This document discusses efforts to reduce cervical cancer in Peru through analyzing the global value chain of a point-of-care colposcope called POCkeT. Field interviews were conducted with public and private sector organizations in Lima, Peru to understand how POCkeT could fit within existing healthcare infrastructure and clinical workflows. The interviews revealed opportunities to leverage telemedicine, train midwives on POCkeT usage, clarify midwife and patient roles, and improve coordination between organizations. Mapping the POCkeT value chain showed its traditional focus on manufacturing and sales. However, the ultimate goal is solving the problem of cervical cancer, requiring a holistic GVC analysis of all actors and factors involved in prevention, screening and treatment.
2. Global Mortality Rates of Cervical Cancer
2
1
1GLOBOCAN 2012 (IARC) , Section of Cancer Surveillance; 2WHO. 2013; 3Crow. Nature, 2012; 4Arbyn. Annals of Oncology, 2011 5 del Carmen, Gyn Onc 2015
Age Standardized Mortality Rate per 100,000
1
3. 3
Tsu, et al. Bull World Health Organ 2013
Burden is “high, growing and inequitable”
• 528,000 new cases reported
annually
• 266,000 women die annually1
• Disproportionate Burden in Low &
Middle-Income Countries (LMIC)
(85%)2-4
• LMICS only have 5% of global health
resources
• Women in developing countries are
twice as likely to die form cervical
cancer than in the US
5. Reduction in Mortality attributed to early
Screening and Diagnosis
Screening:1,2
Pap Smear & HPV
Diagnosis:1,2
Colposcopy & Biopsy
Therapy:1,2
LEEP / Cryo-Therapy
50-75% of women in LMIC are lost to follow-up after cervical cancer screening 3,4
A profound need to have “see and treat” paradigm!
1 Saslow, Can Cancer J Clin 2012; 2 Cronje, Int. J of Gyn & Ob 2004 3 Musa, Inf. Agents & Cancer 2016; 4 Ezechi, BMC Health
Serv Res 2014.
6. See and Treat Paradigm
11 WHO 2013; 12 ASCCP 2012; 13 Sankaranyanan Best Pract. & Res Clin Ob Gyn 2012.
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Limitations of VIA 13
- Subjective
- High False + Rate
- Over-treatment
7. Visual Inspection Test
• Visual inspection with acetic acid (VIA)
• Can be done with the naked eye or low magnification
• Microscope
• Digital camera
• Magnifying glass
• Vaginal speculum exam where the health care
provider applies acetic acid to identity color change
on the cervix
• To determine whether the test result is positive or negative
for possible precancerous lesions or cancer
7
8. Leisegang Optik 2
Multiple Mags.: 3.75, 7.5, and 15 X
US$ 20,000 and >150 lbs
Not Portable, depends on AC source
Canon SX50HS Digital Camera
Single Mag.: 2.5-2.75 X
US$ 500 and ~1.5 lbs
External light source,
Stand for stability
Digital Cervicography Digital Colposcopy
Technologies used for VIA
9. Majengo primary health center
clinic, Moshi, Tanzania
The Reality
Clinical 66, Kenyatta National
Hospital, Nairobi, Kenya
Limited access to
Referral Centers
Health provider
Shortage
11. Medical Device Global Value Chain
1111
Components
Manufacturing
Plastics
Extrusion &
Molding
Precision Metal
Works
Electronics/Electric
al Components
Software
Development
Weaving/Knittin
g Textiles
Assembly
Packaging
Sterilization
Assembly
Wholesale
distributors
Individual
Patients
Doctors &
Nurses
Hospitals
(Public/Private)
Cardiovascular
Orthopedics
Infusion
Systems
Others
Marketing &
Sales
Resin Metals
Chemicals Textiles
Input
Suppliers
Disposables
Surgical &
Medical
instruments
Capital Medical
Equipment
Therapeutic
Devices
Final
Products
Distribution
Market
Segments
Post-Sales
Services
Consulting
Maintenance,
Repair
Training
Adopter
Research &
Product
Development
Regulatory
Approval
Process
Development
Sustaining
Engineering
Prototype
Process
Development
14. Field Interviews
PUBLIC SECTOR
- La Liga Clinic
- Pathfinder
- Pontifica
Universidad
Catolica Peru
PRIVATE SECTOR
- Roche
Pharmaceuticals
- Medical Start-
Ups
GOVERNMENT
- Ministry of Health
- City of Lima
- Public Hospitals
15. • Women’s cancer clinic with 26 locations in Lima
• 5 mobile vans
• Partner clinic running 200 patient clinical trial
• Failure of preventative measures being taken (HPV Vaccine)
• Dr. Venegas supports training midwives to use POCkeT
• Full gold standard care provided alongside POCkeT
La Liga Contra el Cancer
21. Leverage Points
1) Tele-connectivity/ Technology
2) Training on use of POCkeT and how it fits in with other trainings
(e.g., if a midwife is already trained on outreach to potential
patients).
3) Midwives on better understanding their role
4) Patients on end user issues, barriers and goals
5) Collaboration and coordination between various actors country
strategy (e.g., who is and isn’t talking to each other and who needs
to be included in the conversation for a national structure)
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26. 1) We built a GVC to map the product, of the
POCkeT colposcope.
2) In reality, we’re doing GVC analysis to solve
the problem of cervical cancer.
27. Key Takeaways
- GVCs are an incredibly flexible tool that can be applied beyond the
traditional scope of a physical product or service.
- The power of GVCs lies in the holistic approach towards factoring in
third party actors (ex: government agencies, technological
infrastructure, dynamics between doctors and midwives).
- Reflect: Taking GVCs in a business classroom context and applying it
to a social context.
Notas del editor
We will go over the biology of cervical cancer, public health aspects, and the POCkeT Colposcope
US 13,000 new cases and 7,000 deaths
445,000 new cases and 230,000 deaths 85% Burden is in LMIC
Tanzania: (in 2014) 4216 deaths due to cervical cancer annually and 7,304 newly diagnosed (see http://www.hpvcentre.net/statistics/reports/TZA.pdf)
Total women at risk population 13.7 million in Tanzania
US: (in 2011) 4092 deaths due to cervical cancer annually and 12,109 newly diagnosed (see http://www.cdc.gov/cancer/cervical/statistics/)
Total women at risk population 44.2 million in the US.
http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0020109
This disproportionate burden is a function primarily of discrepancies in the availability of effective screening and treatment methods. This lack of access to adequate care is well-illustrated when we look at ratios of mortalities to new cases between developed and developing countries. In the US, this ratio is 0.27 while in developing countries it rises to 0.53 and climbs even further to 0.67 in sub-Saharan Africa. Developing an effective treatment method appropriate for resource-limited settings could stem this growing disparity.
http://globocan.iarc.fr/old/FactSheets/cancers/cervix-new.asp
Tsu, V.D., J. Jeronimo, and B.O. Anderson, Why the time is right to tackle breast and cervical cancer in low-resource settings. Bull World Health Organ, 2013. 91(9): p. 683-90.
The GLOBOCAN project, which presents epidemiologic data on all forms of cancer as provided by the International Agency for Research on Cancer in Lyon, France, classifies North America, Europe, Australia/New Zealand and Japan as “more developed” and the rest of the world as “less developed”
This is purely due to population changes, assuming no change in per capita rates for specific regions.
The good news is since that time the incidence of cervical cancer has declined dramatically due to the advent of well established screening and diagnostic programs, particularly in high income countries.
Loop electrosurgical procedure
Also the implementation of cytology in resource poor settings has often been accompanied by low compliance of screening high risk group, use of a too low a threshold for colposcopy, need for repeated visits, and general over treatment of non-malignant disease[14].
The concern with VIA as a primary screening tool is the poor sensitivity and resultant overtreatment of healthy women despite the general recommendation for its implementation in low resource settings [49]. Studies on VIA have indicated very large inter-observer variability that would be indicative of a need for improving training due to the subjective nature of the test[14]. However, there are no mandated standardized teaching or training programs in low-resource settings[50]. For example, an intensive 5 day education program for VIA was implemented on a cohort of healthcare workers from Uganda and El Salvador and pre-test accuracy was 57% and post-training markedly improved to 80% with sustained retention at 6 months post training[51]. Barriers for widespread implementation of VIA include lack of funds for training[49], staff shortages prevent in-service training[49], “brain drain” loss of skilled workers to other countries, leading to a shortage of nearly 1,000,000 skilled health care works in 2006 [52]and in some cases lack of required equipment[52].
American Society for Colposcopy and Cervical Pathology & World Health Organization, recommend visual inspection with acetic acid followed by cryotherapy if + and eligible (visible lesion / transformation zone). If lesions is too deep then must have LEEP (loop electrosurgical excision procedure). If too late, cancer chemo therapy/ but often in resource settings palliative care only.
Goal: Our goal is to bring benefits of colposcopy to the point of care
VIA
no magnification
no image capture
Leads to poor quality control
Requires training
VIAM/Colposcopy
Costly
Not portable
Requires extensive training
Cervicography
External light source required
Stabilization is problematic
Unfortunately, challenges in scaling screening still remain.
An exploded schematic view of the transvaginal digital colposcope with essential components,
(1) linear film polarizer (to get rid of specular reflection),
(2) concentric 3W (max electrical power) white 5000Kelvin (color temp) and 3W green LED ring
(3) Mount for polarizer and LED
(4) the hydrophobic optical window with antireflection coating (prevent fogging and allows more light),
(5) linear glass polarizer (for imager/CMOS dectector),
(6) color CMOS digital camera,
(7) and (8) ABS medical grade shell.