From Early Cancer Detection to Advanced Diagnosis – A Project at Pallivasal, Kerala
Dr. Devu Prakash, General Practitioner, Screening NCD, Karkinos Healthcare
In November 2021, the Munnar-Idukki branch of Karkinos Healthcare had collaborated with the Pallivasal Panchayat to organize an early cancer screening and detection program for its citizens. The Panchayat has 14 wards altogether with a population of approximately 10,875 (male population: 5,417; female population: 5,458).
Pallivasal is a small village located around 10 Kms from Munnar in the Idukki district of Kerala. Most of the adult citizens in this Panchayat are workers at the tea or cardamom plantations.
The entire screening program was successfully conducted by the joint efforts of Pallivasal Gram Panchayat, Primary Health Center Kallar, Community Health Center (CHC) Chithirapuram, and Karkinos Cancer Center Munnar.
The cancer incidence (load) in and around Munnar area is known to be relatively high. The awareness about cancer and the impact of this disease in the Pallivasal Panchayat was found to be low. Hence, Karkinos Healthcare chose Pallivasal for conducting the screening program.
The uniqueness of this program is that citizens were ensured of an end-to-end service by Karkinos Healthcare. At no point was the citizen made to drop out of the programme. The staff and volunteers of Karkinos and the Panchayat strived to ensure that high risk citizens, identified in the early detection camp, were guided appropriately to the next step in cancer care.
Kickstarting the programme
Identifying High Risk Citizens: The screening program was officially inaugurated by Adv. A. Raja, MLA Devikulam on March 7th, 2022.
Prior to the official inauguration, the period between November 2021 and March 2022, volunteers were chosen and trained on the protocols of the cancer risk assessments by Team Karkinos. The volunteers were mainly ASHA workers, Anganwadi workers, Kudumbashree members, healthcare workers from the Health Centers of the Panchayat and other volunteers from Karkinos Healthcare.
As Pallivasal is remotely located with poor internet connectivity, Karkinos’ Risk Assessment Questionnaires were created as Google Sheets that can be accessed offline.
On December 31, 2021, Karkinos Cancer Center, Munnar trained 120 volunteers, involved in the programme, on the working of Google sheets and then they conducted door-to-door, in-person surveys. Training of the volunteers required about 3 follow-up training sessions as the volunteers lacked knowledge about the working of the Google Sheets.
Simultaneously, the volunteers were also trained to impart awareness on the importance of early detection and its methods (including self-breast and oral examination) to the citizens who took the survey.
Once the survey was thoroughly completed, the data was collated and analysed to identify High Risk Citizens (HRA). A ward-wise list of the HRAs, who may be susceptible to cancer in their life time, were identified. This list was then handed over to the concerned volunteers, who counselled the citizens to participate in the Early Detection Camp, which was conducted in their respective wards.
The following data was the outcome of the Risk Assessment Survey:
- Total Risk Assessment done in 2 months: 4700 citizens
- Total High Risk citizens recorded: 1068 citizens
A repeat meeting with the volunteers was done to do a survey accuracy check. Also, the list of high-risk individuals noted from the survey were handed to the ASHA workers and volunteers of the camp to further educate the cancer risk-prone citizens to partake in the early detection program (organized by the Panchayat with Karkinos’ support).
Timeline
- Nov 22, 2021 – Discussion on Project
- Dec 31, 2021 – Volunteer Training for High Risk Assessment (HRA)
- Mar 7, 2022 to Mar 18, 2022 – Early Detection Screening Camp
- May 4, 2022 to Jul 22, 2022 – Advanced Detection Programme
The Early Detection Programme
- The volunteers recruited in this program canvased among the citizens on early detection and its impact on cancer treatment.
They were also tasked to spread awareness about the different cancer conditions and risk factors that predispose the disease, its consequences and fatality when not diagnosed at an early stage. Pamphlets were distributed on the importance and symptoms of common forms of cancer.
Press and Media coverage through regional news channel and newspaper; publicity via mic announcement using the Panchayat’s jeep; and social media messages about the program’s dates and venues were also sent out through Facebook and WhatsApp to increase the reach of the information.
A total of 8 screening camps covering 14 wards at different locations were organized.
The workforce at each camp site included:
- Registration Desk: 4 Volunteers;
- Vitals Recording: 2 Volunteers;
- Anthropometry (Height Weight): 2 Volunteers;
- Risk Assessment: 2 Karkinos Healthcare (KH) Community Outreach staffs or KareMitras;
- Clinical Breast Examination: 2 KH staff nurses;
- HPV sample Collection: 1 trained KH staff nurse; and
- Oral Visual Examination & Consultation: 1 KH Doctor
Services offered at each camp site:
- Basic screening for common cancers;
- BMI analysis and lifestyle modifications accordingly;
- NCD screening including Type 2 Diabetes Mellitus, systemic hypertension;
- Clinical Breast Examination;
- Mammogram for screened positives using mobile mammogram units stationed near camp site;
- Oral Visual Examination;
- HPV Screening and Counselling
- Educating on steps of self-breast examination and self-oral examination monthly; and
- FIT test for Colon cancer screening
Registration desk, vitals, anthropometric assessment were done by volunteers of Kallar PHC and Chithirapuram CHC (2 at registration, 2 for vitals and anthropometry, 2 as navigators, 2 as assistants, 1 as senior supervisor); all medical/paramedical staffs from CHC/PHC.
The navigators helped the male citizens to undergo an OVE and the female citizens to undergo CBE.
Out of 824 citizens screened, 400 HPV tests to screen for cervical cancer were done and 64 Faecal Immunochemical Test (FIT) kits were issued. Sixty-six citizens who were screened positive for Clinical Breast Examination were guided to undergo a Mammogram from the Mobile Mammogram Unit stationed at each camp site.
Other citizens Screened Positive (including 42 Oral Visual Examination (OVE) positive citizens were followed up by the Karkinos Command Center and were given appointments at the Karkinos OPD.
CLINICAL BREAST EXAMINATION (CBE): After completing the registration formalities, Risk Assessment (RA) vitals and anthropometry, the female citizens are directed to CBE examination room by the navigators. The citizen’s personal details are recorded in the CBE register and is then directed to the staff nurse for examination. After CBE, if the screened individual is suspected to be positive the information is then conveyed to the volunteer who records it in the register.
Eligible citizens (i.e., hysterectomy not done, age group of 30 to 65) are then screened for HPV are then directed to the HPV room for further screening.
HPV (For Cervical Cancer): In the HPV room, the female citizen’s personal details are verified by the volunteers. Swab samples from the cervix are collected in a labelled container. The label has the relevant patient details.
ORAL VISUAL EXAMINATION (OVE): The navigators directed the males to undergo OVE in a separate room and the females are directed to the OVE room after HPV examination.
After OVE the citizen if eligible for FIT goes to the FIT issuing counter where the details of the citizen are captured in the register. The procedure of sample collection is explained with a printed copy of FIT.
Highlight of the Program: Advanced Cancer Detection Service
Members of the Panchayat and Karkinos Healthcare did not want to stop with just primary screening. The medical team at Karkinos Healthcare were certain that all the screened positive cases to undergo the next step in investigation, diagnosis, and treatment.
To ensure that the rate of dropouts from the program is minimum, an Advanced Detection Camp (Colposcopy +/- Biopsy for HPV positives and Ultrasound Breast correlation and Trucut Biopsy for citizens with High-risk Mammogram report) for screened positives was organized. The screened positives from the camp were financially supported by the Panchayat to conduct the next diagnostic step using another Panchayat Fund.
Outcome of the Advanced Detection Tests
HPV screened positive individuals were led to colposcopy.
Suspected CBE positive individuals were led to USG BREAST and TRUCUT BIOPSY
Karkinos Healthcare’s Gynec-Oncologist performed the Colposcopy on HPV positive citizens.
The outcome was as follows:
- HPV 18 Positive: 3
- HPV 16 Positive: 8
- Other HR HPV: 22
Colposcopy assisted Biopsy was taken for
- Adenocarcinoma in situ: 1
- Squamous Carcinoma in Situ: 1
- High Grade Squamous Intraepithelial Lesion: 4
- Low Grade Squamous Intraepithelial Lesion: 16
- Chronic Cervicitis: 3
- Normal: 3
The citizens were treated according to the KH Treatment Pathway during their subsequent visit.
The case of 2 citizens who were harbouring Carcinoma in situ were discussed in the KH Tumour Board and a treatment plan was communicated.
CBE Positive citizens who were suspects from Mammogram were followed up in the center. 25 citizens required USG correlation. 4 suspects from the USG underwent Trucut Biopsy in KH OPD and are under follow up.
Pallivasal Panchayat Cancer Screening Programme – Report till date
CBE Positive: 66
Mammogram: 69
Out of which 29 inconclusive, required USG correlation
25 did USG Both Breast and Axilla
4 suspects Trucut Biopsy Taken
HPV: 33 Positive
COLPOSCOPY done for 30 HPV positive cases, 10 Major lesions, 18 Minor lesions
28 LEEP samples
11 ECC samples
18 Biopsy samples
13 Thermal Ablation
10 Major lesions, 18 Minor lesions;
FIT issued for: 64
2 COLONOSCOPIES done
1 Polypectomy done
1 advised follow up
OVE POSITIVE: 44
1 biopsy
15 came to OPD as Follow up
Follow up after 3 months
Key Take Aways from this Programme and the Way Forward
The Panchayat office and the camp organizers including Karkinos Healthcare staff received good feedback about the services offered. Those individuals screened positive felt the importance of early detection, which was otherwise gone unnoticed and would have ultimately led to fatal cancer condition.
The entire project at Pallivasal impressed upon other Panchayats, who approached the organizers to conduct similar projects in their wards. In the coming months, Karkinos Healthcare will organize such similar projects in few other Kerala districts covering a wider population. Karkinos is also in advanced talks with NGOs of Kerala to conduct special 1-day camps for early diagnosis and screening.
Testimonial
Mrs. Flora Kajendran – A Pallivasal Citizen
Flora was completely asymptomatic when she came for screening. In the routine sample collection as part of the screening protocol, HPV sample was collected, tested, and Flora reported positive for HPV 16. Further, a colposcopy was performed to visualize the cervix for any cancerous or precancerous changes. Tissue sample from the cervix was collected for laboratory study. The sample on histopathological examination was reported to be Adenocarcinoma in situ. An MRI of the abdomen and pelvis was performed to rule out any spread, which was reported as normal. This case was discussed in Karkinos Healthcare’s tumour board. The board suggested total hysterectomy with bilateral salpingo oophorectomy. She had a lesion in the cervix, which was pre-cancerous and could have become cancerous in the near future. With the removal of the uterus, Flora can be completely cured with no further treatment.
“I am Flora Kajendran. I am 54 years old. I participated in the Karkinos-Pallivasal Panchayat cancer screening camp conducted in March 2022. At the camp many tests were done to check if I have cancer. One test found that I have cervical cancer. When I went for the tests in the camp, I had no symptoms. But the doctors at the camp said that I am very lucky because diagnosis has been made at a treatable stage. Initially, I was very very scared to undergo the tests. It was the doctors at the camp who assured me to be bold and also they explained every treatment step in detail and gave me the confidence to take up further tests. I am very happy that cancer has been prevented in me and I urge every woman to come forward to take up the cancer screening tests like me.”
