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In 2020, the highest rates of cervical cancer incidence and mortality were reported in Asian and African regions of the world. Across the globe, growing evidence confirms cancer disparities among racial and ethnic minorities, low socioeconomic status groups, sexual and gender minorities, uninsured individuals, and rural residents. Recognition of these stark disparities has led to increased global efforts for improv­ing screening rates overall and, in medically underserved populations, highlighting the urgent need for research to inform the suc­cessful implementation of cervical cancer screening. Implementation science, defined as the study of methods to promote the integration of research evidence into health care practice, is well-suited to address this challenge. With a multilevel, implementa­tion focus, we present key research direc­tions that can help address cancer dispari­ties in resource-limited settings. First, we describe several global feasibility studies that acknowledge the effectiveness of self-sam­pling as a strategy to improve screening cov­erage. Second, we highlight Project ECHO as a strategy to improve providers’ knowl­edge through an extended virtual learning community, thereby building capacity for health care settings to deliver screening. Third, we consider community health work­ers, who are a cornerstone of implement­ing public health interventions in global communities. Finally, we see tremendous learning opportunities that use contextually relevant strategies to advance the science of community engagement and adaptations that could further enhance the uptake of screening in resource-limited settings. These opportunities provide future directions for bidirectional exchange of knowledge between local and global resource-limited settings to advance implementation science and address disparities. Ethn Dis. 2022; 32(4):269-274; doi:10.18865/ed.32.4.269

Cervical cancer is the leading cause of death among women in Nepal. The American Society of Clinical Oncology (ASCO) and The University of Texas MD Anderson Cancer Center collaborated with international and local experts to hold a cervical cancer prevention course in Nepal in November 2019. The course included didactic lectures and a hands-on workshop. The didactic lectures included the epidemiology of cervical cancer globally and locally, cervical cancer screening guidelines, human papillomavirus vaccination, colposcopy and visual inspection with acetic acid (VIA), cervical dysplasia, and cervical cancer treatment. The hands-on workshop consisted of four stations: (1) VIA; (2) colposcopy, cervical biopsy, and endocervical curettage; (3) thermal ablation; and (4) loop electrosurgical excision procedure (LEEP). A train-the-trainer model short course was held by the international faculty to assist six local faculty to become familiar with the instruments, procedures, and models used in the hands-on training stations. Forty-two people (84% gynecologist, 8% radiation oncologist, and 8% other) attended the course. Following the course, the international faculty visited the regional hospitals for additional educational activities. Increased knowledge in cervical cancer screening guidelines and ability in performing VIA, colposcopy and cervical biopsy, thermal ablation, and LEEP were reported by 89%, 84%, 84%, 87%, and 84% of participants, respectively, from the postcourse on-site evaluations. From the 6-month follow-up survey, all respondents reported that they had made practice changes based on what they learned in the course and had implemented or tried to implement the cervical cancer screening guidelines presented at the course. In conclusion, the course evaluations suggested an improvement in participants' ability to perform cervical cancer screening and diagnostic procedures and reported the changes in practices after training.

ImportanceAlthough Africa has the highest burden of cervical cancer in the world, educational resources to achieve the 90-70-90 targets set by the World Health Organization in its strategy to eliminate cervical cancer are lacking in the region.ObjectivesTo adapt, implement, and evaluate the Project Extension for Community Health Care Outcomes (ECHO), an innovative learning tool, to build capacity of clinicians to better incorporate new evidence-based guidelines into cervical cancer control policies and clinical practices.Design, Setting, and ParticipantsThis cross-sectional study assessed knowledge and practices of clinicians and support staff regarding cervical cancer prevention and control and compared them among respondents who had attended Project ECHO sessions (prior ECHO attendees) with those who had not but were planning on attending in the near future (newcomers) as part of the Cameroon Cervical Cancer Prevention Project ECHO. Satisfaction of prior ECHO attendees was also evaluated. Data were analyzed from January to March 2022.Main Outcomes and MeasuresMain outcomes were practices and knowledge regarding cervical cancer education and prevention and preinvasive management procedures compared among prior ECHO attendees and newcomers.ResultsOf the 75 participants (mean [SD] age, 36.4 [10.0] years; 65.7% [95% CI, 54.3%-77.1%] women) enrolled in this study, 41 (54.7%; 95% CI, 43.1%-66.2%) were prior ECHO attendees, and most were clinicians (55 respondents [78.6%; 95% CI, 68.7%-88.4%]). Overall, 50% (95% CI, 37.8%-62.2%) of respondents reported performing cervical cancer screening with visual inspection of the cervix after application of acetic acid (VIA) and/or visual inspection of the cervix after application of Lugol’s iodine (VILI), 46.3% (95% CI, 34.0%-58.5%) of respondents reported performing human papillomavirus (HPV) testing, and 30.3% (95% CI, 18.9%-41.7%) of respondents reported performing cervical cytological examination in their practices, Approximately one-fourth of respondents reported performing cryotherapy (25.4% [95% CI, 14.7%-36.1%]), thermal ablation (27.3% [95% CI, 16.2%-38.3%]) or loop electrosurgical excisional procedure (LEEP, 25.0% [95% CI, 14.4%-35.6%]) for treatment of preinvasive disease. The clinical use of many of these screening and treatment tools was significantly higher among prior ECHO attendees compared with newcomers (VIA/VILI: 63.2% [95% CI, 47.4%-78.9%] vs 33.3% [95% CI, 16.0%-50.6%]; P = .03; cryotherapy: 40.5% [95% CI, 24.3%-56.8%] vs 6.7% [95% CI, 0.0%-15.8%]; P = .002; thermal ablation: 43.2% [95% CI, 26.9%-59.6%] vs 6.9% [95% CI, 0.0%-16.4%]; P = .002). Knowledge about cervical cancer education, prevention, and management procedures was satisfactory in 36.1% (95% CI, 23.7%-48.5%) of respondents; this proportion was significantly higher among prior ECHO attendees (53.8% [95% CI, 37.7%-69.9%]) compared with newcomers (4.5% [95% CI, 0.0%-13.5%]; P Conclusions and RelevanceThese findings suggest that the Project ECHO e-learning and telementoring program was associated with improved skills for clinicians and support staff and enhanced quality of care for patients. In the COVID-19 era and beyond, reinforced efforts to strengthen cervical cancer knowledge and best practices through distance learning and collaboration are needed.

Solving health problems requires not only the development of new medical knowledge but also its dissemination, particularly to underserved communities. The barriers to effective dissemination also contribute to the disparities in cancer care experienced most everywhere. This concern is particularly acute in low and middle-income countries which already bear a disproportionate burden of cancer, a situation that is projected to worsen. Project ECHO (Extension for Community Healthcare Outcomes) is a knowledge dissemination platform that can increase workforce capacity across many fields, including cancer care by scaling best practices. Here we describe how Project ECHO works and illustrate this with existing programs that span the cancer care continuum and the globe. The examples provided combined with the explanation of how to build effective Project ECHO communities provide an accessible guide on how this education strategy can be integrated into existing work to help respond to the challenge of cancer.

The NCI Center for Global Health convened the 9th Annual Symposium on Global Cancer Research as a virtual 2-day meeting alongside the Consortium of Universities for Global Health Annual Conference, March 10–11, 2021. The virtual format allowed for diverse and inclusive participation by over 400 attendees from 70 countries, 25+ speakers from 12 countries, and sharing of research conducted in 68 countries. The highly interactive 2-day program explored the science and complex considerations around resilience and equity in global cancer research and control. The Symposium convened individuals working in global oncology to discuss trends in global cancer research and control and map out collaborative efforts to move the field forward. The accepted scientific abstracts are published in this special supplement of AACR Cancer Epidemiology, Biomarkers, and Prevention.

BackgroundCervical cancer is the leading cause of cancer and related deaths among women in Mozambique. There is limited access to screening and few trained personnel to manage women with abnormal results. Our objective was to implement cervical cancer screening with human papillomavirus (HPV) testing, with navigation of women with abnormal results to appropriate diagnostic and treatment services.MethodsWe prospectively enrolled women aged 30–49 years living in Maputo, Mozambique, from April 2018 to September 2019. All participants underwent a pelvic examination by a nurse, and a cervical sample was collected and tested for HPV using the careHPV test (Qiagen, Gaithersburg, Maryland, USA). HPV positive women were referred for cryotherapy or, if ineligible for cryotherapy, a loop electrosurgical excision procedure. Women with findings concerning for cancer were referred to the gynecologic oncology service.ResultsParticipants (n=898) had a median age of 38 years and 20.3% were women living with the human immunodeficiency virus. HPV positivity was 23.7% (95% confidence interval 21.0% to 26.6%); women living with human immunodeficiency virus were twice as likely to test positive for HPV as human immunodeficiency virus negative women (39.2% vs 19.9%, pConclusionCervical cancer screening with HPV testing, including appropriate follow-up and treatment, was feasible in our study cohort in Mozambique. Women living with human immunodeficiency virus appear to be at a significantly higher risk for HPV infection and the development of invasive cervical cancer than human immunodeficiency virus negative women.

Aims: Cervical cancer incidence and mortality rates are approximately 55% higher in the Rio Grande Valley (RGV) along the Texas–Mexico border compared with the average rates in the US. Our aim was to improve cervical cancer prevention efforts in the RGV through a comprehensive multilevel intervention initiative focused on community education, patient navigation, and training of local providers. Methods: We initiated a program in the RGV which consisted of (1) community education, (2) patient navigation, and (3) a training/mentoring program for local medical providers including hands-on training courses coupled with telementoring using Project ECHO® (Extension for Community Health Outcomes). We assessed the number of women undergoing cervical cancer screening, diagnosis, and treatment at three participating clinics caring for underserved women in the region. Results: From November 2014 to October 2018, 14,846 women underwent cervical cancer screening. A total of 2030 (13.7%) women underwent colposcopy for abnormal results (179% increase over baseline) and 453 women underwent loop electrosurgical excision procedures (LEEPs) for treatment of cervical dysplasia. Invasive cancer was diagnosed in 39 women who were navigated to a gynecologic oncologist for treatment. Seven local medical providers were trained to perform colposcopy and/or LEEP. Project ECHO telementoring videoconferences were held every 2 weeks for a total 101 sessions with an average of 22 participants per session and a total of 180 patient cases presented and discussed. Conclusions: Our program led to a large number of women undergoing diagnosis and treatment of cervical dysplasia in the RGV. If sustained, we anticipate these efforts will decrease cervical cancer rates in the region. The program is currently being expanded to additional underserved areas of Texas and globally to low- and middle-income countries.

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.

It is estimated that there will be 2 523 200 new cases of cancer in Latin America in 2040, a 79% increase over current numbers.[1][1] This is especially concerning when considering the scarce human resources in some low resource countries in the region. For example, there are 3.1 physicians per

Purpose: Explore attitudes about education and training in cancer prevention research and practice on dissemination and implementation of cancer prevention practices in India. Methods: Conduct focus groups to understand how cancer prevention education and training – or their absence – influence dissemination and implementation of cancer prevention and control strategies from stakeholder groups: o Professionals with leadership responsibilities in cancer and public health, managing people and resources, and with experience working with patients and communities, clinicians and public health professionals, health administrators, government agencies, and non-profits; and o Patients with cancers for which prevention and early detection strategies exist. Results: In focus group discussion guides, we consider how to appropriately probe aspects of individual and professional responsibility, leadership style, public and system capacity, cultural and educational influence, and surface other aspects important to the influence of education and training of professionals, leaders, and the public in cancer prevention and control. We expect to gain rich insight from leaders and professionals with knowledge of cancer prevention and control success achieved in developed countries and lived experience managing cancer resources for patients and systems in India. We also anticipate rich insight from survivors about their expectations of and experiences with oncology care for contrast and alignment of themes from leaders and professionals. Conclusio:n Slow progress in dissemination and adoption of proven cancer prevention and control initiatives in LMICs creates critical opportunities missed. Through focus groups, we hope to unearth foundational barriers to cancer prevention in low-resource settings related to cancer prevention education and training for fuller NCI R01 dissemination science investigations in India and other low-resource settings that share the experience of preventable cancers diagnosed at advanced stage but are culturally different for comparison. Insight from such studies may reveal new directions for achieving high impact, long-term implementation of cancer prevention strategies. Citation Format: Melissa Varon, Chang Shine, Sharmila Pimple, Surendranath Shastri. Slow Progress in Low-Resource Environments: Is Lack of Education and Training in Cancer Prevention Key? [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 72.

Objectives Cervical cancer is the leading cause of cancer and related deaths among women in Mozambique. There is limited access to screening and few trained personnel to manage women with abnormal results. Our objective was to implement primary HPV screening in Mozambique and navigate women with abnormal results to appropriate diagnostic and treatment services. Methods We prospectively enrolled women aged 30 to 49 at Mavalane General Hospital in Maputo, Mozambique. All participants underwent a pelvic examination by a nurse and a cervical sample was collected and tested for HPV DNA using careHPV (Qiagen, Gaithersburg, MD, USA). Women who tested positive for HPV (HPV+) underwent visual assessment for treatment (VAT) using visual inspection with acetic acid (VIA) to assess eligibility for cryotherapy. All HPV+ women were treated with cryotherapy, loop electrosurgical excision procedure (LEEP), or referred for cancer management based on results. Results From April 2018 to February 2019, 427 women underwent HPV testing. The median age was 39 years. 86/426 patients (20.2%) were HIV positive. 93 patients (21.8%) were HPV+ and 97.8% (91/93) returned for VAT and treatment including cryotherapy (n=68, 74.7%), LEEP (n=10, 11.0%) and referral for cancer management (n=4, 4.4%). Treatment is pending in 9 patients for cryotherapy. Conclusions Cervical cancer screening with primary HPV DNA testing, including follow-up and treatment, was found to be feasible in Maputo, Mozambique. This study is ongoing to and includes training medical providers to diagnose and treat cervical preinvasive disease and cancer.