Introducing Cervical Cancer Screening in Nigeria through a Social Franchise Project

Cervical Cancer is the most common female cancer in developing countries, with approximately 500,000 new cases and 250,000 deaths each year. In Nigeria, it is thesecond most frequent cancer in women, after breast cancer. Around the world, a woman dies of cervical cancer every two minutes. Women in developing countries suffer disproportionately from the burden of cervical cancer and account for over 80% of cases. Ada Ezeokoli and Chioma Thomas of the Nigeria Health Watch team recently visited a cervical cancer screening project run by the Society for Family Health in Nyanya, Abuja, to learn about the work they are doing to improve the awareness and treatment of this silent killer amongst women.

Cynthia sits quietly with a group of other women at Saffron Hospital in Nyanya, an outlying annex to the city of Abuja. The women are waiting for a nurse to check their vitals and do some paperwork before being ushered into an adjoining room where a doctor and two other hospital personnel are waiting to conduct a simple screening test that will tell if a woman has changes in her cervix that may dispose her to cervical cancer (Cervical pre-cancer). Some of the women, clutching small children, look around nervously. Cynthia however is calm. She is not here to be tested. She has already been diagnosed with cervical pre-cancer and is undergoing cryotherapy treatment, which involves using a cold probe to freeze away the abnormal cells. Until recently, a service like this would not have been available to Cynthia in Nigeria.

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Hauwa Abbas: Reducing Mortality Through Cervical Cancer Screening

The United States Congress designated January as Cervical Cancer Awareness Month. With the upcoming Cancer day on February 4th, it is necessary for us in Nigeria to increase our knowledge of cervical cancer and human papillomavirus (HPV). This brings me to a recent discussion on cervical cancer amongst different professions. It was strange to discover that many do not have the facts. Individuals in the group were surprised to hear the figures; many assumed that it was a Western burden, so here goes the facts

Cervical cancer is an important reproductive health problem for women globally. The highest mortality rates have been reported in developing countries such as western and southern Africa, southern and Central America, Caribbean and south-central Asia. Cervical cancer is the second most common type of cancer among women. Nearly half a million women are diagnosed with it every year and just under half of these will die of the disease. It is estimated that approximately 80% of these deaths occur in developing countries.

In an article by radiologist and cancer control activist, Professor Ifeoma Okoye, cervical cancer is a major killer disease among women, and Nigeria is the tenth in cervical cancer death-toll worldwide. Professor Okoye also added that in Nigeria, 48, 000, 000 (48 million) women are at risk of cancer, while 17, 550 women are diagnosed yearly, with a total of 9, 659 women dying annually. The breakdown according to her means 26 women die daily, in Nigeria from cervical cancer.

Cervical cancer is preventable. Precursor lesions can be detected and ablated long before development of invasive disease.  Unfortunately, the majority of women in low and middle income countries still do not have easy access to screening programmes which detect and treat precancerous lesions. The consequence is that cervical cancer can remain undetected until it is too late for curative treatment and, as a result the death toll and disease burden, cervical cancer remains high in low-income countries in contrast to marked declines observed in high income countries.

CERVICAL CANCERThe cervix is the lower end of the uterus that protrudes into the upper end of the vagina.  The cells on the outside of the cervix are squamous mucosa. The cells on the inside of the cervix are glandular (columnar) mucosa and are responsible for the production of mucus.  Cervical cancers tend to occur where the two cell types mix; we call this the transformation zone. Cancers can come from the squamous or the glandular cells. The majority of squamous cell cervical cancers originate in the squamous component of the cervix.  The main cause of cervical cancer is the human papillomavirus (HPV). HPVs are a group of more than 100 related viruses.  More than 30 subtypes are genital-area specific.  Most women get infected with HPV at least once in their lifetime. Usually women contract HPV during adolescence with peak infection coinciding with the onset of sexual activity. Most HPV infections occur without any symptoms and go away without any treatment over the course of a few months to a few years. Important risk factors for cervical cancer include having multiple sexual partners or having partners who in turn have multiple partners. This is because having multiple sexual partners increases the risk of acquiring HPV, the aetiological agent for cervical cancer.

According to Ronke Atamewalen of Marie Stopes Nigeria, types of HPV (HPV-16 and HPV-18) are responsible for about 70% of the cases of cervical cancer worldwide. Persistent over time, these HPV infections produce abnormal changes in the cells of the cervix.

Global efforts to reduce mortality from cervical cancer have been through the screening of women with Pap smear, Visual Inspection with Acetic Acid (VIA) and vaccinations for younger people. Ideally, vaccination should occur before a youth becomes sexually active, since those who have not yet been infected with any HPV types will get the full benefit of the vaccine. Therefore, it is recommended by the Centre for Disease and Control (CDC) that 9 to 13year old boys and girls receive three doses of the vaccine. Parents should seriously consider the vaccination for their children otherwise it presents a missed opportunity for prevention.

The number of young women diagnosed with cervical cancer has soared in the last decade. In Nigeria, many women have never been screened either through a Pap smear or VIA; according to data from cancer registries in developing countries, 80-90% of confirmed cervical cases occur among women aged ≥35. Incidence increases around ages 35-40 and reaches a maximum in women in their 50-60s it is recommended for women of reproductive age between 30-60 to get screened either by VIA or pap smear at least once in a life time.  Immune compromised women, such as HIV-positive women, are more easily infected with high-risk HPV types 16 and 18, more likely to develop precancerous lesions, and more vulnerable to rapid development and persistence of these lesions than HIV-negative women. However, HIV-positive women with a CD4 count above 400 are more likely to eliminate the virus spontaneously or respond to treatment.

Knowledge is still extremely low; Lack of awareness about cervical cancer and its prevention is an important barrier to women seeking cervical screening. Some women admit they are too embarrassed to go for screening tests, others said they are concerned it will be painful, while some said they don’t think the tests are necessary.

At a workshop organized by Silver Lining for the Needy Initiative (SLNI), for its support group- Pearl ACTs: for women living with HIV- a session dedicated to cervical cancer had Marie Stopes Nigeria enlightening the women on cervical cancer, the fact that they had a higher risk of developing it due to a lower CD4 count, and were more likely to have cervical abnormalities.

Due to the cost and timing of collecting result for Pap smear which identifies early abnormalities, a   single-visit approach (SVA) to cervical cancer prevention involves visual inspection of the cervix with acetic acid wash (VIA) and treatment of precancerous lesions with cryotherapy was introduced. This is the internationally recognized and cost effective approach recommended by WHO for developing countries.

Now we know the facts, it is evident that there is lack of awareness, resources and qualified health attendance for cervical cancer. Radiotherapy and chemotherapy are not available in many resource-limited settings in Nigeria for reasons of cost and limited health infrastructure. We must encourage and promote health checks and screening for early detection and prompt treatment of cancer cases thus reducing mortality.

 

Article as published on The Punch