Cervical cancer is a leading cause of death among women in Peru, and 80% of cervical cancer cases are detected at advanced, incurable stages. Early identification and treatment of precancerous lesions is critical for reducing cervical cancer progression and mortality. Before treatment can be offered, women with suspected pre-cancer or cancer at screening are referred for an additional visit where confirmatory diagnosis is provided using colposcopy - a technique where a low-powered microscope is used to inspect for cervical lesions. However, loss-to-follow-up for these additional visits is as high as 50% in some regions of Peru, creating a bottleneck for women who need treatment. One approach for mitigating this bottleneck is to improve access to colposcopy for women where they live, i.e., in community settings. In partnership with La Liga Peruana de Lucha Contra el Cancer (The Peruvian League for the Fight against Cancer) and the Peruvian Ministry of Health (MINSA), the proposed study will evaluate the efficacy of an mHealth-supported telecolposcopy approach in communities within Lima Province, Peru. During the study, midwives conducting community-based screening will acquire cervical images using a low-cost ultraportable colposcope, and receive remote feedback from expert colposcopists using a mobile device. The central hypothesis is that access to expert colposcopists using an mHealth-supported telecolposcopy approach will improve the quality and timeliness of patient triage in community-based settings, increasing the proportion of women who receive a diagnosis, and adhere to treatment.
The specific aims are: (1) to identify processes within the screening workflow that facilitate or inhibit effective implementation of mHealth-supported telecolposcopy, (2) to pilot test mHealth-supported telecolposcopy in a community-based setting in women who have a positive screen test based on either visual inspection with acetic acid (VIA), Pap smear, or both, and (3) to evaluate efficacy of mHealth-supported telecolposcopy for improving rate of colposcopies in women who are screen-positive compared to women referred for conventional referral colposcopy. Our proposal is significant because community-based colposcopy can improve the convenience and accuracy of triaging women as those who do or do not need treatment. The anticipated cost-effectiveness of reducing two visits into one, boosts significance and scalability of this approach. Global prioritization of reduction of cervical cancer burden and disparities, high rates of mobile phone subscriptions among families in Peru, and growing investments in telemedicine infrastructure by MINSA further support the significance and feasibility of the proposed approach. The proposed study is innovative as it reframes the standard of care by using telemedicine to allow women to receive colposcopic evaluations in the communities where they live, precluding need for additional and distant clinical visits for diagnosis of cervical lesions. Results will inform an R01 study comprising a randomized controlled trial measuring clinical outcomes and cost-effectiveness of the mHealth-supported telecolposcopy approach, as well as, integration with the national cervical cancer program in Peru with support from MINSA.
Early screening and treatment of pre-cancerous lesions is a cost-effective strategy for reducing preventable mortality in cervical cancer; however, the need for an additional colposcopy visit prior to treatment is a bottleneck for women with suspected cancer or pre-cancer in Peru. In this study, we seek to evaluate the efficacy of an mHealth-supported telecolposcopy approach for boosting rates of colposcopies among women in community settings in Lima Province, where access to expert colposcopists is limited. Results will inform a randomized controlled trial measuring clinical outcomes and cost-effectiveness of the mHealth-supported telecolposcopy approach, and in the future, integration of the mHealth-supported telecolposcopy approach within the national cervical cancer program in Peru with support from the Ministry of Health.
