The Female Cancer Foundation has over 10 years of experience in See & Treat programmes in Asia and Africa. This has taught us a lot about the implementation of screening in areas where medical care is not available and accessible to everyone. There are shortages of trained staff, many clinics have no electricity and/or water and the roads in remote areas are sometimes difficult to traverse. This makes our work challenging and especially needed in these areas. Research in our See & Treat programmes can help us better understand these limitations and find alternatives. We conduct research on various elements that influence practice. Besides research, our supervising physicians are also involved in the fellowship and mentorship programme in Uganda, to train specialists in gynaecology-oncology there. Read moreabout that here.

1. Major research project in four countries PRESCRIP-TEC

PRESCRIP-TEC is a research project in Uganda, Bangladesh, Slovakia and India.

BNR news radio paid attention to the new project in their Podcast Better with an interview with Jogchum Beltman, gynecologist-oncologist. You can listen to it here.

Jogchum Beltman was also interviewed by the LUMC about this major research project:

The World Health Organisation recently launched a global strategy to eradicate cervical cancer. The ambitious PRESCRIP-TEC research project is in line with this and can save many women's lives. LUMC researchers are also taking part, says gynaecologist-oncologist Jogchum Beltman.

The global strategy and the research are both urgently needed, says Beltman. He is one of the main applicants for the European grant, to which Marlieke de Fouw, AIOS Gynaecology at LUMC, also made a major contribution. "Cervical cancer is a huge problem, especially in developing countries south of the Sahara and in Southeast Asia," Beltman says. "In some regions, people have little or no access to healthcare. 85% of global cases occur there. The disease claims many lives there, because in many areas there is no possibility of radiation, chemotherapy or surgery. And yet this cancer is preventable.

Screening with acetic acid

Beltman explains that cervical cancer is caused by the human papillomavirus (HPV). Women with a chronic HPV infection develop cervical cancer precursors, which can be detected by screening during a population screening. Pap smear screening is common in the Netherlands, but in low- and middle-income countries there is often poor access to health care and screening is rare.

"Fortunately, there is a quick, alternative way of screening," says Beltman. "This involves a health professional applying acetic acid to the cervix - vinegar from the supermarket is already sufficient for this. Any abnormalities cause a colour change that can be seen with the naked eye. Treatment is then carried out using a freezing or heating technique, which stops the development of cancer. All this can be done directly on site, without any complicated surgery.

More effective with artificial intelligence

Despite the simplicity of this screening and treatment, they are relatively labour-intensive in remote areas. This while rapid intervention is very important. Therefore, the new research project PRESCRIP-TEC focuses on a "winning" combination of a HPV self-test and screening using artificial intelligence (AI). The self-test is performed on women using a cotton swab. If they are found to have HPV and a screening is needed, AI technology helps health professionals recognise the discolouration of the cervix.

Based on thousands of photos of cervical mouths, an algorithm was developed using deep learning that assists them with interpretation via an app. The app indicates which medical actions are required. PRESCRIP-TEC recently received a €3 million European Horizon 2020 grant. The research has the potential to significantly reduce the number of cervical cancer cases worldwide.

Fighting in developing countries

Researchers from the LUMC are involved in the study through the Female Cancer Foundation (FCF), at the invitation of the UMCG. The FCF was founded by emeritus professor Lex Peters. As LUMC-gynaecologist Peters worked a lot in the tropics and saw there the terrible consequences of cervical cancer. The foundation is committed to combating it by means of screening, particularly in developing countries. Thus, there is a close relationship between the foundation and the departments of Gynaecology (where the FCF is located) and Pathology. PhD students do research in countries that are hard hit. There, the foundation and local partners try to reach the most vulnerable women.

Jogchum Beltman: "This combination of HPV self-testing and AI-supported screening will save many lives and hopefully reduce the pressure on healthcare in developing countries. Now that the grant has been approved, we will be carrying out the project for the next three years. This will happen in Uganda, India, Bangladesh and Slovakia. The Global Health Unit of the UMCG is in charge of the project."

2. Investigate difference in treatment of precursors

Marlieke de Fouw, supervised by Jogchum Beltman and Lex Peters, is researching an alternative treatment method in screening programmes. In some countries, gas for cryotherapy is only available to a limited extent, and the transport of gas cylinders is very expensive. Therefore, women cannot always be screened and treated in the same visit. We started looking for an alternative: thermal coagulation. Thermal coagulation is a treatment that, like cryotherapy, can be performed by trained nurses and midwives and has few side effects. It uses electricity to heat the cells of the cervix. The device has a rechargeable battery and is therefore easy to transport. In this study, we compare the implementation of cryotherapy and thermal coagulation in different programmes in Africa.

The team in Uganda, Malawi and Gambia has now been trained in thermal coagulation, by experienced nurses from Nkhoma Hospital in Malawi. The study was launched in 2018.

Part of this research is an extensive meta-analysis study, which can be found here. This shows that both cryotherapy and thermal coagulation are effective methods for treating CIN lesions in low-income countries.

Read more about the project here.

3. In-depth examination of differences in treatment

In addition to the above research, Marlieke de Fouw and colleagues conducted in-depth practical research in collaboration with TU Delft into the technical differences in the performance of the treatment between thermal coagulation (heating) and cryotherapy (freezing). This involves important factors such as the temperature, the number of seconds of treatment and how many rounds it is applied and the effect this has on the tissue. This research contributes to and lays the foundation for manuals for healthcare professionals on how to best use the devices in practice. You can read the entire study here.

4. Include research men in education

There is also research on men's involvement in cervical cancer prevention in Uganda: see an extensive article published by Marlieke de Fouw and a blog here

5. Research role of coffee ceremonies in Ethiopia

Marlieke de Fouw has done research with local partners, important outcomes are:

  • Mobilising women to come for screening is essential. Coffee ceremonies play an important role in educating the community about screening and building women's confidence in screening services.
  • This is particularly the case in rural areas. In urban areas, it plays a slightly lesser role because here women also collect information in a different way and there is less social cohesion.
  • However, many challenges remain in the implementation of screening in Ethiopia. There is too little trained staff, too few materials, there is no national vaccination programme yet and the screening service is often not integrated into regular health care.

The full article can be viewed here.

6. Palliative care research

Palliative care is important for women with cervical cancer who can no longer be properly treated. Findings from this study are that:

  • There is a great need for palliative care services and these are not provided in sufficient numbers at present.
  • The services should be more focused on pain and symptom management including training of family members.
  • Palliative care services should be integrated into existing community networks, religious structures and local and national health systems.

The full article can be viewed here.