Objective: Gynecologic malignancies remain a leading cause of death among women in low-and middle-income countries. In 2017, the International Gynecologic Cancer Society (IGCS) started the Global Gynecologic Oncology Fellowship Program in countries without existing training. This 2-year structured program allows fellows to train locally with support from international mentors through in-person visits, virtual mentorship, and didactic instruction. Fellows participate in monthly tumor boards, conduct research, complete international observerships, log surgical cases, and complete an oral exam upon graduation. Our objective was to characterize the growth of this program from 2017 to 2024 and determine best practices and areas for improvement. Methods: Between February and April 2024, 40 IGCS fellowship graduates were invited via email to complete a 38-question survey about their training and post-fellowship experiences. Data were analyzed using descriptive statistics and thematic analysis. Results: Since 2017, the IGCS fellowship program has expanded from 5 pilot sites to 22 training sites in 18 countries. To date, 52 fellows have graduated and 38 are currently in training. There are 40 international mentors and 53 local supervisors, of whom 15 are previous graduates. Twenty fellows (50%) completed the survey. Nineteen respondents (95.0%) reported practicing as gynecologic oncologists, with an average of 70% of their clinical work focused on this area. However, most reported continuing to provide obstetric and benign gynecology care. Six respondents (30%) reported being the sole gynecologic oncologist at their hospital. Half of respondents never visited their international mentor's site, although 70% reported consistent virtual support. All graduates expressed a need for post-fellowship support, including mentorship, meetings with other graduates, advanced surgical training, and sub-specialty collaboration. Conclusions: The IGCS fellowship program has significantly expanded gynecologic oncology capacity in low-resource settings. Graduates report valuable training experiences but desire ongoing post-fellowship support, a next step in growth for the IGCS fellowship program.

Objective:Cervical cancer is a leading cause of cancer death in Sub-Saharan Africa. Go Further provides funds for prevention and screening in Sub-Saharan Africa, but access to treatment for invasive disease remains limited. This survey aims to assess delays in accessing curative-intent chemoradiotherapy for cervical cancer in countries receiving Go Further funding. Methods:Oncology providers in countries receiving Go Further funding (Botswana, Eswatini, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Tanzania, Uganda, Zambia, Zimbabwe) and South Africa were invited to participate in a web-based survey beginning September 2023. Results:Fifteen oncology providers responded, with all countries except Malawi represented. Nearly half (46.3 %) reported wait time of ≥two months for chemoradiotherapy consultation. 93.3 %, 71.4 %, 53.7 % and 73.3 % had access to at least one CT, linear accelerator, cobalt, and brachytherapy machine, respectively. Majority (60 %) reported wait time of 95 % of patients complete external radiotherapy within 42 days, and 33 % reported >95 % of these patients receive brachytherapy. Only 26.7 % reported overall treatment time within 56 days for >95 % of patients. Lack of transportation, funding, and patient fear, were other treatment barriers reported. Conclusion:These results highlight the need for additional chemoradiotherapy resources in Go Further-funded countries. In addition to expanding radiotherapy, supplemental avenues to improve access in Sub-Saharan Africa include addressing barriers that increase wait times along the care continuum and implementing social support. This survey serves as a call to Go Further, highlighting the urgent need for resource allocation for cervical cancer treatment.

In 2022, over 662,000 cases of cervical cancer were diagnosed globally and over 348,000 deaths occurred from the disease, with almost 94 % of these deaths occurring in low- and lower-middle income countries (LMIC). Effective intervention strategies, including prophylactic Human Papillomavirus (HPV) vaccination for adolescents and primary HPV screening for adult women, are highly effective and cost-effective methods of prevention; however, delivering population-wide access to these prevention methods has been challenging, particularly in LMIC. The World Health Organization (WHO) has launched a global strategy for the elimination of cervical cancer as a public health problem through the scale-up of HPV vaccination, cervical screening and precancer and cancer treatment services. In this review article, we present the rationale, history and strategy behind the global cervical cancer elimination efforts, including the evidence underpinning the WHO's three pillars of cervical cancer control, and essential considerations for implementation, sustainable financing, and health systems implications. Many countries and regions are currently formulating frameworks to achieve cervical cancer elimination within their setting. Here, we consider implementation challenges for both LMIC, and high-income countries (HIC), calling upon the experiences of implementation guided by the WHO Western Pacific Region and Australian frameworks as exemplar settings.

Background Scaling up surgical services for cervical cancer in low and middle income countries requires quantification of the need for those services. The aim of this study was to estimate the global burden of cervical cancer for which access to surgery is required. Methods This was a retrospective analysis of publicly available data. Cervical cancer incidence was extracted for each country from the World Health Organization, International Agency for Research, Global Cancer Observatory. The proportion of cases requiring surgery was extrapolated from the United States Surveillance, Epidemiology and End-Result database. The need for cervical cancer surgery was tested against development indicators. Results Data were available for 175 countries, representing 2.9 billion females aged 15 and over. There were approximately 566,911 women diagnosed with cervical cancer (95% CI 565,462–568,360). An estimated 56.9% of these women (322,686) would require surgery for diagnosis, treatment or palliation (95% CI 321,955 − 323,417). Cervical cancers for which surgery is required represent less than 1% of cancers in high income countries, and nearly 10% of cancers in low income countries. Conclusions At least 300,000 cervical cancer cases worldwide require access to surgical services annually. Gathering data on available cervical cancer surgery services in LMIC are a critical next step.

We describe the outcomes of The Extension for Community Healthcare Outcomes-Elimination of Cervical Cancer in The Americas (ECHO-ELA) program, which was developed as a tri-lateral cooperation between Pan American Health Organization (PAHO), the U.S. National Cancer Institute (NCI) and The University of Texas MD Anderson Cancer Center (MD Anderson). The program's purpose is to disseminate strategies for cervical cancer prevention and is structured around the three pillars of the World Health Organization's (WHO) Cervical Cancer Elimination Strategy and the associated 90-70-90 target goals. The target audience includes health authorities from Latin American and Caribbean countries, as well as PAHO's non-communicable disease Focal Points in country offices as well as clinical and public health collaborators. The virtual sessions are held in Spanish for 1.5 hours every month using the ECHO & REG; format. From May 2020 to June 2021, 14 ECHO sessions were held with an average of 74 participants per session (range: 46 - 142). We conducted two anonymous surveys (baseline and follow up) and two focus groups. Respondents stated that the topics they learned the most about included the state of HPV vaccination in the region and strategies for implementing HPV vaccina-tion. Identified needs included support between ECHO sessions and country-specific technical assistance. The ECHO-ELA program provides a forum for increased collaboration between countries in Latin America/ Caribbean and the dissemination of best-practice strategies to reach the WHO Cervical Cancer Elimination target goals.

PURPOSE: To evaluate the relative effect of percent maximal cytoreductive surgery and other prognostic variables on survival among cohorts of patients with advanced-stage ovarian carcinoma treated with platinum-based chemotherapy.MATERIALS AND METHODS: Eighty-one cohorts of patients with stage III or IV ovarian carcinoma (6,885 patients) were identified from articles in MEDLINE (1989 through 1998). Linear regression models, with weighted correlation calculations, were used to assess the effects on log median survival time of the proportion of each cohort undergoing maximal cytoreduction, dose-intensity of the platinum compound administered, proportion of patients with stage IV disease, median age, and year of publication.RESULTS: There was a statistically significant positive correlation between percent maximal cytoreduction and log median survival time, and this correlation remained significant after controlling for all other variables (P < .001). Each 10% increase in maximal cytoreduction was associated with a 5.5% increase in median survival time. When actuarial survival was estimated, cohorts with ≤ 25% maximal cytoreduction had a mean weighted median survival time of 22.7 months, whereas cohorts with more than 75% maximal cytoreduction had a mean weighted median survival time of 33.9 months—an increase of 50%. The relationship between platinum dose-intensity and log median survival time was not statistically significant.CONCLUSION: During the platinum era, maximal cytoreduction was one of the most powerful determinants of cohort survival among patients with stage III or IV ovarian carcinoma. Consistent referral of patients with apparent advanced ovarian cancer to expert centers for primary surgery may be the best means currently available for improving overall survival.

Purpose To meet the demand for cervical cancer care in Africa, access to surgical and radiation therapy services needs to be understood. We thus mapped the availability of gynecologic and radiation therapy equipment and staffing for treating cervical cancer. Methods and Materials We collected data on gynecologic and radiation oncology staffing, equipment, and infrastructure capacities across Africa. Data was obtained from February to July 2021 through collaboration with international partners using Research Electronic Data Capture. Cancer incidence was taken from the International Agency for Research on Cancer's GLOBOCAN 2020 database. Treatment capacity, including the numbers of radiation oncologists, radiation therapists, physicists, gynecologic oncologists, and hospitals performing gynecologic surgeries, was calculated per 1000 cervical cancer cases. Adequate capacity was defined as 2 radiation oncologists and 2 gynecologic oncologists per 1000 cervical cancer cases. Results Forty-three of 54 African countries (79.6%) responded, and data were not reported for 11 countries (20.4%). Respondents from 31 countries (57.4%) reported access to specialist gynecologic oncology services, but staffing was adequate in only 11 countries (20.4%). Six countries (11%) reported that generalist obstetrician-gynecologists perform radical hysterectomies. Radiation oncologist access was available in 39 countries (72.2%), but staffing was adequate in only 16 countries (29.6%). Six countries (11%) had adequate staffing for both gynecologic and radiation oncology; 7 countries (13%) had no radiation or gynecologic oncologists. Access to external beam radiation therapy was available in 31 countries (57.4%), and access to brachytherapy was available in 25 countries (46.3%). The number of countries with training programs in gynecologic oncology, radiation oncology, medical physics, and radiation therapy were 14 (26%), 16 (30%), 11 (20%), and 17 (31%), respectively. Conclusions We identified areas needing comprehensive cervical cancer care infrastructure, human resources, and training programs. There are major gaps in access to radiation oncologists and trained gynecologic oncologists in Africa.

Objectives To meet demands for cervical cancer care in Africa, there is a need to understand current access to surgery and radiotherapy. Methods We collected data on gynecologic and radiation oncology staffing and infrastructure capacities from each African country from February-July 2021 through collaboration by querying partners at the International Atomic Energy Agency, National Cancer Institute, International Gynecologic Cancer Society, and African Organisation for Research and Training in Cancer. Cancer incidence data were obtained from GLOBOCAN. The number of radiation oncologists, therapists, physicists, and gynecologic oncologists were reported. The adequate number of radiation and gynecologic oncologists were both defined as 2 physicians per 1000 cases (assuming a radiotherapy utilization rate of 65% for cervical cancer cases). Results Six of 54(11%) countries reported an adequate number of gynecologic and radiation oncologists. Seven(13%) had neither. Thirty-one(57%) countries reported external beam radiation availability, 25(46.3%) brachytherapy availability, and 31(57%) gynecologic oncology availability. In 6(11%) countries, general gynecologists perform radical hysterectomies. Where data were reported, there were a median of 2 (range 1–13, IQR 2) physicists and 6 (range 1–40, IQR 7) radiation therapy technicians. The number of countries with training for gynecologic oncology, radiation oncology, medical physics, and radiation therapy was 14(26%), 16(30%), 11(20%), and 17(31%) respectively. Conclusions This study maps available gynecologic and radiation oncology services for cervical cancer care in Africa. Our results suggest major gaps in infrastructure, human resources, and training. These data serve as a cervical cancer treatment capacity database, which can facilitate multi-national collaborative clinical, implementation and research projects.

In May, 2018, Tedros Adhanom Ghebreyesus, Director General of WHO, called for a global initiative for cervical cancer prevention and control. 2 years later, the World Health Assembly endorsed a strategic plan based on three pillars: prophylactic HPV vaccination; screening for HPV-associated precancer with appropriate follow-up; and timely, effective treatment for women found to have invasive cancer, including symptom management and palliative care.1 The strategic plan also included specific goals for member states to aim to meet by 2030 (90% of eligible girls vaccinated, 70% of women screened with an effective screen at least once in their lifetime, 90% of women found to have precancer or cancer receiving timely and effective treatment, and a 30% reduction in deaths from cervical cancer).

PURPOSE Cervical cancer (CC) is one of the leading causes of cancer deaths among women in some countries in the Region of the Americas.1 CC is preventable through HPV vaccination, screening and treatment of precancerous lesions, and can be effectively treated if diagnosed early. METHODS Under the framework of the Global Strategy to Accelerate the Elimination of CC as a Public Health Problem, The University of Texas MD Anderson Cancer Center (MD Anderson), the US National Cancer Institute (NCI), and the Pan American Health Organization (PAHO) partnered to develop the Project ECHO for the elimination of CC in Latin America (ECHO ELA). ECHO ELA is modeled on Project ECHO® (Extension of Community Healthcare Outcomes) a hub-and-spoke knowledge-sharing approach where expert teams lead virtual didactic lectures and case discussions, building capacity for participants to deliver best-practice programs to their regions.3 ECHO ELA consists of monthly, Spanish telementoring conferences to assist Latin American (LA) countries reaching the WHO CC elimination goals “90-70-90:” vaccinating 90% of girls against HPV by the age of 15, screening 70% of women for cervical cancer at ages 35 and 45 and treating 90% of women diagnosed with pre-invasive disease or cervical cancer. Program targets professionals from Ministries of Health, including Immunization and Screening Program Managers, and cervical cancer stakeholders. RESULTS In the first year of the program (2020-2021), 294 participants from 22 countries were registered. Fourteen sessions were held averaging 77 participants per session on topics spanning comprehensive program planning, presenting country experiences on HPV vaccination strategies, new technologies for screening and treatment. Eighteen participants completed the post survey addressing priorities, capacity, and desired outcomes, and two focus groups collected facilitators/barriers to achieving goals. CONCLUSION ECHO ELA is potentially an effective tool to enhance collaboration and support countries’ progress towards the elimination of CC.

•WHO is calling governments to upscale their services for cervical cancer control.•Women in in low- and middle-income countries (LMIC) will benefit most.•Gynecologic oncology and other specialists' competences are scarce in LMIC.•Global activities of gynecologic oncology and other societies are still fragmented.•A joint interdisciplinary cervical cancer management platform is urgently needed.

Low-income and middle-income countries (LMICs) have a disproportionately high burden of cancer and cancer mortality. The unique barriers to optimum cancer care in these regions necessitate context-specific research. The conduct of research in LMICs has several challenges, not least of which is a paucity of formal training in research methods. Building capacity by training early career researchers is essential to improve research output and cancer outcomes in LMICs. The International Collaboration for Research methods Development in Oncology (CReDO) workshop is an initiative by the Tata Memorial Centre and the National Cancer Grid of India to address gaps in research training and increase capacity in oncology research. Since 2015, there have been five CReDO workshops, which have trained more than 250 oncologists from India and other countries in clinical research methods and protocol development. Participants from all oncology and allied fields were represented at these workshops. Protocols developed included clinical trials, comparative effectiveness studies, health services research, and observational studies, and many of these protocols were particularly relevant to cancer management in LMICs. A follow-up of these participants in 2020 elicited an 88% response rate and showed that 42% of participants had made progress with their CReDO protocols, and 73% had initiated other research protocols and published papers. In this Policy Review, we describe the challenges to research in LMICs, as well as the evolution, structure, and impact of CReDO and other similar workshops on global oncology research.

Purpose: Cervical cancer is one of the leading causes of cancer deaths among women in some countries in the Region of the Americas.1 Cervical cancer is preventable through HPV vaccination, screening and treatment of precancerous lesions, and can be effectively treated if diagnosed early.2 Methods: Under the framework of the Global Strategy to Accelerate the Elimination of Cervical Cancer as a Public Health Problem, the US National Cancer Institute (NCI), the University of Texas MD Anderson Cancer Center (MD Anderson) and the Pan American Health Organization/World Health Organization (PAHO/WHO) partnered to develop ECHO Latin America (ECHO ELA). ECHO ELA is modeled on Project ECHO® (Extension of Community Healthcare Outcomes) a hub-and-spoke knowledge-sharing approach where expert teams lead virtual didactic lectures and case discussions, amplifying the capacity for participants to deliver best practice programs to their regions. ECHO ELA consists of monthly, Spanish-language telementoring conferences about cervical cancer prevention and control. The program targets Ministries of Health, Immunization Program Managers and key cervical cancer stakeholders in Latin American (LA) countries. Its primary goal is to assist countries in reaching their WHO cervical cancer elimination goals “90-70-90:” vaccinating 90 percent of girls against HPV by the age of 15, screening 70 percent of women for cervical cancer at ages 35 and 45, and treating 90 percent of women diagnosed with pre-invasive cervical lesions or cervical cancer. Results: To date, 222 participants from 21 countries have registered. Seven sessions have been held averaging 93 participants per session. 85 participants completed the baseline survey addressing priorities, capacity, and desired outcomes. Baseline, mid-year evaluation results, within the COVID-19 context, and learned lessons will be presented. Conclusion: ECHO ELA is potentially an effective tool to convene participants from multiple countries to enhance collaboration and support countries9 progress towards the elimination of cervical cancer in the Americas. Citation Format: Sandra L. San Miguel-Majors, Edward L. Trimble, Doug Lowy, Melissa Lopez-Varon, Ellen Baker, Kathleen Schmeler, Silvina Arrossi, Maria Tereza da Costa Oliveira, Mauricio Maza, Jane R. Montealegre, Mila P. Salcedo, Lucia Helena de Oliveira, Silvana Luciani. Promoting WHO9s Cervical Cancer Elimination Goals ‘90-70-909 by Developing, Implementing, and Evaluating the ECHO Latin America (ECHO ELA) Program [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 53.

BACKGROUND:Cervical cancer is the fourth most common cancer among women worldwide, causing more than 300 000 deaths globally each year. In addition to screening and prevention, effective cancer treatment is needed to reduce cervical cancer mortality. We discuss the role of imaging in cervical cancer management and estimate the potential survival effect of scaling up imaging in several different contexts. METHODS:Using a previously developed microsimulation model of global cancer survival, we estimated stage-specific cervical cancer 5-year net survival in 200 countries and territories. We evaluated the potential survival effect of scaling up treatment (chemotherapy, surgery, radiotherapy, and targeted therapy), and imaging modalities (ultrasound, x-ray, CT, MRI, PET, and single photon emission CT [SPECT]) to the mean level of high-income countries, both individually and in combination. FINDINGS:We estimate global cervical cancer 5-year net survival as 42·1% (95% uncertainty interval [UI] 33·8-48·5). Among individual imaging modalities, expanding MRI would yield the largest 5-year survival gains globally (data are absolute percentage point increase in survival 0·6, 95% UI 0·1-2·1), scaling up ultrasound would yield the largest gains in low-income countries (0·5, 0·0-3·7), expanding CT and x-ray would have the greatest effect in Latin America (0·8, 0·0-3·4) and Oceania (0·4, 0·0-3·2), and expanding PET would yield the largest gains in high-income countries (0·2, 0·0-0·8). Scaling up SPECT did not show major changes in any region. Among individual treatment modalities, scaling up radiotherapy would yield the largest absolute percentage point gains in low-income countries (5·2, 0·3-13·5), and expanding surgery would have the largest effect in lower-middle-income countries (7·4, 0·3-21·1) and upper-middle-income countries (0·8, 0·0-2·9). Estimated survival gains in high-income countries were very modest. However, the gains from expanding any single treatment or imaging modality individually were small across all income levels and geographical settings. Scaling up all treatment modalities could improve global 5-year net survival to 52·4% (95% UI 44·6-62·0). In addition to expanding treatment, improving quality of care could raise survival to 57·5% (51·2-63·5), and the cumulative effect of scaling up all imaging modalities together with expanded treatment and quality of care could improve 5-year net survival for cervical cancer to 62·5% (57·7-67·8). INTERPRETATION:Comprehensive scale-up of treatment, imaging, and quality of care could substantially improve global cervical cancer 5-year net survival, with quality of care and imaging improvements each contributing about 25% of the total potential gains. These findings suggest that a narrow focus on the availability of treatment modalities could forgo substantial survival gains. Investments in imaging equipment, personnel, and quality of care efforts will also be needed to successfully scale up cervical cancer treatment worldwide. FUNDING:Harvard T H Chan School of Public Health and National Cancer Institute.

Efforts are being made to scale up human papillomavirus (HPV) vaccination for adolescent girls in India. Bivalent and quadrivalent HPV vaccines were licensed in the country in 2008, and a nonavalent vaccine was licensed in 2018. Demonstration projects initiated in Andhra Pradesh and Gujarat in 2009 introduced HPV vaccination in public health services in India. Following a few deaths in these projects, although subsequently deemed unrelated to vaccination, HPV vaccination in research projects was suspended. This suspension by default resulted in some participants in a trial evaluating two versus three doses receiving only one dose. Since 2016, the successful introduction of HPV vaccination in immunisation programmes in Punjab and Sikkim (with high coverage and safety), government-sponsored opportunistic vaccination in Delhi, prospects of a single dose providing protection, and future availability of an affordable Indian vaccine shows promise for future widespread implementation and evaluation of HPV vaccination in India.

Treatment of preinvasive lesions is critical to the success of secondary prevention of cervical cancer. In many settings, however, excision or ablation of preinvasive lesions can prove challenging. Thermal ablation (TA) is a form of treatment for cervical precancer that may present fewer logistical challenges in resource limited settings. In 2013, Dolman and colleagues wrote a meta-analysis of publications reporting cure rates from TA. This included only one article from a low or middle-income country (LMIC). We updated Dolman's meta-analysis to include more recent articles from LMICs. A formal review of the world literature was performed for the years 2014-2017. Article titles and abstracts were reviewed for relevance; full articles were assessed for quality. The primary endpoint was treatment outcome for cervical intraepithelial neoplasia grade 2 or higher (CIN2 +). The I2 statistic was used to assess heterogeneity between studies. Studies were stratified by geographic region, decade that the study was published, World Bank economic classification of the country where the study was performed, and other factors. We reviewed 34 total reports and included 23 in our meta-analysis, including 10,995 and 6371 patients, respectively. A total of 7 studies were performed in LMICs, including 6 studies included in the meta-analysis. The overall response rate for TA treatment of biopsy proven CIN2 + was 93.8%. Consistent with the wide variety of settings and patient populations, there was significant heterogeneity between studies. TA appears to be an effective treatment for CIN2 + across a variety of settings, including in LMICs.