Andy Gard

Analysis of referral patterns from regional cervical cancer screening centers to Ocean Road Cancer Institute (ORCI), Dar es Salaam, Tanzania

Eastern Africa has the highest cervical cancer burden worldwide, and in Tanzania it is by far the most common women’s cancer (1). The Pap smear and HPV DNA testing have been successfully applied in the developed world to significantly reduce the burden of the disease by facilitating early detection and treatment. However, these tests require substantial medical infrastructure and resources to implement, and are not currently feasible for most developing countries. A simpler screening method is visual inspection with acetic acid (VIA) or with Lugol's iodine (VILI), which has been shown effective for cervical cancer prevention in large developing country studies (2, 3), including one conducted in Dar es Salaam that demonstrated the feasibility of visual inspection and clinic-based treatment in the Tanzanian population (4). 
Following that study, ORCI continued to offer screening on a daily basis (4). To broaden access to the screening program outside of Dar es Salaam, since 2006 ORCI has implemented an outreach program to educate nurses and doctors about cervical cancer and train them to do VIA and VILI screening, biopsy, and treatment of lesions when possible (5). By mid-2010, over 43,000 women had been screened through the program, and almost all for the first time (5) (5). 6.6% of these women screened positive and 2.2% had suspected invasive cervical cancer (5). However, since the outreach screening program occurs in rural regions, follow-up treatment at ORCI is not feasible for all women who are referred.

The objective of this study is to characterize the referral patterns and outcomes of women referred by rural screening clinics to ORCI and compare them to women screened at ORCI (Phase I). We also aim to compare characteristics of women presenting for treatment from a regional screening clinic to women from the same region not referred by a screening clinic (Phase II).

Phase I will be conducted at rural screening clinics in several regions near Dar es Salaam. A list of women who screened positive and were referred for follow-up at ORCI will be compiled from clinic log books. A similar comparison list will be drawn from ORCI screening clinic records. Both lists of names will be cross-referenced with ORCI patient charts to understand which referred women presented for treatment. Patient charts at Muhimbili National Hospital will also be checked for women who presented for surgery, but did not continue to ORCI. Data abstracted will include invasive disease stage, treatment prescribed, treatment completed, and patient demographics.
Phase II will utilize ORCI patient records to compile a list of women who presented for cervical cancer treatment from the same rural regions as Phase I, but were not referred by a screening clinic. These women will be compared to treated women who were referred from a rural screening clinic in these regions.

1. IARC. GLOBOCAN. 2008.
2. Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial. Sankaranarayanan, Rengaswamy, et al. 9585, August 4, 2007, The Lancet, Vol. 370, pp. 398-406.
3. Effectiveness of cervical cancer screening using visual inspection with acetic acid in Peru. Luciani, Silvana, et al. s.l. : International Journal of Gynecology and Obstetrics, 2011, Vol. 115, pp. 53-56.
4. Evaluation of cervical visual inspection screening in Dar es Salaam, Tanzania. Ngoma, Twalib, et al. s.l. : International Journal of Gynecology and Obstetrics, 2010, Vol. 109, pp. 100-104.
5. Outreach Cervical Cancer Prevention Program in Tanzania: Achievements and Challenges. Mwaiselage, Julius. Dar es Salaam : Ocean Road Cancer Institute, 2010.


About Andy
Andy attended William Jewell College (Liberty, Missouri), graduating in 2007 with majors in Institutions and Policy (political science/economics/philosophy), Math, and History. He then worked four years at a global strategic communications agency for healthcare and biotech clients, with an emphasis on oncology. He graduated from the University of Michigan with an MPH in International Health/ Epidemiology in 2013.