Papers by Dr.Sharon Kapambwe
ecancermedicalscience
Background: Africa is home to many countries with the highest incidence of cervical cancer in the... more Background: Africa is home to many countries with the highest incidence of cervical cancer in the world. It is encouraging to see that the efforts to prevent and manage this disease are intensifying across the continent. The World Health Organization (WHO) has, in the last years, led a worldwide initiative to eliminate cervical cancer as a public health problem, starting by setting clear targets for 2030. Aim: To assist those African countries with the largest burden of cervical cancer, to reach the set targets, as a first step, WHO initiated a baseline capacity assessment in African high burden countries. We present and discuss the results thereof in this paper. Method: The countries selected for the baseline evaluation were Eswatini, Guinea, Malawi, Rwanda, Uganda and Zambia. The data were collected by a mailed questionnaire in English, with 129 questions, most of them with preset answer options. It was answered by national coordinators of non-communicable diseases, cancer control or reproductive health programmes in the ministries of health and by the WHO country representatives. Based on the answers, suggestions were made towards optimising the efforts for cancer control. Results: Except for Eswatini and Guinea, vaccination against the human papilloma virus (HPV) has reached between 74% and 98% of girls in the age bracket. The main method for cervical screening is still inspection with acid acetic. HPV testing, recommended by WHO, is being introduced slowly. The numbers of women screened are not yet nearing the required levels. Between 30% and 70% of the cervical cancers diagnosed are being treated with palliative intent. A deficit of personnel was reported for all professions involved in cervical cancer care. Conclusions: Guinea will need assistance to implement HPV immunisations and expand screening. In all six countries surveyed, steps should be taken to introduce or scale up the more precise HPV screening instead of acid acetic inspection of the cervix, to replace the current cryoablation of the preinvasive lesions of the cervix with thermal ablation and to increase the capacity for screening. Solutions need to be found for covering the dearth in gynaecological oncologists and radiotherapy installations and personnel.
Nature Medicine
MICs face a double burden of disease, with non-communicable diseases, including cancer, rising ra... more MICs face a double burden of disease, with non-communicable diseases, including cancer, rising rapidly alongside continued morbidity and mortality from infectious diseases. While age-standardized rates of cancer have changed only marginally, the absolute number of patients diagnosed with cancer annually in LMICs is growing rapidly 1,2. By 2030, approximately three-quarters of all cancer deaths will occur in LMICs, with one in eight people experiencing a cancer diagnosis in their lifetime 3. Most of the increase in the global cancer burden in the next 50 years will come from LMICs (400% in low-income countries, 168% in middle-income countries and 53% in HICs) 4 due to rising population, increasing life expectancy, growing urbanization and lifestyle changes. Although age-standardized incidence rates for cancer are lower in LMICs than in HICs, the mortality:incidence ratio is higher in LMICs 1,2. Efforts for cancer control in LMICs should aim to reduce exposure to common modifiable risk factors such as tobacco, alcohol and obesity, improve access to care and improve outcomes for those diagnosed 5. While ongoing efforts focus predominantly on expansion and strengthening of treatment facilities, relatively less attention is paid to generating country-specific evidence for effective prevention, early detection, access, survivorship and palliation, with an emphasis on quality and value. Cancer research is heavily skewed toward HICs, with disproportionately less research conducted in, and relevant to, the problems of LMICs 6,7. For example, of all phase 3 trials of anti-cancer therapies conducted worldwide between 2014 and 2017, only 8% were initiated and conducted in LMICs, despite increasing recognition that trial results are not necessarily generalizable across populations and country contexts 7-9. The gross imbalance in cancer knowledge generation and application through the global research enterprise raises several issues. First, research and innovation conducted in HICs fail to adequately address certain cancers that are prevalent in LMICs, for example, oral, esophagogastric, hepatobiliary and cervical cancers 7,10. Second, cancer-control strategies that are effective in HICs are often not applicable to LMICs as a result of differences in disease characteristics, health systems capacities, sociocultural factors, treatment-completion rates, lack of availability of medicines, and pharmacokinetic and biological variation associated with ethnicity. There are also within-region and racial differences in disease incidence as well as cancer characteristics owing to differences in genetics and environmental exposures 11 (for example, higher proportion of triple-negative breast cancer, EGFR-mutated lung cancer and microsatellite instability-high colorectal cancer in certain groups). Third, health systems research is highly context-specific, as resources, infrastructure and sociocultural values vary widely between HICs and LMICs and even within countries. Finally, the high costs of many interventions developed in HICs render them non-implementable in LMICs. In addition to reducing cancer-specific mortality, cancer research also brings other benefits such as improved quality of clinical care,
Cancer research in Zambia: Programs, progress, and opportunities, Apr 1, 2018
International Journal of Gynecology & Obstetrics, 2021
Thermal ablation (TA) was implemented in public sector cervical cancer prevention services in Zam... more Thermal ablation (TA) was implemented in public sector cervical cancer prevention services in Zambia in 2012. Initially introduced as a treatment modality in primary healthcare clinics, it was later included in mobile outreach campaigns and clinical research trials. We report the feasibility, acceptability, safety, and provider uptake of TA in diverse clinical contexts.
Background: Screening for cervical pre-cancerous lesions may be inequitable among women in sub-Sa... more Background: Screening for cervical pre-cancerous lesions may be inequitable among women in sub-Saharan African countries. This study examined age, residence, education and wealth inequalities and their combinations on cervical pre-cancer screening in Ethiopia, Malawi, Rwanda, Tanzania, Zambia, and Zimbabwe. Methods: We used the Population-Based HIV Impact Assessment (PHIA) data, including cervical pre-cancer screening variables and measured the magnitude of inequality between subgroups in percentages points, considering differences of 20%+ as high inequality, 5% to 20% medium, 0 to 5% as low. We described the sample characteristics using descriptive statistics for each country and examined the associations between cervical pre-cancer screening and each inequality. We analysed the differences using multivariable logistic regressions, controlling for covariates. We estimated the inequalities in cervical pre-cancer screening probability for each inequality alone and in combinations usi...
Preventive Medicine, 2022
Cervical cancer is a significant public health problem, with 570,000 new cases and 300,000 deaths... more Cervical cancer is a significant public health problem, with 570,000 new cases and 300,000 deaths of women per year globally, mostly in low- and middle-income countries. In 2018 the WHO Director General made a call to action for the elimination of cervical cancer as a public health problem. New thinking on programmatic approaches to introduce emerging technologies and screening and treatment interventions of cervical precancer at scale is needed to achieve elimination goals. Implementation research (IR) is an important yet underused tool for facilitating scale-up of evidence-based screening and treatment interventions, as most research has focused on developing and evaluating new interventions. It is time for countries to define their specific IR needs to understand acceptability, feasibility, and cost-effectiveness of interventions as to design and ensure effective implementation, scale-up, and sustainability of evidence-based screening and treatment interventions. WHO convened an expert advisory group to identify priority IR questions for HPV-based screening and treatment interventions in population-based programmes. Several international organizations are supporting large scale introduction of screen-and-treat approaches in many countries, providing ideal platforms to evaluate different approaches and strategies in diverse national contexts. For reducing cervical cancer incidence and mortality, the readiness of health systems, the reach and effectiveness of new technologies and algorithms for increasing screening and treatment coverage, and the factors that support sustainability of these programmes need to be better understood. Answering these key IR questions could provide actionable guidance for countries seeking to implement the WHO Global Strategy towards cervical cancer elimination.
Journal of Cancer Policy, 2021
The Lancet Global Health, 2021
Background Globally, cervical cancer is the fourth leading cause of cancer-related death among wo... more Background Globally, cervical cancer is the fourth leading cause of cancer-related death among women. Poor uptake of screening services contributes to the high mortality. We aimed to examine screening frequency, predictors of screening results, and patterns of sensitisation strategies by age group in a large, programmatic cohort. Methods We did a cohort study including 11 government health facilities in Lusaka, Zambia, in which we reviewed routine programmatic data collected through the Cervical Cancer Prevention Program in Zambia (CCPPZ). Participants who underwent cervical cancer screening in one of the participating study sites were considered for study inclusion if they had a screening result. Follow-up was accomplished per national guidelines. We did descriptive analyses and mixed-effects logistic regression for cervical cancer screening results allowing random effects at the individual and clinic level.
Preventive Medicine, 2021
The World Health Organization (WHO) is leading a call to action to eliminate cervical cancer by t... more The World Health Organization (WHO) is leading a call to action to eliminate cervical cancer by the end of the century through global implementation of two effective evidence-based preventive interventions: HPV vaccination and cervical screening and management (CSM). Models estimate that without intervention, over the next 50 years 12.2 million new cases of cervical cancer will occur, nearly 60% of which are preventable only through CSM. Given that more than 80% of the cervical cancer occurs in low- and middle-income countries (LMICs), scaling up sustainable CSM programs in these countries is a top priority for achieving the global elimination goals. Multiple technologies have been developed and validated to meet this need. Now it is critical to identify strategies to implement these technologies into complex, adaptive health care delivery systems. As part of the coordinated cervical cancer elimination effort, we applied a systems thinking lens to reflect on our experiences with implementation of HPV-based CSM programs using the WHO health systems framework. While many common health system barriers were identified, the effectiveness of implementation strategies to address them was context dependent; often reflecting differences in stakeholder's belief in the quality of the evidence supporting a CSM algorithm, the appropriateness of the evidence and algorithm to context, and the 'implementability' of the algorithm under realistic assessments of resource availability and constraints. A structured planning process, with early and broad stakeholder engagement, will ensure that shared-decisions in CSM implementation are appropriately aligned with the culture, values, and resource realities of the setting.
Journal of Global Oncology, 2018
Background: Cervical cancer is a highly preventable disease and the major cause of cancer related... more Background: Cervical cancer is a highly preventable disease and the major cause of cancer related illness and deaths in Africa. Cervical cancer screening to find precancers before becoming invasive cancer is a well-proven way to prevent cervical cancer. In Zambia alone, over 2000 cervical cancer cases are diagnosed each year accounting for over 30% of new cancer cases with a mortality of above 35%. Women access screening services regardless of HIV status as long as they are sexually active. Cervical cancer screening for HIV-positive women in Zambia remains low despite the high burden of the disease among this population. Aim: We aimed to determine the trends of incidence of cervical precancer lesions among women who ever presented for screening in Lusaka. Methods: We conducted a retrospective cohort study of 95,520 women who presented for cervical cancer screening between 2007 and 2017 at 11 Lusaka district clinics that provide cervical cancer screening. Data were merged from these ...
Journal of Global Oncology, 2019
In 2016, the Zambian government made cancer control a national priority and released a National C... more In 2016, the Zambian government made cancer control a national priority and released a National Cancer Control Strategic Plan for 2016 to 2021, which focuses on malignancies of the breast, cervix, and prostate, and retinoblastoma. The plan calls for a collective reduction in the cancer burden by 50%. In support of this vision, Susan G. Komen sponsored a consultative meeting in Lusaka, Zambia, in September 2017 to bring together the country’s main breast cancer stakeholders and identify opportunities to improve breast cancer control. The recommendations generated during the discussions are presented. There was general agreement that the first step toward breast cancer mortality reduction should consist of implementation of early detection service platforms focused on women who are symptomatic. Participants also agreed that the management of all components of the national breast cancer control program should be integrated and led by the Ministry of Health. As much as possible, early d...
Journal of Cancer Policy, 2019
Background: With high rates of HIV/AIDS and rising burdens of non-communicable diseases, Zambians... more Background: With high rates of HIV/AIDS and rising burdens of non-communicable diseases, Zambians increasingly need palliative care. While efforts are underway to grow Zambia's palliative care system, the most recent situational analysis of palliative care in Zambia, conducted in 2008, revealed substantial gaps in availability. Methods: To provide an updated appraisal of breast and cervical cancer services in Zambia, including palliative care, we conducted a nationwide provincial and tertiary hospital survey. All 9 provincial hospitals and the University Teaching Hospital and Cancer Diseases Hospital in Lusaka Province participated (N = 11). The survey was conducted between August 2014 and January 2015 and administered in-person at each facility. Data regarding the availability of inpatient, outpatient, and community-based palliative care services, palliative medications, and psychosocial supports was obtained at each facility. The reported results are descriptive in nature. Results: Although the need for palliative care services was recognized, many facilities (64%) lack palliative care policies and only 18% offer palliative care in a coordinated program. The majority of services are only available to inpatients and rarely include community-based programs. While all facilities had adequate supplies of acetaminophen, 82% reported unavailability of codeine and 45% reported no access to oral morphine. Conclusions: This assessment confirms the dearth of palliative care services across Zambia. Less than half of its provincial hospitals offer community-or home-based services and only 55% offer opioid analgesics. Immediate and substantial improvements in policy, drug procurement and distribution, and service expansion are needed to ensure high-quality palliative care is available throughout Zambia.
International Journal of Gynecology & Obstetrics, 2018
Objective: To evaluate how the influence of traditional Chiefs can be leveraged to promote access... more Objective: To evaluate how the influence of traditional Chiefs can be leveraged to promote access to cervical cancer prevention services in rural Zambia. Methods: A retrospective review of outcome data was conducted for all screening outreach events that occurred in Zambian Chiefdoms between October 4, 2015, and October 3, 2016. Members of the health promotion team of the Cervical Cancer Prevention Program in Zambia visited local Chiefs to inform them of the importance of cervical cancer prevention. The local Chiefs then summoned adults living within their Chiefdoms to assemble for cervical cancer prevention health talks. Screen-and-treat services were implemented within each of the Chiefdoms over a 1-week period. Results: VIA-enhanced digital imaging of the cervix (digital cervicography) was offered to 8399 women in ten Chiefdoms as part of a village-based screening (VBS) program. In all, 419 (4.9%) women had positive screening test results. Of these women, 276 (65.8%) were treated immediately with thermocoagulation and 143 (34.1%) were referred to provincial government hospitals to undergo either the loop electrosurgical excision procedure/large loop excision of the transformation zone (n=109, 26.0%) or punch biopsy (n=34, 8.1%). Conclusion: The influence of traditional Chiefs was leveraged to facilitate access to cervical cancer prevention services in rural Zambia.
PloS one, 2018
Long delays to diagnosis is a major cause of late presentation of breast diseases in sub-Saharan ... more Long delays to diagnosis is a major cause of late presentation of breast diseases in sub-Saharan Africa. We designed and implemented a single-visit breast care algorithm that overcomes health system-related barriers to timely diagnosis of breast diseases. A multidisciplinary team of Zambian healthcare experts trained a team of mid- and high-level Zambian healthcare practitioners how to evaluate women for breast diseases, and train trainers to do likewise. Working collaboratively, the two teams then designed a clinical platform that provides multiple breast care services within a single visit. The service platform was implemented using a breast outreach camp format, during which breast self-awareness, psychosocial counseling, clinical breast examination, breast ultrasound, ultrasound-guided biopsy, imprint cytology of biopsy specimens and surgical treatment or referral, were offered within a single visit. Eleven hundred and twenty-nine (1129) women attended the camps for breast care....
Health care for women international, Jan 10, 2018
Cancer has become a global health concern with marked differences in the incidence and mortality ... more Cancer has become a global health concern with marked differences in the incidence and mortality rates between developing and developed countries. Understanding the factors that shape uptake of preventative and screening services is the key. We use in-depth interviews with 13 Zambian urban-based female cancer survivors to explore the facilitators and barriers to screening, diagnosis and treatment, with a particular focus on cultural influences. We identified a central theme (i.e. a story told about cancer) in all of the interviews: 'cancer is a death sentence'. Most women referenced this theme to describe their own, their family members', or community members' reactions to their diagnosis, along with references to cancer as 'contagious' and 'a shameful illness'. We also identified a theme entitled 'survivors as advocates', within which women described engaging in advocacy work to challenge stigma, misconceptions and misinformation about cancer...
Journal of Cancer Policy, 2017
Introduction: By 2030 cancer will kill one million Africans each year. Women will bear the heavie... more Introduction: By 2030 cancer will kill one million Africans each year. Women will bear the heaviest burden, as cancers of the breast and cervix are the most common malignancies and causes of cancer-related death in the African region. National-level data that map the status of women's cancer control services are needed to inform strategies for implementing platforms for the early detection and treatment of these "priority" cancers. Methods: Using mixed-methods, we assessed available services for breast and cervical cancer detection and treatment at all provincial hospitals, the national referral hospital, and the national cancer treatment center in Zambia. Results: A system for cervical cancer prevention using visual inspection with acetic acid (VIA) and ablation/ excision of precancerous lesions has been established at the provincial level. The potential for mammography, clinical breast examination, diagnostic ultrasound and biopsy exist at the provincial level, albeit on a much smaller scale. Breast wedge resections and mastectomy can be performed in provinces where general surgeons are located; however, breast conserving and reconstructive surgery are not available. Invasive cancers are generally referred to University Teaching Hospital in Lusaka, where services for radiation, chemotherapy and hormonal therapy are available but overburdened. Pathology services nationwide are woefully inadequate. Discussion: The assessment revealed a critical need for centrally coordinated, but decentralized, public service platforms for women's cancer control. Efforts are underway, through multiple stakeholders, to implement recommendations related to training healthcare workers who can provide advanced diagnostic and therapeutic services, improving pathology services, and innovative financing for these initiatives.
International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 2017
The problem of cervical cancer in low- and lower-middle-income countries (LLMICs) is both urgent ... more The problem of cervical cancer in low- and lower-middle-income countries (LLMICs) is both urgent and important, and calls for governments to move beyond pilot testing to population-based screening approaches as quickly as possible. Experiences from Zambia, Bangladesh, Guatemala, Honduras, and Nicaragua, where scale-up of evidence-based screening strategies is taking place, may help other countries plan for large-scale implementation. These countries selected screening modalities recommended by the WHO that are within budgetary constraints, improve access for women, and reduce health system bottlenecks. In addition, some common elements such as political will and government investment have facilitated action in these diverse settings. There are several challenges for continued scale-up in these countries, including maintaining trained personnel, overcoming limited follow-up and treatment capacity, and implementing quality assurance measures. Countries considering scale-up should asse...
The Journal of Arthroplasty, 2012
Little is known about the economic value patients place on effective treatment of osteoarthritis ... more Little is known about the economic value patients place on effective treatment of osteoarthritis (OA) of the hip. The purpose of this study was to evaluate the value of total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA) to patients with advanced hip OA by measuring their preferences and willingness to pay (WTP) for either procedure. Seventy-three patients younger than 65 years with advanced hip OA reviewed information about the risks and benefits of THA and HRA and were asked which procedure they would choose and how much they would be willing to pay for it. Sixty-nine percent of patients chose THA (average WTP, $69 419) and 31% chose HRA (average WTP, $83 195). There was no correlation between WTP and annual income or total assets. However, patients with modest income and assets could have reported that they were willing and able to pay more than they could actually afford, and WTP dropped and correlation with income rose if we excluded high responses from the poorest respondents. These results may have important policy implications as patients are asked to share a greater burden of the cost of their care for chronic conditions such as OA.
JCO Global Oncology, 2021
Globally, breast and cervical cancers are the two most common causes of cancer deaths in women ag... more Globally, breast and cervical cancers are the two most common causes of cancer deaths in women age 1565 years. Of the estimated 592,000 premature deaths from the two cancers in 2020, nearly 90% occurred in lowand middle-income countries. The recently launched WHO Global Strategy to Accelerate the Elimination of Cervical Cancer and Global Breast Cancer Initiative both promote the strengthening of comprehensive cancer control with improved access to effective interventions. Although countries expand access, it is critical that they are able to measure the impact of scale-up over time. At the population level, cancer-specific incidence, survival, and mortality are the core indicators for assessing cancer burden trends. Ideally, incidence and survival are provided through a population-based cancer registry and mortality through vital statistics of each country. However, these health information systems are underdeveloped in many resource-constrained countries with high cancer burden. Wi...
Preventive medicine reports, 2017
Among the identified barriers to HPV vaccination is the concern that women may compensate for the... more Among the identified barriers to HPV vaccination is the concern that women may compensate for their reduced susceptibility to cervical cancers by reducing cervical cancer screening. This exploratory study examined the relationship between cervical cancer screening rates and HPV vaccination. We conducted a cross-sectional survey using a convenience sample of women aged 21-35 attending a local minority health fair in July 2015. Data were analyzed in 2015-2016. Outcomes assessed were: receiving a Pap test within the last three years, awareness and comfort with current Pap test recommendations, and knowledge regarding the purpose of a Pap test. A total of 291 women were included in the analyses. Mean age was 28.5 years and 62% were non-Hispanic black. 84% had received a Pap test in the last three years and 33% had received at least one HPV vaccine. Logistic regression results showed that women who had been vaccinated did not have lower odds of having a Pap test in the past three years (...
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Papers by Dr.Sharon Kapambwe