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Abstract
In low-resource areas of China, enhancing the quality of cervical and breast cancer screening is essential for effective prevention and control. Systematic training and technological empowerment can strengthen these screening programmes, optimise processes and improve diagnostic accuracy. For cervical cancer screening, it is crucial to employ approved, efficient screening technologies and integrate them with population management platforms to enhance screening and follow-up processes, thereby ensuring comprehensive coverage and effectiveness. Developing targeted training programmes, fostering multiparty collaboration and establishing scientific evaluation mechanisms can further improve the quality and effectiveness of cervical cancer screening, supporting the goal of eliminating cervical cancer by 2030. Similarly, advancements in breast cancer screening require appropriate training and technical support to bolster early detection and intervention capabilities. Overall, comprehensive strategies targeting these two cancers are critical in reducing the disease burden.
- Women's Health
- Uterine Neoplasms
- Public Health
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Cervical and breast cancer are major threats to women’s health worldwide. In 2022, these cancers accounted for 30.7% of new cancer cases and 23.5% of cancer-related deaths worldwide, with the majority of cervical cancer cases and deaths occurring in low-income and middle-income countries.1 The disease burden of breast cancer and cervical cancer in China varies across regions, leading to different challenges in prevention and treatment.2 Since 2009, China has launched the National Cancer Screening Program for Rural Women, which provides free cervical and breast cancer screening services for women aged 35–64. Ultrasound was used as the primary screening method for breast cancer, while cytology and HPV (Human Papillomavirus) DNA testing were used as the primary screening method for cervical cancer. However, the technical conditions and professional capabilities of screening personnel varied across regions. Therefore, it is essential to strengthen the prevention and control capacity, especially in areas with limited healthcare resources, to improve the quality of cervical and breast cancer screening in China. In addition, there are other challenges in cervical and breast cancer screening, including but not limited to: unnecessary repeated screening (for individuals with a negative screening result, screenings may not be necessary for 3–5 years, depending on the method. Multiple screenings in this period are unnecessary and considered redundant.), difficulty in reaching the target population, suboptimal screening technologies and inefficient screening management. This article will discuss the importance of cervical and breast cancer training in low-resource areas and provide tailored recommendations.
Current situation
Considering China’s vast size and complex administrative structure—with a total of 2843 county-level administrative regions, including 977 districts, 394 county-level cities, 1301 counties, 117 autonomous counties, 49 banners, 3 autonomous banners, 1 special district, and 1 forest region—significant challenges remain in achieving nationwide elimination goals. The large population and health and economic development disparities across these regions mean that imposing elimination targets without appropriately coordinated management and government support could lead to local confusion or lack of motivation. Such outcomes could exacerbate health inequities within the country and impede efforts like cervical cancer elimination.3 According to the data of China Health Statistics Yearbook 2022, the number of health technicians per 1000 population showed significant differences between urban (9.87) and rural (6.27) areas in China. The most significant disparity was found in central China, which was 10.52 and 5.97, respectively. A similar trend was observed for practising (assistant) physicians and practising physicians. Over the past decade, central China has faced a shortage of health human resources, reflecting the inequitable population allocation. In Western4 China, although the health human resources have gradually increased in the process of deepening the reform of the medical and health service system during the 13th Five-Year Plan period, the allocation of physician resources remained insufficient, making central and Western China facing challenges to meet the medical demands. Tibet, Qinghai, Xinjiang and Inner Mongolia had a high proportion of health workforce shortage.5 Grassroots medical and health services play a crucial role in our healthcare system. The imbalance in health professional resources exacerbated the inequity of the health resources allocation across the country and hindered the development of regions with limited health resources.
The allocation of medical resources across China’s six major regions is inequitable. For instance, the Central-Southern region boasts the highest average number of medical institutions, with a total of 45 705, whereas the Northwest region has the fewest, with only 17 605. Regarding per capita total health expenditure, the North China region ranks highest at ¥4736.90, while the Central-Southern region ranks lowest at ¥3060.31. Disparities also exist within individual regions. For example, in North China, Beijing’s per capita health expenditure is ¥9429.73, significantly higher than Shanxi’s ¥2650.33. Although the number of health technicians per thousand people shows minimal variation (ranging from 7.93 to 9.54), numerous studies highlight significant disparities in doctors’ service capabilities. Consequently, the primary issues are identified as funding and hospital service capacity.6–8
Technical training to improve screening capacity
Ultrasound combined with mammography is the main technique for breast cancer screening in China. The screening effect of these two methods is highly dependent on the proficiency of the examining doctors. In addition, there are relatively few opportunities for primary diagnosis of breast malignant lesions, so doctors may lack sensitivity in detecting such malignant lesions, which is easy to cause missed diagnosis or misdiagnosis.
The comprehensive prevention and control of cervical cancer can be divided into three levels: HPV vaccination, screening and disease management. At present, the three-level measures have been well developed. However, implementing these measures in the above-mentioned low-health resource areas remains a major challenge. Cervical cancer screening technology evolved from conventional cytology to liquid-based cytology and HPV DNA testing. The sensitivity and specificity of these detection techniques are different, and numerous studies have shown that HPV DNA testing, in both RCT (Randomized Controlled Trial) and real-world settings, performed better9 10 in low areas of health resources. Unlike usual liquid-based cytology, HPV DNA testing no longer depends on the doctor’s subjective judgement, providing more objective results. From 2020 to 2022, many parts of China have developed the capability for PCR testing. In areas without such capability, HPV testing can also be implemented through the hybrid capture technology. Generally, it only takes a week for a clinical laboratory technician to master the technology.
Technology enables optimisation of the screening process
The development and application of advanced technologies have brought significant convenience to screening diagnosis and treatment. Using new technologies, such as automated breast ultrasound and artificial intelligence in colposcopy, can help improve the accuracy of screening while reducing labour costs. For example, in the ‘Internet+artificial intelligence’ cervical cancer screening project in Hubei Province in 2020, the cost coefficient of early detection was 0.2865, and the benefit–cost ratio was 6.4:1, indicating that screening was cost-effective.11 Additionally, effective intelligent population management in screening can reduce the need for medical staff. However, another major issue has remained unresolved in the previous screening: repeated screening. Screening records were traditionally kept on paper, and reports were submitted at the end of the year. If cases need to be digitised, dedicated information entry staff were required. Without digitisation, statistical analysis and duplicate checking became challenging. In previous screening studies, many women were screened annually. Individuals with negative results are considered safe for 3–5 years. The unnecessary repetition of screenings hinders the effective utilisation of medical resources. Advancements in technologies for cervical cancer screening and management hold great significance regarding public health impact and social benefits.
Diagnostic and therapeutic capacity that can be improved
Systematic training can improve the diagnosis and treatment capacity of primary medical institutions, enabling them to carry out primary screening and diagnosis.12 Gynaecological sampling and colposcopy for individuals with positive results are critical steps in the screening process. Both traditional and digital training tools can improve the doctors’ ability and confidence during screening.13 14
Recommendations for training implementation
Develop a training plan
Develop targeted training plans according to regional characteristics and actual needs. The training content should include basic knowledge of the disease, screening methods, diagnostic techniques and population management.
Multiparty cooperation
Cooperation and collaboration between governments, NGOs (Non-Governmental Organizations) and medical institutions should be encouraged to mobilise resources and carry out training programmes jointly. Integration of digital health into the screening process can lower the barrier to accessing screening knowledge and improve the controllability of the screening process. In addition, digital health can be used to combine online and offline training improving both the coverage and effectiveness of the training.
Establish a training evaluation mechanism based on a scientific training evaluation model
Establish a scientific evaluation mechanism, such as Kirkman evaluation model: evaluate and provide feedback on participants’ reactions, learning, behaviour and outcomes, then continuously update the training content and methods based on this feedback. Training evaluations should include, but not be limited to, participant feedback, knowledge evaluation and practical ability tests. Based on the evaluation results, the training plan should be adjusted and optimised to ensure the quality and effectiveness of the training.
In conclusion, implementing the training programme in low-health resource areas in China is helpful in exploring the screening mode for different region. It allows for the collection of screening experiences from various conditions. The experience gained in point areas can be shared with other regions. The core tools/technical skills training is crucial for improving women’s health and reducing the disease burden. Systematic training is necessary to enhance the accurate dissemination of knowledge about cervical cancer and to improve primary care providers’ screening service and management ability. Ultimately, this will help to achieve the goal of eliminating cervical cancer throughout China.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Footnotes
Contributors YQ was responsible for conceptualisation, methodology, formal analysis, investigation, and served as the guarantor of the overall content. XJ was responsible for conceptualisation, analysis and writing. HY, ZS and HD were responsible for reviewing and discussion of perspectives. CG and JZ were responsible for reviewing. All authors agreed to the publication of this article.
Funding This work has been supported by the Tencent Sustainable Social Value Inclusive Health Lab and through the Chongqing Tencent Sustainable Development Foundation "Comprehensive Prevention and Control Demonstration Project for Eliminating Cervical Cancer and Breast Cancer in Low Health Resource Areas of China" (Project Number: SD20240904145730).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.