A community-focused cervical and breast cancer screening program using a sustainable funding model in a training center in Ghana.

Abstract

Background: While Ghana prepares to roll out a nationwide breast and cervical (pre)cancer screening policy, it is necessary to continuously document high-impact and scalable models. Over the years, the Cervical Cancer Prevention and Training Centre (CCPTC), Battor, has utilized a sustainable funding model in which each trainee pays for 15 women to be screened with visual inspection with acetic acid. This paper details the framework of community-focused trainer-led coordinated cervical and breast screening outreaches carried out under this model. The paper further reports the outcomes of screening over a 5-year period and discusses the advantages and shortcomings of the model in an effort to make recommendations for the development and scale-up of combined cervical and breast screening in a largely opportunistic setting.

Methods: This descriptive retrospective cross-sectional study investigated women who underwent cervical precancer screening using visual inspection with acetic acid or mobile colposcopy and/or high-risk human papillomavirus (hr-HPV) DNA testing between September 2017 and July 2022 (n = 2,273) and clinical breast examination between June 2021 and March 2023 (n = 622) by trainees of the CCPTC on outreaches conducted primarily to solidify their practical skills. For women screened using HPV DNA testing and visual inspection, respectively, the study explored factors associated with HPV infection or visual inspection 'positivity' using nominal logistic regression.

Results: The overall prevalence of hr-HPV infection was 14.3% (95% CI, 10.0-19.6) among women with valid results for hr-HPV DNA testing, while the overall visual inspection 'positivity' rate was 2.8% (95% CI, 2.2-3.6). After controlling for age, earning an income was the only factor associated with hr-HPV infection (aOR = 3.00; 95% CI, 1.35 - 6.64; p-value = 0.007). Factors associated with visual inspection 'positivity' after adjusting for age were: number of births (aOR = 0.71; 95% CI, 0.52 - 0.97; p-value = 0.029), number of lifetime pregnancies (aOR = 0.79; 95% CI, 0.67 - 0.93; p-value = 0.004), being single (aOR = 2.42; 95% CI, 1.19 - 4.90; p-value = 0.014), and earning an income (aOR = 0.44; 95% CI, 0.26 - 0.74; p-value = 0.002). Breast examination showed clinically significant masses in 20 women (3.2%), lymphadenopathy in 13 (2.1%), and nipple discharge in 37 women (6.0%) and only n = 3/67 women (4.5%) requiring referral followed up for further management.

Conclusion: While the outreach approach adopted by the CCPTC has myriad benefits, further evidence-based studies and structured program evaluations are needed to assess if this approach can be adopted on a large scale, especially without the backing of a training institution with the needed resources and capacity to investigate and manage screen positives.