailand embraced and scaled up the innovative approach, making it available in rural health care facilities across the country and helping save lives every day.
According to the Ministry of Health, 1,175 nurses and 150 doctors have been trained in Jhpiego’s single visit approach — screen women with a visual inspection technique that uses a dilute solution of acetic acid, commonly found in household vinegar, and then immediately offer cryotherapy (freezing of the cervix) to treat any precancerous lesions. More serious cases are referred to the hospital.
“Carcinoma of the cervix is a disease of poor, low-socioeconomic women who never had a chance for early detection and that means no early treatment,” explains Limpaphayom, who helped pilot the approach in four rural districts of Thailand in 2000. “This carcinoma can be cured if detected early. This is a most important public health problem . . . almost 480,000 new cases a year, half of them in developing countries like most of Southeast Asia and Africa.”
As the United Nations High-Level Meeting on Non-Communicable Diseases convenes September 19–20, Thailand’s decision to provide screening services for the leading cancer killer of women in the developing world is a good example of how innovative solutions can address global health challenges. A recent World Health Organization (WHO) bulletin promotes the Jhpiego approach: “A discussion for policy-makers attending the (UN) meeting recommends cervical cancer screening using VIA”—visual inspection with acetic acid (vinegar)—“and treatment of precancerous lesions as a ‘best buy’ because of its inexpensive cost”—less than 50 cents per test in hospitals or health centers in developing countries.
“Thailand’s work is significant because the government has adopted and applied a WHO-recognized screen-and-treat service, establishing, for the first time, cost-effective cervical cancer prevention at points of service where women routinely get their care,” said Dr. Ricky Lu, Jhpiego’s reproductive health and cervical cancer prevention expert.
VIA is simple, effective and developed for use in settings with limited resources. Nurses and midwives can be trained in VIA. The approach utilizes a 3–5 percent vinegar wash on the cervix and a bright light to identify white plaque-raised lesions that are precancerous. In the same visit, women who have been found with suspect lesions can be treated with cryotherapy. Although Pap tests are the routine screening method in developed countries, these tests require cytotechnicians, physicians, laboratories and reliable infrastructure, which are not readily available in Thailand. Jhpiego developed the single visit approach to ensure that women, no matter where they live, can be screened and treated.
In 2000, Jhpiego collaborated with the Ministry of Public Health and the Royal Thai College of Obstetricians and Gynaecologists to introduce the then-innovative VIA with cryotherapy approach in a seven-month pilot project. The goal was to demonstrate that the approach could be used efficiently in a rural setting and yield reliable results. The Bill & Melinda Gates Foundation and the Thai health ministry funded the project to make screening more accessible to women.
The project team trained 12 nurses in VIA and cryotherapy, who then screened nearly 6,000 women. Of those, 798 were found to be positive for precancerous lesions and 92 percent received cryotherapy. Four women suspected to have cancer were referred to the local hospital for colposcopy or biopsy; one was confirmed with cancer.
As reported in a 2003 article in The Lancet, the demonstration project showed that “a single-visit approach based on VIA and cryotherapy done by rural nurses is safe, acceptable, and feasible.”
The Thai government, which for three decades had sought a safe, effective method to screen women for cervical cancer with little success, had found an alternative approach that could be successfully implemented in areas where traditional screening and treatment services were unavailable. When the demonstration project began, only about 5 percent of women were screened for cervical cancer.
Today, the Thai government funds and manages VIA screening in 22 provinces, and an additional nine provinces provide services in a more limited capacity, representing nearly half of all provinces in Thailand. Nurse providers have screened an estimated 600,000 women. Of those women, an estimated 3–5 percent were positive for precancerous lesions, and the majority, 90 percent, received cryotherapy, according to government statistics.
This effort—which began with Jhpiego’s technical expertise, evidence and knowledge—has transformed the health outlook for women across an entire nation. Not only has the Thai government blazed a trail in reproductive health for its women, the health ministry is supporting a Jhpiego-led study focused on protecting the next generation of women from cervical cancer.
Jhpiego is working with two university-affiliated health care facilitiesin Thailand and the Philippines to vaccinate adolescent girls against the human papillomavirus (HPV), a sexually transmitted virus and leading cause of cervical cancer. This “Mother-Daughter Initiative” has enlisted the help of women who have been educated about and screened for cervical cancer to enroll their daughters in the two-year study and have them vaccinated.
Jhpiego continues its leading role in cervical cancer prevention, introducing the WHO-recognized VIA and cryotherapy approach across the globe. More than a dozen countries, from Guyana to Mozambique, are now using VIA and the single visit approach.