Operation Stop Cervical Cancer in Nigeria Second International Meeting Report July 2006 A joint effort of the ExxonMobil Foundation, the M.D. Anderson Cancer Center in Houston, The British Columbia Cancer Agency in Vancouver, the University of Ibadan School of Public Health and College of Medicine, and the University College Hospital, Ibadan, Nigeria A Report on the Proceedings of a Site Representative Meeting and Training Session at the International Institute for Tropical Agriculture (IITA) in Ibadan, Nigeria, July 9-16, 2006 Prepared by the Center for Biomedical Engineering at the University of Texas M. D. Anderson Cancer Center Page 1
Page 2 The first international meeting of this initiative took place in Ibadan, Nigeria on February 2-3, 2006. The meeting was an extraordinary success, and short-term goals that were agreed upon there have been met. The proceedings of the first meeting are detailed in the report entitled, Operation Stop Cervical Cancer in Nigeria: February 2006.
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he second meeting of OPERATION STOP CERVICAL CANCER IN NIGERIA was held at the International Institute for Tropical Agriculture (IITA) from July 9-16, 2006. This conference included instruction in all aspects of cervical cancer screening for teams of physicians, nurses, bioengineers, data managers, and administrators from Ibadan, Lagos, Enugu, Port Harcourt, Zaria, and Jos. These six areas represent centers for the three major tribes in Nigeria (Yoruban, Ibo, and Hausan) and the three major religious groups. ExxonMobil medical director Dr. Dominic Upzong attended and helped distribute $350,000 worth of equipment to local centers. Nigerian television filmed the distribution and reported favorably on the meeting. Generous sponsorship was provided by grants from the ExxonMobil Foundation and Mr. T. Boone Pickens. IITA provides a wonderful venue for a meeting. The Institute is an international nongovernmental agency that also functions as a university for agriculture in the developing world. The IITA has facilities in Africa and Malaysia. The campus in Ibadan is beautiful and houses dormitories, several laboratories, classrooms, a fullservice conference center, banks, and administrative offices. There is a charming staff, wonderful food, and pleasant atmosphere. The security is excellent. All guests were happy with their stay and further meetings there are planned. Page 2
On Sunday, conference leaders met and prepared a detailed agenda in an afternoon session. Each participant was registered by a team of five from Houston. Photographs were taken, titles were reviewed, contact information was collected, and name pronunciation was recorded phonetically. The meeting began early Monday morning and ran through Sunday evening. Evening sessions were used for clinical practicum where the physicians and nurses learned skills for treatment and diagnosis. Additional pedagogic sessions were held on Monday, Tuesday, Wednesday, and Thursday evenings according to need or request. Courses ran through the weekend and culminated on Sunday at 6pm. The last participants departed Monday morning. The meeting began with introductory remarks by Professor Adewole, Professor Oladepo, Dr. Miller, and Dr. Follen. Prof. Adewole is the provost of the University of Ibadan College of Medicine. Prof. Oladepo is the chair of the Department of Health Promotion and Education at the University of Ibadan School of Public Health. Dr. Miller is the division director of gynecologic oncology at the British Columbia Cancer Centre. Dr. Follen is a gynecologic oncologist and epidemiologist at the University of Texas M.D. Anderson Cancer Center. Page 3
In the first session, Prof. Adewole and Dr. Follen discussed progress in organization with the meeting participants. The opportunity was embraced to help nearly 25% of the population of the African continent in a country with eighteen medical schools and twenty-five schools of engineering. In all, the meeting was attended by seventy-six people from six academic medical centers and numerous state hospitals. Each team consisted of an obstetrician-gynecologist, a nurse, a data manager, a health care administrator, and a bioengineer. Each site detailed a history of their progress. In total, the six sites had performed 1500 pap smears over the past four months. This represents a tenfold increase over previous activity. The team leaders reported that all had gone well. One invasive cancer and fifty cervical pre-cancers had been detected. The second morning session was preceded by participants taking a pre-test of their current knowledge of cervical screening. In order to facilitate teamwork, participants were divided into ten small groups and summarized chapters of the manual, Planning and Implementing Cervical Cancer Prevention and Control Programs. This is a very well-written and inclusive text that can be downloaded from the World Health Organization (WHO) website. It is a joint publication of the Association for Cervical Cancer Prevention, EngenderHealth, the International Agency for Research on Cancer (IARC), JHPIEGO affiliated with the Johns Hopkins University, the Pan-American Health Organization, and PATH. The Bill and Melinda Gates foundation provided funding for this comprehensive manual. Page 4
There were ten groups with seven members in each study groups. Participants initially studied one chapter with their group, with one team for each chapter. The groups then reorganized into teams whose members included one representative who had studied each chapter of the manual. In these new groups, participants shared their knowledge and discussed the text in its entirety. A post-test was given. The content and answers to the test were reviewed. Participants reported that they had enjoyed the interaction with health care professionals from across Nigeria. Parallel training sessions were held for administrators, data managers, physiciancolposcopists, physicianpathologists, nurses, and bioengineers from Monday afternoon to Sunday evening. Physician-colposcopists were taught about the Pap smear, various other cervical cancer screening techniques, colposcopy, treatment of cancer precursors, and surgical radical hysterectomy. The basis for the course was a text developed by the IARC, Colposcopy and Treatment of Cervical Intraepithelial Neoplasia: A Beginner s Manual. Disseminating these WHO texts and manuals makes maximum leverage of ExxonMobil funds for training. The evening practicum sessions were used to impart skills using a colposcope and for the practice of loop electrosurgical excision procedure on beef tongue. Each physician and nurse used a colposcope to view fruit in various positions. They learned to position and focus the device in this four hour session. Six loop electrosurgical excision devices were set up for practice in treatment. In this three hour practicum, each participant performed at least eighty individual drills. The beef tongue was then mounted at the height of a model patient and each participant was taught to perform the procedure through a speculum and vaginal retractor. Head lights were used for illumination to simulate the frequent necessity of working in dark conditions with only portable power supplies to run critical equipment. Participants demonstrated competence in a setting comparable to the experience in a Nigerian clinic. Page 5
Physician-pathologists were taught methodologies in cervical screening cytology, cervical histopathology, normal cytologies that are called either cancerous or precancerous, quality assurance procedures in the histopathology laboratory, use of automated screening devices, liquid Pap preparations, statistical analysis of quantitative cytological measurements, Fine Needle Aspiration, and frozen section setup. Dr. Gregg Staerkel, associate professor at the M.D. Anderson Cancer Center, also taught at the Ibadan College of Medicine in the days following his conference lectures. Nurses were instructed in the pelvic exam using models of the female pelvis provided with funds from ExxonMobil. Additionally, they learned procedures for Pap smears, clinic setup, care provider assistance, Visual Inspection with Acetic Acid (VIA), Visual Inspection with Lugol s Iodine (VILI), instrument care, retrieving and recording patient results, and clinic log disposition. Nurses also received instruction in HIPPAA privacy regulations, informed consent, clinical paperwork, patient flow, protocol data management, scheduling, clinic supply orders, and patient chart maintenance. The pelvic models and other training materials will continue to facilitate the training of nurses, medical students, and residents for many years to come. Page 6
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Data managers were instructed in the use of a Filemaker database for cervical cancer prevention that was developed specifically for use at these Nigerian cancer screening centers. The participating data managers were taught to use this software tool to manage follow-up, pathology and cytology reports, collection of demographic information, and comprehensive histories and physical exam forms for patient care. The nurses were also introduced to the database during weekend sessions that allowed them to learn and interact with their data managers. Bioengineers received instruction in the care and management of the equipment given to each site. Five years of replacement parts were provided for crucial equipment. The head engineer at the University College hospital, Mr. Adewole, was appointed as the lead bioengineer for the project. He will receive further training in Vancouver and Houston. He will ultimately make scheduled and unscheduled site visits to ensure that equipment is being properly used, maintained, and repaired. He engraved all the equipment that was provided for sites in Nigeria with the words, OPERATION STOP CERVICAL CANCER IN NIGERIA EXXONMOBIL. Page 9
Administrators were instructed in management and implementation of cervical cancer control programs. Prof. Oladepo and faculty from Houston met with the administrators over ten sessions that focused on implementation in their particular region. Roadblocks implementation barriers were discussed so that they could facilitate the overall progress of the team when they returned. The vital importance of assessing needs and reporting progress was covered in detail. All were delighted to be included and very excited about the program. Dr. Dominic Upzong, medical director for ExxonMobil in Nigeria, was present for the distribution of $350,000 of educational materials, computers and printers, clinical supplies, and equipment for screening and colposcopy to the six groups. Nigerian television broadcast the report nationwide. Several state hospitals participated and provision for equipment was made for them as well. Page 10
Drs. Miller and Follen instructed senior medical residents from Ibadan and Lagos in several clinic sessions in which patients received colposcopy and loop excision. Each resident performed at least two procedures competently under their instruction. The College of Medicine is a collaborator for optical cancer detection technologies with both the M.D. Anderson Cancer Center and the British Columbia Cancer Agency. The Ibadan group is developing optical technologies that are optimized for use in Nigeria and will be leading a project in the National Cancer Institute Program Project, Optical Technologies for Cervical Neoplasia, an extensive study for which Dr. Follen is the principal investigator. Dr. Miller provided further instruction in aspects of the radical hysterectomy with faculty at the College of Medicine. Participants were interested in onsite instruction beyond the lectures. Further instruction for radical hysterectomy will include: 1) a six week training session in the US and Canada for each site team leader, 2) review of surgical video, 3) site visits and surgeries on cadavers for training, and 4) patients with early cancers to be seen during a week with Drs. Miller and Follen operating onsite with team leaders in Nigeria. The six team leaders will become responsible for teaching other physicians in Nigeria in post-graduate courses and practicum. Page 11
Drs. Follen and Miller held weekend sessions for senior residents from each site to teach leadership, team dynamics, and presentation skills. Over two days, the residents adapted three lectures for use in Nigeria. All the participating residents presented twice and received feedback from Prof. Adewole, Dr. Miller, and Dr. Follen. They were encouraged to give these lectures to the medical students and all junior residents. Colposcopy textbooks, training manuals, and CD image galleries were distributed to each center and each senior resident in attendance. Professor Oladepo is planning a study of barriers to cervical screening and vaccination in the six sites over the next six to nine months. Because the sites are representative of Nigeria s diversity, he believes that several barriers will be encountered and multiple strategies for overcoming these barriers will be encountered and multiple strategies for overcoming these challenges can be designed and implemented as the project grows. One of the largest barriers is the cost of the Pap smear test (approximately $6 USD), which is prohibitive for most women because most patients must pay for the test by themselves. Another frequently-mentioned barrier is that in a Nigerian family, the husband must often give permission for his wife to undergo the Pap smear. While this could be perceived as an obstacle to large-scale screening, it can also be seen as an opportunity to screen the whole family as a unit. This could provide the possibility of cancer screening, cardiovascular evaluation, vaccinations, infectious disease screening, and health education all at one time. Page 12
The two greatest risk factors for cervical cancer in Nigeria are lack of screening and Human Papilloma Virus (HPV) infection. Other factors, such as early age at first intercourse, multiple partners, smoking, and other sexually transmitted diseases are not major threats among Nigerian women. At this meeting, cervical cancer care at the six centers was discussed. Currently, only three of the six centers offer radiation therapy and fees must be charged. Until radiotherapy training and implementation are complete at the other three centers, patients will have to be transferred for treatment to one of the operational locations using matched ExxonMobil and hospital funds. The Chief Medical Director at each site will be contacted to use discretionary funds to pay for cancer therapy for impoverished patients. A visit to the Health Minister is planned for October to discuss radiotherapy dissemination, cancer treatment, and Pap smear screening subsidization. At this time, we will discuss comprehensive radiotherapy and imaging equipment, as well as training for physicians and technologists. Radiotherapists from each site are planned to visit the US and Canada later this year. Page 13
Dr. Okolo, an instructor in pathology at the College of Medicine in Ibadan, was named as the project leader for overall management of cervical smears and biopsies. Once granted a visa to the US and Canada, he will spend approximately six weeks training in Vancouver and Houston to use an automated Pap smear screening device that performs as well as clinical cytopathology. Dr. Follen and Prof. Adewole will remain in positions to oversee the entire project. They have planned a WHO training session for cancer registrars in Ibadan in February of 2007. This ten day session is designed to instruct registrars in coding of pathology and staging for all cancers. Seven registrars from each of the six states will be trained and provided with a computer and printer. Further courses will be scheduled every four months until cancer registry is sufficient for the whole country. If the family unit is being screened, registries for infectious diseases, maternal mortality, and infant mortality could also be established. The infrastructure for the coordinating center in Ibadan is a budget priority for the coming months. Page 14
Prof. Adewole, Dr. Follen, and Dr. Miller are using practicum, textbooks, video, educational software, and cadavers for instruction. They are committed to an ethical approach to training so that all care given through this program will be provided by well-trained physicians and nurses. Visits to the M.D. Anderson Cancer Care Center and the British Columbia Cancer Research Centre are planned for leaders in each discipline from each site: nurse, physician-colposcopist, pathologist, radiotherapist, chemotherapist, bioengineer, data manager, administrator, and surgeon. They view this as a unique opportunity train well and measure progress in training. The Ibadan group is now being scheduled for colposcopy instruction with Drs. Miller and Follen in August and September of 2006. The participants will feel confident of their skills prior to seeing patients, and the patients will benefit from a high level of care. Ultimately, Nigeria will need post-graduate courses for surgeons, pathologists, nurses, radiotherapists, cytologists, data managers, bioengineers, and administrators. Initial courses can be held in Ibadan and further programs may be organized regionally by the six centers. The College of Medicine holds many post-graduate courses and has the infrastructure for this work. Although there is a school of laboratory science, the school has no program for cytology or histopathology technician training. Dr. Okolo met with Dr. Staerkel, and they will meet again shortly in Houston to review the curriculum. Additional meetings with a director of the histology technician training program are planned. Organization of these courses and degree granting programs was in line with the objectives of the College of Medicine. Furthermore, training of radiotherapy technicians in the College of Medicine is also being planned. Page 15
In the next three to four months, we will focus on the following tasks: 1. An operational executive committee composed of the coordinating center and leaders from each of the six sites will be formed 2. Internal and external advisors will be invited to regularly-scheduled meetings of the newly-formed executive committee 3. A new budget proposal will be submitted to ExxonMobil 4. ExxonMobil employees and spouses will be screened in Nigeria 5. Logistical and support employees will be hired for the coordinating center 6. The Barriers Study will be launched at all six sites 7. Studies of training will be performed by faculty at all sites so that the timing and effectiveness of development for nurses and physicians can be optimized 8. Studies to assess the effectiveness of direct visual inspection, VIA, VILI, and colposcopy will be performed at each site 9. Proposals will be submitted to the NCI and Canadian Cancer Institute for peerreviewed funding 10. Academic manuscripts will be planned and submitted for publication. We believe there is a great opportunity to help Nigeria benefit from their investment in education. We hope to help Nigerian health professionals learn from fifty years of screening experience in Canada and the US. We seek to address barriers unique to Nigeria in creative and constructive ways. We can study and develop technologies that replace expensive and outdated infrastructure needs using the cell-phone tower model as an ideal of what can be done. Nigeria is poised to undergo exponential change and we hope to make this partnership with the US and Canada a lasting one. Page 16
The University of Texas Center for Biomedical Engineering and the Rice University Department of Bioengineering gratefully acknowledge the support of ExxonMobil and Mr. T. Boone Pickens, which has enabled us to move forward with this valuable program. We also thank FedEx for generously donating their time and resources to transport equipment and supplies to Nigeria. Prepared by Dr. Michele Follen and Brian T. Crain Photos by Latira Chenevert, Kathy McCravy, Trey Kell, Sun Young Park, Roderick Price, Donald Rabel, Paula Roberts, and Darren Roblyer Page 17