Podcast "Let's Talk Cancer": Cervical cancer – achieving equity through innovation

Dr Chemtai Mungo from the University of North Carolina explains the challenges and progress in cervical cancer care and looks at how technological innovation, effective national cancer control plans, and other advances and strategies can help close the gap in cancer care.
23 August 2022

In this episode of Let’s talk cancer, Dr Chemtai Mungo from the University of North Carolina explains the challenges and advances in cervical cancer care and improving access to life-saving services for all populations.

Cervical cancer is one of the most highly preventable and curable forms of cancer. And yet it remains the leading cause of cancer deaths in women in over 40 countries. 

What are the causes of inequity? Why do so many women lack access to life-saving services due to where they live or other socioeconomic factors? How we overcome these barriers? What role can innovation and technology play?

Dr Chemtai Mungo, a 2021-2022 UICC Young Leader from the University of North Carolina, explains the challenges and progress in cervical cancer care and looks at how technological innovation, effective national cancer control plans, and other advances and strategies can help close the gap in cancer care. 

"Cervical cancer gives us a unique opportunity to work towards equity, as this is the first cancer that we can actually eliminate."
Dr Chemtai Mungo, Assistant Professor of obstetrics and gynaecology at University of North Carolina at Chapel Hill, USA; UICC Young Leader 2021-2022

See podcast transcript below

Podcast transcript:

Eric Grant, Communications and Media Manager, UICC   

Hello and welcome to Let's Talk Cancer by the Union for International Cancer Control, an organisation that unites and supports the cancer community to reduce the global burden. I'm Eric Grant, communications and media manager at UICC. I'll be taking over today from our usual host, Carry Adams while he's out of the office. We are living in a time of awe inspiring advancements in cancer prevention, diagnosis and treatment. And yet half the world's population lacks access to essential health services, and many are denied basic cancer care. What are some of the causes of this inequity, both in high and low middle income countries? How are we to overcome these barriers? And what role can innovation and technology play? Cervical cancer is one example of this inequity. Despite being one of the most highly preventable and curable forms of cancer, it remains the leading cause of cancer deaths in women in over 40 countries with over 340,000 women dying of this disease in 2020. 90% of all new cases and these deaths occur in low and middle income countries. With us to discuss this is Dr. Chemtai Mungo, Assistant Professor of Obstetrics and Gynecology at the University of North Carolina, at Chapel Hill in the United States. Dr. Mungo, thank you so much for being with us today. How are you doing? 

Dr Chemtai Mungo, Assistant Professor of obstetrics and gynaecology at University of North Carolina at Chapel Hill, USA   

I'm doing great, thank you. 

Eric Grant   

Can you speak to me about some of the inequities you see between high and low income countries, you've worked both in Kenya and now in the United States. 

Dr Chemtai Mungo     

So I was born and raised in Kenya. And growing up, you see a lot of unnecessary death and suffering. And as a gynecologist practicing in the US and spending a lot of time in Sub-Saharan Africa, there's a significant amount of inequity, as far as where a woman lives determining whether or not should live or die. Access to vaccination, access to screening, access to early treatment: there's so many diseases, not just cancer, but others, where women who live in low and middle income countries just don't have access to preventative care. And for treatment, it's often too late by the time they get them. So generally speaking, as a community, we really have to work on ensuring that health systems are strong, regardless of where women live. 

Eric Grant   

Yes, you mentioned vaccines. This is part of the prevention strategy that was laid out by WHO, the World Health Organization, in its global strategy to eliminate cervical cancer. Could you perhaps tell us more about this global strategy and the role played by HPV vaccination? 

Dr Chemtai Mungo   

This is an exciting moment in history where we have a chance to eliminate this preventable disease. And the WHO set  global targets with a goal of eliminating cervical cancer by 2030. These targets are called the 90 70 90 targets, where by 2030, we need all countries in the world to have vaccinated 90% of girls against HPV by the age of 15. We need 70% of women in all these countries to have screening for cervical cancer. And we aim to get 90% of all who have been found to have pre-cancer or cancer to get access to treatment. If we meet these 90 70 90 targets than we are on target to eliminate cervical cancer by 2030. So cervical cancer gives us a really unique opportunity to work towards equity, where this is the first cancer that we can actually eliminate. And the elimination target is the idea that you will get to less than four cases per 100,000, which in comparison, currently in Malawi, which has highest rates of cervical cancer, it's about 75 cases per 100,000. So we have a lot of work to do. 

Eric Grant     

How can that be implemented in low income countries in a resource efficient way, and perhaps there are some examples of where that is being done effectively? 

Dr Chemtai Mungo   

So vaccination is one area where there's significant inequity. Human papilloma virus causes cervical cancer, so when you vaccinate a young girl before she's 15 years old against HPV, you basically eliminate the possibility that she will contract HPV and hence get cervical cancer. But you see a huge disparity in where girls have been vaccinated. For example, in the United States, at least 75% of girls have gotten at least one dose of the vaccine. This is compared to less than 5% of girls in low and middle income countries. That just lays out the depth of the inequality. There's a lot of things that can be done, are being done, to bridge this gap of access to primary prevention, which is what vaccination is. For example, cost reduction programs. We cannot expect a low income country to pay $150 per vaccine for a girl, which is the cost of the vaccine in the United States or in high income countries. So you really have to have preferential pricing that is not aimed at profit maximization, but really at access. That is one way that we can really increase access to vaccination: by making them affordable. 

Eric Grant   

Obviously, cost goes up with the number of required doses. I understand that while an effective prevention strategy required three doses there are some studies going on around reducing the number of required doses. Could you tell us more about that? 

Dr Chemtai Mungo   

There's a lot of work going on, recent really exciting research, around what is the minimum number of vaccines needed to give a girl protection. Initially, the data suggested that girls needed three vaccines, so three doses of the vaccine, but really recent work coming from researchers around the world, including Kenya, have shown that just one dose can give excellent protection. Now, our goal is how can we get every girl all over the world, at least one dose of that HPV vaccine, because that's how we can eliminate this very preventable cancer. 

Eric Grant   

So that's the first pillar of vaccination. What about the second pillar: screening. What are some of the means to increase the pickup of screening in low income settings? 

Dr Chemtai Mungo   

Screening is one area where we have really robust research. And a lot of people who I greatly admire have done work to change the paradigm of screening and to make it what we call resource appropriate. So traditionally, screening for cervical cancer required something called a Pap smear, which many people have probably heard about. That was very resource intensive, where a woman needed a pelvic exam, collection of the Pap smear, a pathologist to read the Pap smear. And then the woman would come back and get the result and get treated. So this needed about three to four visits, which is just not feasible for women who live in rural areas, who don't have a pathologist, within the district or even within 100 mile vicinity. So we now have very exciting work building on very robust research that shows that women can self collect a sample for HPV screening, or cervical cancer screening. This is huge, because if a woman does not need a pelvic exam, and can self collect a sample in the privacy of their own home, in a market, in a community campaign to really increase reach of screening, and you take it away from health centres, or hospitals or clinics, which are just too far between, and then move them into community campaigns, which is very innovative work that's been done in lower settings to reduce that multi-step need to get to a diagnosis. And really, the WHO endorsed paradigm now is what we call "screen and treat", where we pair screening and treatment in the same day to maximise uptake. 

Eric Grant   

You mentioned self testing and as I understand that can help overcome another barrier, which is stigma discrimination surrounding a cancer that affects the sexual reproductive organs. And I know that some women are reluctant to go into care centers, or perhaps sometimes are not even allowed in certain cultures where men make decisions, medical decisions, for them. So self testing enables them to to check in the privacy of their homes. Could you perhaps tell us more about the the barriers that stigma and discrimination constitute for accessing cancer services? 

Dr Chemtai Mungo   

Stigma is a is a big, big challenge in trying to tackle this very preventable disease. HPV and cervical cancer screening or a diagnosis has a negative connotation, somehow related to sex or promiscuity. But we know that that is not true. And we know that from a scientific perspective, anybody who has been sexually active has likely been exposed to HPV. So there's a lot of work that we need to do and that's ongoing to break these norms of shame or fear around screening, and around a diagnosis of HPV. And there's multiple ways to do that. Using survivors for example: a woman who has had screening and treatment and is healthy is a really excellent advocacy tool to tell the women not to be afraid - changing these norms of fear on sexuality. I grew up in a conservative society and sort of anything below the waist, you didn't talk about, but that's changing. We have really robust social media campaigns currently happening around cervical health and let's talk about your cervix. So we can both utilise women who have gone through the process and come out healthy and active to be agents of change, while also ensure that the messages we're passing across are not negative messages - that any woman can have HPV. It has nothing to do with your sexuality. 

Eric Grant   

Yes, really interesting because that touches upon the fact that even though sometimes services are available, there may be other factors which prevents people from accessing them and these may not require huge technological innovations to overcome. Can you perhaps tell us some of the non-technological innovations in terms of programs or services being set up to facilitate people's access to care when it exists? 

Dr Chemtai Mungo   

This is a really exciting field as far as innovation, both technology and non technology related. So from a non-technology perspective, the use of community health workers, or women or men who live in the community who know the women, girls, children, the families within their catchment area, they're a great tool to get messages of screening and prevention. So rather than waiting for families, or for women to come to clinics that are far off from where they live, having an army of community health workers who are very educated, very aware of the need for cervical cancer screening, who can take the self sampling kits to the community, return them, and then take results back to women - that is a great innovation that really removes or decentres the hospital, the clinic as a point of service provision. 

Eric Grant   

And what are some of the technological advances that can support this, some of this community work, particularly in low income settings? We often think of technology as restricted to high income and the whole point is to see these advances reduce rather than increase inequities. 

Dr Chemtai Mungo   

So for example, I'm a gynecologist in in San Francisco or in North Carolina. I see women, I screened them for cervical cancer. But women in Sub Saharan Africa, the average woman does not have access to a gynecologist. So what we're doing and a lot of groups are doing this is using a cell phone, which most people now around the world have access to a cell phone, they're cheap, they have good cameras, the internet is increasingly accessible and affordable. So we're using telehealth where a nurse in a rural community can take a picture of what she thinks is an abnormal lesion of the cervix, and transmit it to a specialist who is in the city, or some far flung place who can offer her guidance in treatment. It is actively being done in Tanzania, in Zambia, to bridge this gap of access to specialists. And you can be able to get women to get care in their communities rather than sending them far off. 

Eric Grant     

You touched on something there, which is also not just the technology itself, but the ability to use it, to interpret it and to move ahead with treatment or other services based on that sometimes it's not just a question of making the technology available, but also the training of staff. What's the situation like in lower middle income countries in that regard? 

Dr Chemtai Mungo   

When technology is being made, it's really critical to have the end user in mind, and to have the end user be part of the process of making the technology. A nurse who is really busy in a clinic who has 30 patients, if you want her to use technology, it has to be really simple. The adoption of the technology has to be thought about and this is work that we call "implementation science" where you can't just make technology in New York or Geneva and dump it or put it in the long way and expect it to be used. We have to keep in mind what is a local context, what's the access to charging of a cell phone. You can't always have technology that relies on a robust internet connection. So offline platforms are really important or that only intermittently need access to the internet. So while anybody's making technology to use in low-resource settings, both involving folks from that area, and really keeping kind of a context in mind is critical, and continuous training to make sure that, for example, if the nurse who was trained is moved to another location, the next person in is able to uptake that technology and is trained on how to use it. 

Eric Grant    

It's interesting because it seems here that what we're really talking about is also looking at a country's needs and resources and sort of matching them I suppose. And we've touched on this in previous UICC podcast is the need for a national cancer control plan. I believe Kenya has worked on one or is developing one. I also know Rwanda is often cited as an example, particularly in the case of cervical cancer. Can you tell us more about how that can work in a low income setting and how we could replicate perhaps on the successes going on in Sub-Saharan Africa? 

Dr Chemtai Mungo   

So having a national cancer control plan is critical, because it's a roadmap that guides policies, guides where do we put grant funding or defines the gaps and how do we move towards cancer control. So certainly, there's several African countries actually, more than several, that have really excellent policies, including Kenya and Rwanda. The government of Rwanda or the leadership in Rwanda has really pushed cancer control and cervical cancer at the forefront. So Rwanda is one of the African countries that has met the targets of vaccinating 90% of girls in that 11 to 15 age group, and that's because they have significant political will, use of the cancer control as kind of a roadmap and really setting targets and making sure we're reaching them. A key thing I think, for a lot of countries is, sometimes it's easy to write a really beautiful cancer control plan. But how are we making sure that we're implementing it? And we've talked about inequalities both between low and high income countries, but even within countries there is significant inequality, where you have women in an urban setting who have excellent access to care, because there's a significant number of specialists in that urban setting, but in rural areas, they do not because specialists are not in the rural areas. So how do we fight the market forces that keep specialists in urban areas to make sure that even while we have an excellent cancer control plan in the books, that really we're taking steps implemented, and making sure that women everywhere are accessing the services? 

Eric Grant   

That's a very important point to make: how a national cancer control plan needs to ensure that it's addressing the needs of all populations, regardless of geographical location, gender, socio economic level and income level. And you mentioned inequities within countries. And I think we touched upon earlier some of the the issues for rural populations, these exist probably in almost every country. What are some of the inequities you see, within the United States, for instance, within a high income country? 

Dr Chemtai Mungo   

The picture is nuanced. While in the United States there's high rates of HPV vaccination, there's very high coverage of screening, but the women who gets cervical cancer, there's significant disparity within the United States. And unfortunately, it mirrors the structural inequities in this country, where women who live in rural areas, women who are poor, women who are marginalised by different identities, including race, socioeconomic status, tend to live in places that don't have access to a gynecologist, for example. So while the United States is one of the richest countries in the world, there are certain counties or states where there are no specialists. And so those women, similar to women in  rural Sub-Saharan Africa, have to go really far to get these services. And we know that the longer a person has to go, especially when it's for preventive service, when they're not sick, it's harder for them to get there. In regards to social economics, you know, when a woman or a person is to take three buses within the context of the United States to get to a clinic, that's only open a certain number of days of the week, then they oftentimes don't get there. Or when they get a health service, and they feel like they're not listened to, this is a big problem for marginalised populations, where they feel like their services are not responsive to their needs. So certainly, inequalities exist, even in high income countries. 

Eric Grant   

You know, I've heard there are some programs that have been developed to help address some of these, for instance, accommodation near health centres, for people have to travel long distances, so they can continue the treatment or even perhaps transportation assistance, how easily can these be put in place? How sustainable are they? 

Dr Chemtai Mungo   

We call these waiting homes, in a sense, where if a woman needs five cycles of chemotherapy, and the chemotherapy centre is 300 miles from where they live, and it's in a city, so philanthropy, etc, build homes or provide accommodation next to the hospital where the patients can be there during the treatment. These are really critical. And oftentimes, they're not that expensive an investment, but they literally can mean the difference between life and death, because it's not uncommon and it's actually very sad that in Kenya, for example, women have to go through the capital city to get radiation therapy if they need it. And the capital city is too expensive for a rural woman to get accommodation. So you actually have patients who literally sleep on the floors overnight as they wait for their radiation, because they have nowhere to sleep - completely unacceptable in today's world, and we can find ways to mitigate those gaps. I actually work in Kenya and Malawi, where the difference for saving a woman's life can be $30, between getting her from home to getting hard to the tertiary center where she can get the life saving surgery, that would literally save her life. But she doesn't have that $30 so she waits a whole year where she's saving to get that money, but in a year's time her cancer is not curable. As a society we can find that $30 to get her to get that life saving surgery. And I think that's the same way we have to think about these kind of waiting homes that can bridge the gap to get people to curative care, where then they can be productive members of society for the rest of their lives. There's good data that shows that when you lose a woman from cervical cancer or for any cancer, and men, but women in this case, there's rippled effects in society, both for their children, so their children are less likely to finish schools, their girl child is more likely to get married. So a whole generation is affected. Which is why while we think about cost effectiveness of some of these programs that need injection of money, for governments, we can make the case that it actually is worth it for you to spend that $30 or $50 to bridge that gap and make sure this person and this woman gets this curative care. Because then from a society perspective, you benefit significantly from the fact that she gets to live the rest of her life. 

Eric Grant   

That's a very important point to make: the cost effectiveness of investing in cancer care. It's obviously a very complex problem in terms of improving access to services. But I think you've shown that especially where there's political will, we have the means, there are the means and the ability to certainly improve the situation and it seems like at least in quite a few areas things are moving, I believe, in the right direction. Well, thank you very much for explaining all of this to us today. And hope you have a great rest of your day. 

Dr Chemtai Mungo   

Thank you so much. Thank you for having me. 

Eric Grant   

Thank you very much for listening. If you're interested in this topic, the topic of cervical cancer or more generally of screening, prevention and treatment or of inequity. Don't hesitate to join us at the World Cancer Congress the 18th to 20th of October in Geneva. And if you like this podcast, please do give us a rating or follow UICC on social media, and stay tuned for more editions of Let's Talk Cancer. 

Last update: 
Thursday 1 September 2022
Share