Toward Cervical Cancer Elimination: Evaluation of Access to Diagnostic Services After Referral to a Specialist Gynecologist Clinic at a Major Referral Hospital in Kisumu, Kenya

PURPOSE Women in low- and middle-income countries bear a disproportionate burden of cervical cancer incidence and mortality. WHO recommends screening with visual inspection with acetic acid (VIA), followed by treatment in a screen-and-treat approach. We evaluate access to diagnostic services after referral for VIA-positive or suspicious lesions to a gynecologist-led colposcopy clinic at a major government referral and teaching hospital in Kisumu, Kenya. METHODS Data on women who were referred for colposcopy at a gynecologist clinic at the Jaramogi Oginga Odinga Teaching and Referral Hospital with positive VIA from referral clinics from 2014 to 2017 were abstracted. We determined the proportion of referred women screening positive after colposcopy-based screening by a gynecologist, the proportion accessing diagnostic biopsy, and histologic results after positive or suspicious lesions. Treatment ascertainment is ongoing. RESULTS Four hundred five women were evaluated after referral for positive VIA screening or suspicious lesions. Mean age was 40.2 years and mean parity was 4 children, with 53% of women self-reporting positive HIV status. Two hundred thirty-three referred women (57.5%) were found to have positive or suspicious lesions after colposcopy-based screening by a gynecologist. Of these women, 147 (63%) had a biopsy performed and results were available for 110 patients (74.8%). Eighty-six women did not receive biopsy, despite positive colposcopy, primarily because of associated costs or lack of supplies. Among women with biopsy results, 25 (22.7%) were benign, 18 (16.4%) had cervical intraepithelial neoplasia grade 1, 9 (8.2%) had cervical intraepithelial neoplasia grade 2 and 3, 57 (51.8%) had squamous cell carcinoma, and 1 (0.9%) had nondiagnostic results. CONCLUSION While drawing from observational, paper-based clinical data with incomplete records, our evaluation demonstrates significant challenges in the cervical cancer prevention cascade at a tertiary referral hospital. This calls for strengthening the ability of facilities to adequately evaluate at-risk women, remove financial barriers, and invest in database systems to facilitate evaluation.