Qalansawe, Israel – The women, heads covered in hijabs, sat outside a small purple aluminium mobile health station parked in a residential neighbourhood here, shooing away any men who happened to pass by.

Plastic chairs formed a small and intimate circle for the women waiting to be screened for cervical cancer – some for the first time ever, and others who had skipped their annual screenings for decades.

Once inside the mobile station, the women were greeted by a female nurse with a digital scope not much longer than the palm of her hand with a full HD camera at the top.

The Gynescope, which is produced by Israeli firm Illumigyn, digitally documents the cervix, vagina and external genitalia, using high-resolution and superior magnification.

It doesn’t need a fancy lab setup and can produce results within minutes. The digital cervical footprint is saved to the cloud and can be used for remote diagnosis, ongoing medical supervision and follow-up consultations.

“I do not have specific numbers,” Dr Gasem Jauousi, head of family medicine for the city’s largest health fund, told Health Policy Watch. “But Arab women get screened less than the Jewish women. They are less connected [to the health system]. If we do not call, they won’t come.”

Janousi, who spoke from his office adjacent to the caravan, is one of the lead collaborators in a field trial of the Gynescope, one of the latest of the new generation of cervical cancer screening tools that are easier diagnosis for the disease that killed more than 340,000 women in 2020, according to the World Health Organization.

Smart-Scope pencil-like device

Other devices include the handheld Indian “Smart-Scope” which will be feature in the innovation fair of the Geneva Health Forum 2022 (3-5 May). The Forum also is hosting a special day-long meeting on innovations in cervical cancer screening and care, Wednesday 4 May.

The Smart-Scope is an even smaller and more portable device, can detect cervical abnormalities in less than 10 minutes using artificial intelligence, with the aid of a tablet and an intuitive app, Veena Moktali, the founder of the Indian start-up Periwinkle Technologies, told Health Policy Watch.

The test result is color-coded and supplemented by a visual report, Moktali explained. The Smart-Scope stores data on a tablet not the cloud, which makes it accessible to clinics without internet access.

Key features of these new devices is their reliance on high-quality digital imagery instead of old-fashioned lab smear samples that entails taking a sample from a woman’s cervix which then has to be analyzed.

The digital storage of images makes for easy referral and portability, and mobile health clinics can offer the service to women who may not otherwise come to a clinic for a screening test, said Moktali.

Moktali is also speaking at the Geneva Health Forum hosted meeting on cervical cancer about how new AI devices like the Smart Scope are enabling improved point-of-care screening for cervical cancer. The full-day workshop, which evolved out of interactions by innovators and health care professionals at the biennial GHF meetings, will look at how new devices and strategies for cervical cancer screening and treatment can advance the World Health Organization goal of eliminating cervical cancer by 2030.

Solutions for harder-to-reach communities

While Israel is a high-income country with a strong public health system, more marginalized communities – including new immigrants, African asylum seekers, and Arab-Israeli citizens – can fall through the gaps of routine checks.

This is especially true when it comes to sensitive medical interventions such as cervical cancer screening around which there may also be cultural taboos.

For several decades, routine screening for cervical cancer has involved a “Pap smear,” a procedure developed in the 1920s by Georgios Papanikolaou and Aurel Babeș.

A trained health worker scrapes a woman’s cervix for a cell sample, which is then relayed to a laboratory for analysis by a trained technician seeking abnormalities that could indicate cancer or a precancerous growth.

Aside from needing laboratory and diagnostic capacity that is unavailable in many parts of the world, many women find Pap smears invasive and uncomfortable.

Over two days in March, Illumigyn in collaboration with the government health-fund Clalit, set up caravans in two disadvantaged Israeli neighborhoods, one of them Qalansawe. Clalit contacted women enrolled in the health fund, who had not previously been screened, and invited them to come for a visit. No appointment was needed.

The women were able to enter the mobile clinics, positioned in a fenced-off area near the neighborhood health clinic, and be screened by a female nurse. The image was sent to their doctors in real time to inform the women if further evaluation or other action was required.

“They told me to go to the hospital and get an ultrasound,” one woman, who asked to remain anonymous, told Health Policy Watch as she left the caravan. “I need to follow up,” she added, saying that she intended to follow their advice.

Another woman, who also asked to be anonymous, said that when she came to the mobile station, she didn’t even know what the check was intended to diagnose.  Her experience raised her awareness about the whole cervical cancer issue:

“I had no idea what to expect,” she said. “But I am told this is a good thing, that it could save lives, God willing. … Doing these screenings, thinking about people and worrying about them. It is really good,” she said, after leaving the mobile station, full of praise for the initiative.

“We know that women are busy – we don’t have time,” said Illumigyn vice president Yam Salman. “Especially women who are raising their families. But women want to live and now we have the technology that can help them do so. Illumigyn can save their lives,” she said.

Eliminating cervical cancer

Cervical cancer claims the lives of around 300,000 women each year, one woman every two minutes, according to WHO.

At the same time, the disease is highly preventable either by being vaccinated against the human papillomavirus (HPV), which causes the majority of cervical cancers, or by early detection through screening.

Most cervical cancer deaths now occur in low- and middle-income countries where fewer girls are vaccinated and women don’t get regularly screened.

In 2020, the World Health Assembly adopted a global strategy to eliminate cervical cancer, with weighty targets to be hit by 2030. The strategy focuses on three aims: vaccinating 90% of all girls against HPV by the age of 15; expanding access to screening services for 70% of women; expanding access to treatment for 90% of women with precancerous lesions; and offering palliative care for 90% of women with invasive cancer.

“Cervical cancer is the fourth most common cancer among women globally, but it is almost completely preventable and, if diagnosed early enough, is one of the most successfully treatable cancers,” said WHO’s Director General Dr Tedros Adhanom Ghebreyesus on Cervical Cancer Elimination Day in 2021.

“Like COVID-19, we have the tools to prevent, detect and treat this disease. But like COVID-19, cervical cancer is driven by inequitable access to those tools,” Tedros said.

The COVID pandemic has slowed progress to eliminating the cancer, but the new, low-cost screening measures that “democratize women’s health care” can help change that, argues Salman.

New AI devices can be used by any trained caregiver

Both the Smart-Scope and the Gynescope can be used by any trained caregiver or a nurse practitioner, allowing women to be screened and diagnosed even in locations where doctors may be unavailable or in short supply.

That is significant, insofar as around two-thirds of cervical cancer deaths now happen in low- and middle-income countries or communities, explains Dr Nomonde Mbatani, a gynaecologist at Groote Schuur Hospital in Cape Town, South Africa.

Women in rural settings also have a tough time taking off a day of work to reach distant clinics to get their Pap smear. And, if they do take off for the screening, they are unlikely to take a second day off to return to the clinic to get their results – which take several days or even longer to produce.  And that makes follow up action even more difficult, she said in an interview with Health Policy Watch.

“Sending them home is not ideal. The ideal is where their results can be readily available on the same day,” Mbatani said.

Awareness and cultural barriers also exist, she added.

“There is very little understanding of how cervical cancer is caused,” Mbatani said. “Some women feel uncomfortable about presenting problems they are experiencing in their lower genitalia or even having it looked at by a male doctor, except when it comes to birthing their children.”

Resistance to HPV vaccines

Along with better and more frequent screening of adult women, vaccination of pre-adolescent girls against the human papillomavirus virus (HPV), a leading cause of cervical cancer, is another important strategy being touted by WHO for eliminating cervical cancer.

South Africa, which has one of the best health systems in Africa, routinely offers the vaccine to young children in public schools, Mbatani said, noting the vaccines have been availalbe in the country for about a decade already. But any girl living in a rural area who does not regularly attend school may still miss out.

In addition, parents of children enrolled in the country’s extensive private school system have to “opt-in” and request that a doctor vaccinate their children in a private clinic, making immunization rates among these youths much lower.

“In public schools, they opt out rather than in,” Mbatani said.

More frequent exams are important

In South Africa, women are only recommended to get a Pap smear once in every 10 years.  It’s too long between examinations, Mbatani says.

WIth screening every 1-3 years, there is a 95% chance that any developing cervical cancer will be caught in time and can be treated. With screening every 10 years, the reduction of cancer risk drops to about 66%.

“That is not ideal, but to make this available to most women is better than not doing anything,” she said. “WHO suggests if women could even have one Pap smear once in their lifetime this could still reduce cervical cancer. The problem is that screening is opportunistic and not everyone takes advantage of that opportunity.”

Over time, it is hoped that the new AI devices can help overcome some of the barriers that Mbatani describes – allowing for better integration of cervical cancer screening into more routine, primary health care services that are already offered for women’s reproductive health or HIV/AIDS prevention and treatment.

As Salman says: “Why do we need to die from something that can be prevented?”

Image Credits: Illumigyn, Periwinkle Technologies , Illumigyn , Periwinkle Technologies.