POLICY BRIEF

Breast and Cervical Cancer

Prevention and Screening in Kenya
Cancer claims an increasing share of the disease burden in Kenya, from causing around three percent of all deaths in 2000 to
nearly eight percent in 2019. In Kenya, where nearly 70 percent of cancer cases are diagnosed in advanced stages (1), cancer
causes over 27,000 deaths each year (2). Cancer also carries a high economic toll, causing loss of productivity in those with
cancer, a significant need for caregiving, high out-of-pocket costs, and reduced opportunities for the children and family
members of people living with cancer.

Kenyan women bear a disproportionate share of the country’s cancer burden. In 2020, Kenyan women experienced 50 percent
more cancer-attributable deaths than men (2)—driven by breast and cervical cancer. Together, breast and cervical cancer are
responsible for about one in five cancer deaths in Kenya, respectively causing 3,100 and 3,200 deaths per year (2).

Kenya is committed to reducing cancer incidence, down-staging diagnosed cancers, and improving survival rates through
access to primary prevention interventions (including the HPV vaccine) and quality early detection, treatment, and palliative
care services (3).

While Kenya has instituted strong, evidence-based cancer prevention and control frameworks, limited fiscal space for
cancer initiatives has curtailed the government’s capacity to achieve these standards (5). The estimated annual cost for the
National Cancer Control Strategy is KES 10.4 billion, about 4 percent of Kenya’s annual combined national and county
health budget (6,7). In 2019, however, 0.4 percent of Kenya’s combined national and county health budget was allocated
for cancer (KES 868 million) (6,7). This funding gap highlights a need to identify and scale interventions that are effective,
cost-effective, and equitable.

The Investment Case for Cancer

The Ministry of Health partnered with the World Bank to prepare an
investment case to scale up cancer care and control. The investment
case helps identify effective pathways of care for breast and cervical
cancer with a positive economic return. The analysis aimed to: (i)
determine the most attractive avenues for scaling up existing and
potential packages of care for breast cancer; and (ii) explore strategies
for reaching Kenya’s HPV vaccination targets.
 BREAST CANCER

The investment case models three scenarios for scaling up breast cancer care and control. Scenario 1 focuses on early
diagnosis of symptomatic women only. Facilitated by investments in awareness campaigns targeting women of all ages,
more women will recognize early-stage cancer symptoms and present within the health system at the primary care level
for an exam (8,9). Met by newly trained health providers (e.g., nurses, midwives, clinical or medical officers, physicians),
women with symptoms receive a clinical breast exam (CBE).

Scenarios 2 and 3 focus on diagnosing symptomatic women through early diagnosis programs AND asymptomatic women
through the scale up of population-level screening programs. The difference between Scenarios 2 and 3 lies in the
screening technology employed. In Scenario 2, the primary screening method is based on CBE. In Scenario 3,
mammography is the primary screening method.

As shown in Figure 1, all scenarios begin with a 5-year early diagnosis program to allow time for cancer infrastructure to
develop and strengthen under lower volume patient loads. In Scenarios 2 and 3, this is followed by implementation and
scale-up of a population-level screening program over 10 years, driven by personalized screening-by-appointment
invitations, breast cancer awareness campaigns and mobile clinic outreach in targeted community or workplace settings.
Finally, a mature, biennial, population-level screening program operates with women aged 40 to 74 regularly screened for
breast cancer.

Figure 1: Modelled breast cancer scenarios: early diagnosis and screening scale up

Scenarios #2 OR #3
ED only — 2022 to 2027
ED + Screening — 2028 to 2061 Programmatic interventions
Scenario #1 • #2 — CBE-led program Clinical interventions
Early Diagnosis - 2022 to 2061 • #3 — MG-led program

Primary are
Start: Symptomatic Start: All women 1 visit
women only-all ages age 40 to 47

Breast cancer demand via

awareness campaigns screening invitations,
recognition of early mobile clinic outreach,
stage symptoms awareness campaigns
Symptomatic and
Symptomatic asymptomatic
women present at women present at
health center health center
CBE services:
national program to train
Strategy #2 & #3-
primary health
National program to
care workers
train primary health
Symptomatic care workers
women are
administered CBE Strategy #2 Strategy #3 Strategy #3 only-
CBE Sceening MG Cost-covered imaging
services; Radiologist
training Secondary level
One-stop rapid
CBE or MG services diagnostic clinic

Established linkages
and referral structures;
and data systems to
track follow-up =
LTFU
Abnormal findings:
Diagnostic MG
administered
Accessible cost-covered
imaging services &
training of radiologists;
est. of cost-covered
histopathology services
Abnormal findings: & training pathologists
= imaging and biopsy Tertiary level
Ultrasound and multiple
FNAC/core biopsy provision
treatment visits

Referral structures,
PPP, treatment
protocals, cost-covered
Treatment Stage 1-4 = treatment
with supportive and
palliative care as
indicated
As Table 1 shows, the benefit-cost ratios (BCR) indicate that over 40 years, the benefits outweigh the costs for each of the scenarios. The
CBE scenario (Scenario 2) delivers the greatest net benefits i.e., total benefits less total costs over the same time period.

Table 1: Summary of primary outcomes across the three modelled breast cancer scenarios (KES millions)

Cumulative
Lives Cumulative
monetized BCR
saved costs

Five years
Scenarios 1, 2 and 3 4,700 6,456 1,694 0.26 -4,762
15 years
Scenario 1 33,600 19,995 24,834 1.2 4,839
Scenario 2 44,900 31,290 29,827 0.95 -1,463
Scenario 3 50,600 53,633 32,634 0.61 -20,999
40 years
Scenario 1 163,200 51,007 253,132 5.0 202,125
Scenario 2 235,800 96,824 357,896 3.7 261,072
Scenario 3 269,800 186,530 407,934 2.2 221,405

CERVICAL CANCER

The economic evaluation combines three Figure 2: Kenya’s Cervical Cancer Intervention Package
different options for HPV vaccine delivery–
Clinical Interventions Population Coverage Rates
school-based, facility-based, and community
outreach (a “mop-up” strategy to vaccinate Prevention • 2-Dose HPV Vaccination
70% of girls aged 9-13 (2023-2029)
90% of girls aged 9-13 (2030-2061)
hard to reach girls) – alongside scale up of
cervical cancer screening to 70% by year Scales up to 70% of women
Screening • HPV DNA Test
2030 (Figure 2). aged 30-49 by 2030

• Visual inspection with acetic

Diagnosis acid (VIA) Scales up to 90% of women by 2030
• Colposcopy, biopsy

• Treatment Stage 1-4

Treatment • Supportive and palliative care Scales up to 90% of women by 2030
as indicated

Table 2:
delivery strategy (KES millions)
Annualized Annualized Summary
cost easures
Mortality Averted health Net
Total Total
avoided expenditures cost ratio
2060
1. School only 20,662 472 21,134 5,975 3.5 15,159
2. Health facility only 5,832 159 5,990 3,258 1.8 2,733
3. School + health facility 18,482 321 18,803 4,982 3.8 13,821
4. School + health facility + outreach 18,299 308 18,608 4,471 4.2 14, 137
2090
1. School only 108,995 1,336 110,331 5,975 18.5 104,356
2. Health facility only 26,401 430 26,831 3,257 8.2 23,574
3. School + health facility 77,164 857 78,021 4,982 15.7 73,039
4. School + health facility + outreach 74,389 816 75,205 4,471 16.8 70,734
 POLICY RECOMMENDATIONS
To facilitate the success of breast and cervical cancer
interventions, the following policy recommendations should be
considered.
1. Establish a breast cancer program that focuses first on
early diagnosis before scaling up population-level
screening efforts:
A phased approach to breast cancer screening - which begins
with improving early diagnosis among symptomatic women for
the first five years, followed by scaling a mass-screening strategy
– ensures the ability to treat all women who tested positive and
carries additional advantages. Implementing early diagnosis
strategies first can help change norms, population knowledge,
and perceptions around breast cancer. Further, focusing on early
diagnosis before expanding to mass screening can provide time
for the health system to adapt to increases in demand, ensuring
that primary-care provider proficiency, imaging services, referral
pathways, and timely treatment are in place—and patient
financial obstacles removed—so that all women who are
diagnosed are met by a health system ready to restore them to
full health.
2. Choose a breast cancer screening modality that considers
health system capacity
Kenya’s choice of breast cancer screening modality – screening
mammography versus CBE – should be based on national
priorities and the human and financial resources available. A
mammography-led screening program can save an additional
34,000 lives compared to CBE-led screening over 40 years. While
mammography-led screening seems like the clear choice based
on these projections, it requires large investments in machines
and maintenance-capacity as well as radiologists, imaging
technologists and other personnel. As a result, the benefit-cost
ratio is 2.2 for mammography compared with 3.7 for CBE (10).
Screening mammography may also lead to overdiagnosis which
can lead to avoidable anxiety and unnecessary testing,
compared with CBE, where 98% of patients with exams
concerning for cancer have clinically significant disease at the
time of diagnosis (11,12).
3. Choose an HPV vaccination delivery strategy that considers
effectiveness, cost-effectiveness, and equity.
The HPV vaccine can effectively prevent cervical cancer.
Delivering the vaccine through schools offers Kenya the best
opportunity to meet the WHO’s cervical cancer elimination
target goal of vaccinating 90 percent of eligible girls against HPV
by 2030. Worldwide, school-based delivery strategies achieve
1. Kenya Ministry of Health. Breast Cancer Screening and Early Diagnosis
Action Plan 2021-2025. Nairobi, Kenya; 2021.
2. International Agency for Research on Cancer. GLOBOCAN 2020 Database
[Internet]. [cited 2022 Feb 3]. Available from: http://gco.iarc.fr/today/home
3. Ministry of Health, Kenya. Kenya National Cancer Control Strategy
2017-2022 [Internet]. Nairobi; 2017 Jun [cited 2022 Feb 8]. Available from:
www.health.go.ke
4. Lehmann J, Machira YW, Schneidman M, Chuma J. Economic and Social
Consequences of Cancer in Kenya: Case Studies of Selected Households
[Internet]. Washington, DC: World Bank; 2020 May [cited 2022 Jan 31].
Available from:
https://openknowledge.worldbank.org/handle/10986/33919
5. International Atomic Energy Agency, WHO International Agency for
Research on Cancer. Integrated Missions of PACT (imPACT)Cancer Control
Capacity and Needs Assessment Report. 2017.
6. Ministry of Health, Kenya. Kenya Cancer Policy 2019-2030 [Internet].
Nairobi; 2020 Jul. Available from:
https://www.health.go.ke/resources/policies/
7. Ministry of Health, Kenya. National and County Health Budget Analysis FY
2019/20 [Internet]. Nairobi; 2020. Available from:
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/viewer.html?pdfurl
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higher coverage rates than other delivery strategies (13). By
rapidly reaching more girls, school-based strategies can avert
more cervical cancer cases and deaths than other strategies in
which scale up cannot happen as quickly. Moreover, providing
vaccines at schools reduces households’ logistical and financial
barriers, minimizing costs of time, transportation, and childcare
needed to visit a health facility. This strategy can yield a net
benefit of KES 28,400 million over 40 years, and KES 104,400
million over 60 years (10).
However, relying solely on school-based approaches may
exacerbate health inequities given lower school attendance rates
in some regions of Kenya. Combining multiple
strategies—school-based, facility-based, and community
outreach—to deliver HPV vaccines can cost-effectively and
equitably reach all girls even in remote areas. The combined
approach requires synchronization of vaccine records across
multiple delivery strategies and the availability of cold-chain
facilities to avoid vaccine wastage. The infrastructure developed
for administering the COVID-19 vaccine, such as interoperable
electronic health record systems and expanded cold-chain
capacity, can facilitate the distribution of HPV vaccines through
various mechanisms.
While HPV vaccination is scaled, services along the care and
control continuum - screening (with HPV-DNA), diagnosis (Visual
Inspection with Acetic Acid or Lugol’s Iodine, followed by
colposcopy or biopsy), and treatment - will also need to be scaled
up to ensure that women who develop cervical cancer are
treated at early stages and thereby have better outcomes.
Regardless of the specific interventions chosen, investing in
breast and cervical cancer prevention and control will
contribute to Kenya’s universal health coverage (UHC) agenda
by enhancing equity of access to needed quality health services
while providing protection from catastrophic health
expenditures. Moreover, the long-term the benefits of breast
and cervical cancer programs outweigh their costs. Respectively,
breast and cervical cancer interventions (from screening to
treatment) are estimated to save 236,000 and 159,000 lives
over 40 years (10). While together, these interventions will cost
KES 749 billion over 40 years, representing about a six percent
increase over existing public health expenditures, every
Kenyan shilling invested can generate up to 2.3 shillings in
return (10). Investing in breast and cervical cancer prevention
and control will thereby create KES 350 billion in net benefits
over 40 years (10).
8. Association of Previous Clinical Breast Examination With Reduced Delays and
Earlier-Stage Breast Cancer Diagnosis Among Women in Peru - PubMed
[Internet]. [cited 2022 Jan 31]. Available from:
https://pubmed.ncbi.nlm.nih.gov/28542677/
9. Pace LE, Dusengimana JMV, Shulman LN, Schleimer LE, Shyirambere C,
Rusangwa C, et al. Cluster Randomized Trial to Facilitate Breast Cancer Early
Diagnosis in a Rural District of Rwanda. J Glob Oncol. 2019 Nov
27;5:JGO.19.00209.
10. World Bank. Economic Evaluation of Breast and Cervical Cancer Control
Interventions in Kenya. Washington, DC: World Bank; 2022. Report No.:
AUS0002775.
11. Verdial FC, Etzioni R, Duggan C, Anderson BO. Demographic changes in breast
cancer incidence, stage at diagnosis and age associated with
population-based mammographic screening. J Surg Oncol. 2017
Apr;115(5):517–22.
12. Ernster VL, Barclay J, Kerlikowske K, Grady D, Henderson C. Incidence of and
treatment for ductal carcinoma in situ of the breast. JAMA. 1996 Mar
27;275(12):913–8.
13. Bruni L, Saura-Lázaro A, Montoliu A, Brotons M, Alemany L, Diallo MS, et al.
HPV vaccination introduction worldwide and WHO and UNICEF estimates of
national HPV immunization coverage 2010–2019. Sci Action Impact Elimin
Cerv Cancer. 2021 Mar 1;144:106399.