In the past few months, I’ve been working with a medical device company in Hubei on a cervical cancer screening project in the province’s rural regions. This project is part of the central government’s efforts to provide equitable healthcare access to rural areas with a three-year cervical cancer screening campaign for underprivileged women. By the end of 2011, for cervical cancer.
Cervical cancer is the second most common cancer in women. China’s account for 20% of the total reported cases. The disease can be detected by early detection through various methods including Pap testing and now HPV testing, but in China, most women are unaware of cervical cancer and prevention methods and there is a shortage of trained and experienced medical workers in Pap diagnosis.
Screening Recruitment
Screening Recruitment
In Wuhan, the city where I work and the most populous in central China, the local government has launched a campaign to screen 200,000 women between the ages of 35-45 in the surrounding rural regions. The massive project was launched in June 2011 and will be complete in six months. Recruitment is led by the Wuhan All-Women’s Federation and is supported by the city’s finance, police and health bureaus.
After working in healthcare marketing at an international-standard hospital to serve wealthy Chinese and expatriates in China, I was surprised by how difficult it was to implement health screenings to the poor. Although the cost of screening is subsidized by the government, patient recruitment is hard, as people have little faith in public healthcare. A gynecology physician who monitors patient recruitment told me about a woman who ran away before reaching the hospital because she thought the doctors were trying to trick her to pay for unnecessary drugs and treatment.
Screening Technology
Cancer screening is difficult for two reasons. On one hand, there is a shortage of cytologists. On the other, new technologies are available however they tend to be too expensive for population-based screening.
The company I’m currently working with, , is responsible for providing the cervical screening cytology results in Wuhan. We use an advanced DNA imaging technology which can be used on the mass population at affordable prices. It is also automatic which means it can provide more objective and accurate results than the traditional method. Since we started in 2000, we have already diagnosed 500,000 early cancer screenings across China and proven that we can make up for the limitations in cytology.
Women who receive abnormal results from the screening are advised to receive further diagnostic testing and if necessary, treatment. The additional costs are also subsidized by the government. So far, Landing Medical Hi-Tech has recommended more than three thousand women to receive further diagnostic testing and of those who did, 300 pre-cervical cancer and cervical cancer cases have been confirmed.
Model for the Future
Providing universal healthcare to China’s rural citizens is daunting. Not all cities have been as successful as Wuhan in their cervical cancer screening projects. Obstacles in recruitment, coordination and technology have made it difficult for many local governments to meet their screening quota. I believe our result in working with the government and testing 200,000 rural women in merely 180 days can serve as a model for the rest of the country and perhaps other developing countries.
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Screening is only really useful if you have effective interventions for those people found to screen positive. If you screen 10 million women for cervical cancer do you have the health practitioners and facilities to follow them up in a timely way with colposcopy and treatment of abnormalities? Is there any organised program for regular screening and re-screening? Besides, it might be more effective to immunise all young women against HPV.
Hi Michael,
Thanks for the message. I’ll try my best to answer from my experience in Wuhan, however I cannot answer for the rest of the country.
Screening is only really useful if you have effective interventions for those people found to screen positive. If you screen 10 million women for cervical cancer do you have the health practitioners and facilities to follow them up in a timely way with colposcopy and treatment of abnormalities?
In Wuhan, for this campaign, there are practitioners/facilities for follow up. The local government is subsidizing the costs for the biopsy and treatment for those with abnormal results. I don’t know if other cities are able to provide the followup.
Is there any organised program for regular screening and re-screening?
There isn’t a regular screening/re-screening program yet. I believe this is the first large-scale rural cervical cancer screening program launched in Wuhan. We hope to see this continue on a regular basis.
Besides, it might be more effective to immunise all young women against HPV.
We hope it is one day. However, the HPV vaccination still doesn’t protect against all cervical cancers and these women will still need to get screened. Furthermore, the HPV vaccine is a relatively new technology so time is needed to prove its long-term effectiveness while cost needs to be reduced for it to become economically feasible for population-based screening. So far cytology-based screening has proved to be the most effective method as it has been used for more than 50 years.
Just to follow up on Michael’s comments: in grad school, a young woman in my cohort did a lot of research on similar cervical cancer screening programs in Bolivia. She looked more in depth to the “follow-up” procedures and found that no, women weren’t being followed up appropriately as the companies who funded the screening had little to do with it, and government subsidies were inadequate. We can imagine what happened to these women.
It is difficult enough to have women screened for cervical cancer folllow-up in high-income countries such as Canada and the U.S., where health care infrastructure is well established. As any of us who have worked in rural China know, good care is often inadequate, whether from lack of trained professionals or sophisticated medical equipment. I think that instead of trying to reach the “most” women in screening, companies such as yours would do more to train medical professionals about how to follow-up with these abnormal results, even if that means home visits to rural areas. Because as Michael says, screening really is only useful if followed-up with treatment.
Another thing is with these government subsidies, women are often expected to pay for the biopsies and treatment up front with the “subsidy” coming later. This creates yet another barrier for these women for treatment.
I think much more energy needs to be put into ensuring appropriate follow-up by competent medical professionals by these companies offering “free” screening.
I’m not sure why the post has generated pessimistic/negative responses (I suspect because a polarizing comment gets more attention..)
In any case these comments suggest that screening go hand in hand with adequate follow-up care. There is nothing in the blog post to suggest that this would not be the case (indeed, the post mentions that follow-up care will be government subsidized). So besides the evidence that one grad student
noted that follow-up was inadequate in a town in Bolivia, I am not sure why follow-up procedures would not be adequate.
But even suppose they are inadequate. Screening is still a first step, and its providing information to individuals who may be at risk about a disease that they would not otherwise know they have. People are better off knowing, and yes there may be barriers to treatment, but surely the potential existence of barriers should not preclude screening in the first place. That is like saying that people should not go see the doctor, because if they are sick then they will have to buy drugs that cost money.
Both screening and follow-up are important, and there doesn’t seem to be evidence that follow-up in this case would be inadequate. But even if it was, screening would still give people access to information they don’t have. And if there is a lack of adequate follow-up care, if you didn’t screen, then this lack would go on unnoticed. Screening at least draws attention to the weaknesses in providing overall care. Thus I think we should encourage companies like this to take these measures, which seem like important first steps in developing a beginning to end care system.
Questions for Lan Wang: What percent of follow-up care is subsidized (i.e. how much would the average woman requiring follow-up care pay out of pocket)? Does this depend on income/residential status? Would follow-up care require traveling from the countryside to Wuhan, or is that available in local hospitals?