More than 800 screened for cervical cancer by UCI medical mission to East Africa
UCI medical students, doctors also conduct ultrasound training and eye care clinic
September 18, 2018
Eleven second year UCI medical students traveled for a month to Mwanza, Tanzania in July to conduct three unique clinical programs, including ultrasound anatomy training for students studying at the Tandabui Institute of Health, Education, Science and Technology (TIHEST), vision clinic in which 300 children were screened for basic vision and eye problems and cervical cancer screening.
For the cervical cancer screen-and-treat program, the students were accompanied by Krishnansu S. Tewari, MD, professor and division director of gynecologic oncology at UC Irvine Medical Center. Tewari taught the medical students how to carefully examine patients with vaginal speculums, how to recognize pre-cancerous changes and how to treat lesions with cryotherapy. View more photos from the mission ›
This is the fifth student group from UCI to instruct and conduct ultrasound research in Tanzania.
Cervical cancer in East Africa
Importantly, the highest burden of cervical cancer mortality exists in East Africa, where approximately 50,000 women die from this disease each year. The UCI group, Team Tanzania 2018, screened 828 patients for cervical cancer and identified 206 pre-cancerous lesions and 15 lesions considered suspicious for cancer. Of the 161 cryotherapy-eligible women with pre-cancerous lesions, 143 were treated immediately with cryotherapy. Those with possible cancers were referred to a local cancer center.
“In resource-limited settings, acetic acid bought at the market as vinegar can be used to help identify pre-cancerous changes to the cervical epithelium, which are then treated with cryotherapy to freeze/kill the cells and prevent progression to cancer,” said UCI medical student Justine Maher, who led planning for the cervical cancer screen-and-treat clinic. “This is a low-cost, high-yield way to reduce morbidity and mortality from the fourth most common cancer among women worldwide.”
Tewari said, “This technique has been shown to reduce cervical cancer mortality by 31 percent in India, and has been used by former UCI gynecologic oncology fellows, Drs. Groesbeck Parham and Krista Pfaendler to provide free cervical cancer screening throughout the East African nation of Zambia. The method has been endorsed by the World Health Organization.”
The current cervical cancer screen-and-treat clinic was developed in partnership with Buzuruga Health Centre, an urban public hospital, and a rural health center in Sangabuye. On-the-ground efforts to reach the women of Mwanza included banners hung from bridges, fliers distributed by the medical students, church announcements and a van equipped with a loudspeaker driven through surrounding communities every afternoon for two weeks preceding the workshop.
“In addition to the standard screening, we developed a risk factor survey in the hopes of learning more about what factors put women at risk for cervical dysplasia in Mwanza,” said Maher. “We also integrated educational videos in Swahili into our screening workflow: one video about cervical cancer itself and the other about their new national HPV vaccine rollout for 14 year old girls. Women were also tested for HIV and counseled as necessary.”
The Buzuruga Health Centre has already hosted two screen-and-treats in the month after the UCI team left.
Challenges to medical mission
The UCI group encountered some challenges along the way.
Tewari said rooms for cervical cancer screenings clinic were quite small and had broken, damaged or outdated equipment. In addition, there were only two cryostat probes that could be used and these needed to be cleaned for twenty minutes after each use.
However, a bureaucratic snafu was among the most unexpected challenges.
“The authorities at Kilimanjaro Airport confiscated the metal vaginal speculums, lubricant packets, patient drapes, and pregnancy tests that the students brought for the trip,” Tewari said. “Fortunately, Dr. Juliet Wolford, a gynecological oncology fellow at UCI, had developed 3D printed vaginal speculums that were created to save the day, once we obtained permission from the regulatory authorities with the Tanzanian Food and Drug Administration to use them with patient consent.”
This pilot study using 3D printed speculums was supported by UCI’s Institute for Clinical and Translational Science. An abstract describing the process was presented at the 2018 International Gynecologic Cancer Society Meeting last week in Kyoto, Japan. Current UC Irvine second year medical student Elizabeth Crawford travelled to Kyoto to give this well-received presentation.
“The 3D printed speculums are inexpensive to create and may contribute to the sustainability of such cervical cancer programs in developing countries where speculums are in short supply,” Crawford said.
The other supplies required for the campaign arrived without incident. The language barrier was also at the root of most other challenges.
“Although Swahili and English are both official languages in Tanzania, being able to communicate directly in the native language would have been very helpful because most people with little formal schooling only speak Swahili and/or tribal languages, as we learned,” said Maher. “A few group members tried to pick up some Swahili before arriving, only to find out that most educational resources teach Kenyan Swahili that is slightly different from that of Tanzania. We learned phrases here and there, but we relied heavily upon translators to iron-out logistics, collect data, and perform clinical duties, such as explaining results to patients or answering their questions.”
Tewari said the medical students planned the trip, identified resources that would be needed, raised more than $16,500, practiced ultrasound, learned basic vision screening, and become comfortable with visual inspection of the cervix with acetic acid — all while completing their first year of medical school.
“Clinically, my professional career at UCI has emphasized the surgical management of women with gynecologic malignancies, including cervical cancer,” Tewari said of his involvement in the medical students’ cervical cancer workshop. “Conversely, my research endeavors have focused on clarifying the role of anti-angiogenesis therapy and checkpoint immunotherapy for women with recurrent and metastatic cervical cancer. Participating in the screening and prevention workshop has allowed me to gravitate to the other side of the struggle, and follow in the footsteps of Dr. Parham who trained at UCI and now has accomplished so much in Zambia in cervical cancer prevention.”
Maher and the other students underwent training using World Health Organization and International Association for Research on Cancer resources.
A trip through Tanzania wouldn’t be complete without visiting Mt. Kilimanjaro, the continent’s highest peak.
“It was an unforgettable sight,” said Maher. “We started our trip by climbing ‘Kili’ as a group—and everyone made it to the summit! The trek was as beautiful as it was difficult, and it really helped us bond before working in Mwanza.
She said the kindness and patience of the group’s guides and the work ethic of the porters set the tone for the rest of the trip.
“Their work reminded us to be gracious and have fun even when cold, exhausted, and in pain,” Maher said.
For Maher, her involvement in planning and executing the trip has had a great impact on how she thinks about her medical education.
“I came into medical school with a background in public health and infectious disease, eager to delve into global health work. However, my interest in women’s health has grown dramatically since joining this team less than a year ago,” Maher said. “I feel so lucky to have had this opportunity, as it changed the way I think about my future specialty just as it shed light on the nuances of global health interventions.”
Maher said she hopes to set up her clinical rotations in a way that will allow a return to Mwanza to help with the screen-and-treat again.
“Beyond the clinical knowledge I gained, this trip taught me how to build meaningful relationships across culture and language, stay flexible in the face of logistical hurdles, and trust that with enough effort and collaboration, anyone can make a difference,” she said. “These are not things that can be taught in a lecture or absorbed from review books. They have to be experienced first-hand.”