Introduction: Though highly preventable, cancer of the cervix uteri (CCU) is the second most frequent female cancer in Sub-Saharan Africa. Major underlying causes include: lack of skilled health professionals and inefficient/inexistent national control programs.

Organizers and objectives: To (further) train health staff and deliberate on challenges and constraints in prevention and treatment of CCU in resource-poor sub-Saharan African settings. This meeting was held under the auspices of the University of Dschang (West - Cameroon) and collaborating organizations were: faculties of medicine of the Universities of Dschang, Geneva, Yaounde I and the Cameroonian network of alumni physicians from Swiss Universities.

Participants: 193 delegates (students, nurses, trainees and residents, physicians, biologists, laboratory scientists, anthropologists, public health specialists, representatives of pharmaceutical industries) from Cameroon, France, Ivory Coast, Switzerland, Gabon, Congo-Brazzaville and the United States of America were present.

Contents: The first part consisted of 25 master-classes on the fundamentals of CCU (epidemiology and control strategy, screening and management of pre-cancerous lesions); in the second part, 37 original researches summarizing field experiences and innovations in prevention and management of CCU were discussed.

Conclusion and recommendations: A national working group should be set up to harmonize clinical practices in preventing and handling CCU. Besides the only radiation therapy unit in the country should be re-started with support of some international agencies like the International Agency for Atomic Energy.

Keywords: Cervix uteri cancer, Sub-Saharan Africa, Prevention, Screening, Management

The 9th edition of the annual congress on Cancer of the Cervix uteri (CCU) in sub-Saharan Africa (SSA) took place from the 29th to the 30th of March 2018. Considering that CCU is the second most prevalent and deadly cancer among sub-Saharan African women especially in rural areas, the organizing committee located the event at the University of Dschang (West-Cameroon) which is dedicated to rural development [1,2]. The meeting had two main goals: to (further) train health workers and to share field experiences among teams in other to optimize cervical cancer control programs in SSA. Under the patronage of the Vice-Chancellor of the University of Dschang, the following institutions co-organized the congress: faculties of medicine of the Universities of Dschang, Geneva, Yaounde I and the Cameroonian network of alumni physicians from Swiss Universities. During the first part of the meeting several international cervical cancer experts gave masterclasses on the fundamentals of the illness. The second part was dedicated to discussions of field experiences. Deliberations were structured under the following themes: 1) Cervical cancer epidemiology and prevention strategy; 2) Basics on cervical cancer; 3) Screening and management of precancerous lesions of the uterine cervix; 4) Cervical cancer control programs in sub-Saharan African settings; 5) Multidisciplinary management of invasive CCU. 193 participants from seven countries took an active part to the meeting. All the domains of the fight against CCU were represented: clinicians (nurses, physicians gynecologists, oncologists, radio-oncologists, cancer surgeons), social workers (anthropologists, sociologists), policymakers (officials from ministries of health, public health specialists), program managers (Director of Hospitals, coordinators of cancer control programs), pharmaceutical industries and lecturers.

1.       Cervical cancer epidemiology and prevention strategy

In this session, the picture of CCU in SSA was presented and different preventive strategies were discussed under the chairmanship of the Director of the CIESPAC (Centre Inter-Etats de Santé Publique d’Afrique Centrale). He emphasized that SSA is the continent with the highest prevalence and morbi-mortality of CCU. Visual methods (visual inspection with acetic acid and lugol’s iodine) in a screen and treat approach are the most appropriate technique that could only be scaled up if the community is fully involved. The 20 year collaboration between the Geneva University Hospitals and some university teaching hospitals in Cameroon for the control of CCU was reviewed and assessed by delegates to be used as a model. The governmental project to introduce free of charge Human Papilloma Virus (HPV) vaccination in Cameroon was not presented as scheduled.

2.       Basics on cervical cancer 

The first part of this session was dedicated to cervical epidemiology, natural history of HPV infection the pathway to CCU. The value of the so-called “HPV-negative CCU” was explored. Following those presentations, demonstrations of visual methods (naked eye and colposcope) of diagnosis of pre-cancerous lesions took place. Participants were also introduced to an online self-training tool to visual diagnostic methods. During two presentations dedicated to digital health and innovations, the potential impact of digital cervicography using smartphones programs and a mobile colposcope were discussed. Current techniques for the management of precancerous lesions of the cervix were reviewed and explained to delegates.

3.       Cervical cancer control programs in sub-Saharan African settings

Several ongoing or planned programs were presented and/or assessed. Delegates from the Cameroon Baptist Convention health services shared their experience in screening CCU in rural Cameroon for more than a decade. Participants thoroughly discussed their following activities: fee-for-service in cervical cancer screening, screening CCU among sex workers and co-testing with care HPV DNA testing - digital cervicography. A clinical trial led by the Geneva University Hospitals and just launched in west-Cameroon was presented; its aim is to assess the efficacy of HPV-test followed by visual methods to detect pre-cancers of the uterine cervix. The ongoing project of setting up a national cancer control center in Cameroon under the leadership of the presidency of the republic with technical assistance from the Sapienza University of Rome was summarized and its shortcomings were discussed [2]. Initiation of cervical cancer screening in two primary care health facilities (one state-owned: Mbouda District Hospital and one faith-based: Mankon (Bamenda) Presbyterian health Centre) were assessed by experts.  The school of public health of central Africa (CIESPAC) presented the project to implement operational cervical cancer screening units in all the seven member states. Delegates from the Evangelic University of Bandjoun (West Cameroon) emphasized the need of training enough pathology technicians for any nationwide cervical cancer control program to be effective. The French National Agency for Research on HIV/AIDS and viral hepatitis (ARNS) presented the mid-term report of the AIMA-CC project focusing on cervical cancer control in HIV-positive women in Cameroon, Ivory Coast and Burkina Faso.

4.       Multidisciplinary management of invasive cervical cancer

The principles of surgery and chemotherapy for invasive CCU were explained to participants. The constraints and challenges for those therapeutic modalities in resource-poor settings in SSA were debated. The head of radiotherapy unit of the Douala General Hospital summarized their experience in managing invasive CCU before the breakdown of their unique machinery in Central Africa.  The opportunity of starting a high-tech radio-oncology unit in Douala with the financial and technical support of the International Agency for Atomic Energy was described by the Head of the corresponding department of the Geneva University Hospitals. The need to promote palliative care for women with advanced/terminal CCU was also emphasized given that this domain is often neglected. Therapeutic modalities not yet available in SSA were not discussed (personalized medicine and immunotherapy).

5.       Free communications

Besides masterclasses, the following free communications were given.

CONCLUSION

The final recommendations were: 1) To set up national working groups to formulate guidelines for screening and management of CCU; 2) To tackle the long lasting breakdown of the radiotherapy machinery at the Douala Regional Hospital. Other sub-Saharan African countries could learn from the partnership model between Cameroon and Geneva in setting up their national cervical cancer control programs.

1.       World Health Organization (2018) GLOBOCAN 2018: Cancer fact sheets. Available at: http://www.gco.iarc.fr/today/fact-sheets-cancers 

2.       Fouogue JT, Sando Z, Fouelifack FY, Tebeu PM, Kamgaing JT, et al. (2016) Report of the 7^th International Workshop on Colposcopy, Screening and Prevention of Cervical Cancer, Douala (Cameroon), March 30-31 and April 1^st, 2016. Int J Reprod Contracept Obstet Gynecol 5: 3269-3274.