Inequities in cervical cancer care in indigenous Peruvian women
Authors: Paul E Nevin, Patricia J Garcia, Magaly M Blas, Deepa Rao, Yamilé Molina
Journal: The Lancet Global Health (2019)

Among Peruvian women, cervical cancer is the leading cause of death from cancer in women of reproductive age and has the second highest incidence of all cancers (behind breast cancer).1Bruni L Albero G Serrano B et al.ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and related diseases in Peru. Summary report.https://hpvcentre.net/statistics/reports/PER.pdfDate: Dec 10, 2018Date accessed: February 20, 2019Google Scholar The coastal capital, Lima, is home to the country's National Institute of Cancer (INEN) and has substantially lower rates of cervical cancer than elsewhere in the country, partially due to higher socioeconomic status and better access to screening and specialised care,2Aguilar A Pinto JA Araujo J et al.Control of cervical cancer in Peru: current barriers and challenges for the future.Mol Clin Oncol. 2016; 5: 241-245Crossref PubMed Google Scholar such as chemotherapy and radiotherapy. This disparity has important implications in Peru, where uptake of early screening via the Papanicolaou (Pap) test is low,3Paz Soldan VA Lee FH Carcamo C Holmes KK Garnett GP Garcia P Who is getting Pap smears in urban Peru?.Int J Epidemiol. 2008; 37: 862-869Crossref PubMed Scopus (33) Google Scholar particularly for women who live in rural areas, have a low socioeconomic status, and speak indigenous languages.4Barrionuevo-Rosas L Palència L Borrell C How does type of health insurance affect receipt of Pap testing in Peru?.Rev Panam Salud Pública. 2013; 34: 393-400PubMed Google Scholar Conceptualised by the household head's native language, about 25% of Peru's population is indigenous.5The World BankIndigenous Latin America in the twenty-first century.http://documents.worldbank.org/curated/en/145891467991974540/pdf/98544-REVISED-WP-P148348-Box394854B-PUBLIC-Indigenous-Latin-America.pdfDate: 2015Date accessed: September 13, 2018Google Scholar Peruvian indigenous populations are more concentrated in the Amazonian and Andean regions, where women are less likely to have had a Pap test than are women living on the coast3Paz Soldan VA Lee FH Carcamo C Holmes KK Garnett GP Garcia P Who is getting Pap smears in urban Peru?.Int J Epidemiol. 2008; 37: 862-869Crossref PubMed Scopus (33) Google Scholar and where the country's mortality from cervical cancer is highest.6Piñeros M Ramos W Antoni S et al.Cancer patterns, trends, and transitions in Peru: a regional perspective.Lancet Oncol. 2017; 18: e573-e586Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar Rural-residing indigenous populations face multiple barriers to cancer services, including restricted access to care, poor quality of care, cultural misconceptions, language barriers, and communication challenges with health-care providers.7Goss PE Lee BL Badovinac-Crnjevic T et al.Planning cancer control in Latin America and the Caribbean.Lancet Oncol. 2013; 14: 391-436Summary Full Text Full Text PDF PubMed Scopus (324) Google Scholar In 2012, to address geographic and economic cancer inequities, the Peruvian government approved the first national cancer plan, Plan Esperanza, which aims to reduce cancer morbidity and mortality in a pluralistic and decentralised way.8PeruSupreme Decree 009-2012-SA. Declaran de interés nacional la Atención Integral del Cáncer y Mejoramiento del acceso a los Servicios Oncológicos en el Perú y dictan otras medidas.https://www.gob.pe/institucion/minsa/normas-legales/241347-009-2012-saDate: 2012Date accessed: February 20, 2019Google Scholar Plan Esperanza provides free comprehensive cancer care for poor and vulnerable Peruvians through the Public Comprehensive Insurance System (SIS). Plan Esperanza attempts to address the financial barrier of referrals to Lima from rural areas by covering the cost of travel and accommodation for the patient and if necessary that of a companion8PeruSupreme Decree 009-2012-SA. Declaran de interés nacional la Atención Integral del Cáncer y Mejoramiento del acceso a los Servicios Oncológicos en el Perú y dictan otras medidas.https://www.gob.pe/institucion/minsa/normas-legales/241347-009-2012-saDate: 2012Date accessed: February 20, 2019Google Scholar for low-income Peruvians living outside the capital. A Spanish-language brochure for patients from rural communities who are transferred to Lima provides logistical guidance and contact information for unanswered questions.9FISSALInformativo para pacientes de provincia que recibenatención oncológica en Lima.http://www.fissal.gob.pe/materiales/Manual24.pdfDate accessed: August 24, 2018Google Scholar A 2017 article10Vidaurre T Santos C Gómez H et al.The implementation of the Plan Esperanza and response to the imPACT Review.Lancet Oncol. 2017; 18: e595-e606Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar in The Lancet Oncology reported that, "with the implementation of the Plan Esperanza, oncological coverage now reaches 100% of low-income population, covering prevention to comprehensive treatment for all neoplasms". Unfortunately, this sentiment is not consistent with our experiences of working with marginalised populations. In 2015 and 2016, we interviewed 18 rural-residing, self-identifying indigenous Peruvian women (11 Shipibo women from the Amazon region and 7 Quechua women from the Andean region) diagnosed with cervical cancer. We used snowball sampling and thematic analysis to explore their experiences of accessing care. The mean age of the women was 52 years, and more than 60% had a primary education or less. Study procedures were approved by the institutional review boards at the University of Washington (USA) and Cayetano Heredia University (Peru). A predominant theme among the women was the continuous absence of decentralised services and the burden of travelling to Lima both before and after the implementation of Plan Esperanza. Here, we highlight some of the experiences of women who had SIS and were diagnosed after Plan Esperanza had been implemented. When informed she must travel to INEN for care, a patient from the Andean region told us: "I started crying, begging the doctors, 'I don't even have enough money to eat. I don't have a job. How am I going to travel to Lima where I don't even have family to stay with?'" Similar to several participants, a woman from the Amazon region, who had SIS and was referred to INEN for free care, did not have the means to travel and sought local traditional herbal remedies, remaining in pain for over a year without treatment. Of the women who were able to travel to Lima, finding accommodation was a substantial barrier to care. Despite receiving care under Plan Esperanza, a woman referred from the regional cancer centre in Arequipa, who was unable to walk because of pain, was forced to sleep on pews in the hospital's chapel with other patients and families, who were unable to afford other housing options: "I slept in the chapel there [INEN] because I didn't have anywhere else to go and I don't know anyone…by myself with my shawl and some cardboard, I slept there until they started chemo…the majority of people without money or family sleep there." Her experience is unfortunately, not uncommon. A 2017 newspaper article11Chumbiauca L Dos noches en el frío piso del Hospital Neoplásicas.http://larepublica.pe/sociedad/1022561-dos-noches-en-el-frio-piso-del-hospital-neoplasicasDate: 2017Date accessed: August 24, 2018Google Scholar highlighted the growing number of cancer patients from rural communities who sleep on the ground at the foot of INEN's chapel while awaiting care. Although the experiences of these women might not be generalisable, their stories are not consistent with 100% coverage of cancer care and their voices deserve to be part of the conversation. In their communities, barriers related to centralised cervical cancer care persist. There is no denying that Plan Esperanza has made positive contributions towards the reduction of inequity in cancer care access and has greatly reduced out-of-pocket spending for low-income Peruvians.10Vidaurre T Santos C Gómez H et al.The implementation of the Plan Esperanza and response to the imPACT Review.Lancet Oncol. 2017; 18: e595-e606Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar However, if individuals do not have the means to access free cancer care owing to additional barriers, the price of services is irrelevant. Furthermore, women who are able to travel for care, but do not have the resources to travel with a family member, face an additional burden of experiencing a traumatic health condition in an unfamiliar environment, using a language they might not speak fluently, without vital social support. The persistent need for travel to receive cervical cancer care indicates that the emphasis on decentralisation in Plan Esperanza could be falling short, whether it be due to poor dissemination regarding resource availability or lags in systematic implementation of resources. The inconsistency between these women's experiences and existing policy highlights the need to assess the gap between the promise of Plan Esperanza policy development and its implementation. Their experiences reflect the importance of comprehensive access to early cervical cancer detection services to reduce the need for advanced treatment that requires travel. The Peruvian Ministry of Health's new Clinical Practice Guide for Prevention and Management of Cervical Cancer12Ministerio de Salud PublicaGuía técnica: guía de práctica clínica para la prevención y manejo del cáncer de cuello uterino.ftp://ftp2.minsa.gob.pe/descargas/Prevencion_salud/guia_tecnica_cancer_cuello_utero.pdfDate: 2017Date accessed: September 13, 2018Google Scholar aims to address this need, using new technology to improve screening throughout the country. Yet, what will happen to rural-residing indigenous patients who remain in need of advanced treatment, even with improved screening? This problem is an important opportunity for community-engaged research to empower marginalised populations and identify gaps in policy implementation. Such work will ensure that the benefits of national cancer control plans are truly accessible to all Peruvians. We declare no competing interests. Partial support for this research came from a Eunice Kennedy Shriver National Institute of Child Health and Human Development research infrastructure grant (R24HD042828) to the Center for Studies in Demography & Ecology at the University of Washington. YM was also supported by the National Cancer Institute (K01CA193918 and R25CA92408). MB was also supported by the Fogarty International Center (1R25TW009710-01).