Cancers that affect women are referred to medically as gynaecological cancers. These are cancers that occur within a woman’s reproductive organs. Breast cancer is often included in this group although its occurrence is not limited to women, as it may on rare occasions occur in men too. Gynaecological cancers in the order of frequency in which they occur are:
Cervical cancer – Cancer of the neck of the womb
Ovarian cancer – Cancer of the ovary
Endometrial or uterine cancer – Cancer of the womb
Vulvar cancer – Cancer of the external genitals
Vaginal cancer – Cancer of the birth canal
Of these, cervical cancer is the only one that lends itself readily to cost-effective preventive measures and whose incidence has been greatly curtailed through effective prevention strategies. It presents the greatest opportunity where the knowledge of the life history of a disease is employed in its control. Paradoxically, cancer of the cervix, which is the commonest, is also the most preventable of the lot. Not only does it occur most commonly, most cases that report to hospital come at very advanced stages of the disease.
About 10,000 new cases of cervical cancer occur annually in Nigeria and 8,000 women die of the disease each year. The same picture exists in other developing countries, compared to the western world where it is rather rare; and where, when it occurs, it is diagnosed at very early stages, leading to less pain and suffering and greater chances of survival.
While this is a result of the interplay of several factors, the absence of an effective screening program is the chief factor for this difference between the developed and developing countries.
Other factors are ignorance of the disease, lack of accessibility to quality and qualified medical care, dearth of relevant healthcare personnel and, of course, pervading poor socio-economic conditions. We shall look at these factors and the state of the Nigerian situation and current activities aimed at curtailing the problem.
By ‘screening’, we mean a situation where the health-seeking behaviour is initiated by the healthcare provider rather than the ‘patient’. In a cervical cancer screening programme, the healthcare provider actively canvases and invites healthy individuals to present themselves for the screening test.
A screening test is a simple test applied to individuals in order to determine who is at risk of disease. The distinction should be noted that this screening test is not a diagnostic test – the purpose of the screening is to prevent cervical cancer and not to diagnose it. This is because the changes that may eventually lead to cervical cancer can be identified and treated by relatively simple methods ever before they become cancer.
The purpose of screening is to identify these changes before the cancer develops.
The traditional screening test that has resulted in the low incidence of cervical cancer in the developed world is the ‘Pap Smear’. The nature of how a pap smear based screening program works is such that it is not applicable to most developing countries. Its success is dependent on sophisticated technology and manpower; it also requires repeated visits to healthcare facilities by women. These conditions are far from obtainable in developing countries. In effect, where the political will exists to establish programmes, the challenge has been to find an applicable screening and prevention method suited to the peculiar situation of the recipient community.
Sophistication in man and material is not available, the mechanism of call and recall for screening do not exist. And women, who often contribute immensely in bringing bread to the family table, do not have the luxury of time to make repeated visits to be screened and treated for a disease which they know nothing about. Mass awareness and acceptance of screening and prevention may also pose special challenges either due to myths or misconceptions. These are the obstacles that must be overcome if screening is to be effective in developing countries.
Human Papilloma Virus
Cervical cancer can be regarded as a sexually transmitted disease. This is because the cancer is caused by a virus – the Human Papilloma Virus (HPV) which is transmitted during sexual activity. This is why the risk of development of cervical cancer in a woman increases with her number of sexual partners, because the risk of acquiring the virus also increases.
Women who are committed to one sexual partner will also be at risk if the partner in turn has several other sexual partners.
Most women who get HPV will naturally eliminate the virus in a short while through their natural body defences. In a small group of women however, the virus persists. Persistence of the virus may then begin to induce some changes in the woman’s cervix; these changes, if not detected and treated, may then progress to develop into cervical cancer. The interval from HPV infection to development of cervical cancer usually takes about 20 years or more. Smoking or exposure to cigarette smoke has also been identified as a major factor that supports progression of HPV infection to cervical cancer.
New low-technology approaches to screening have lately been developed which address the obstacles outlined earlier, and these approaches have been proved to compare favourably and sometimes better than the traditional pap smear.
In Nigeria the Federal Ministry of Health is promoting one such method, called Visual Inspection with Acetic acid (VIA). This method has been proved to be effective and cheap; the result is immediate and where the test is positive, treatment can be provided in a short period of time and at the same visit. This service can be delivered at the local primary health centre and by non-physician practitioners following an appropriate period of training. Nigeria has gained ground over the last few years in propagating this method and is currently in the process of a scale-up of the service to achieve a wide reach of previously un served populations.
Another interesting new approach to cervical cancer prevention is the development of vaccines against the virus – HPV – that is responsible for the development of cervical cancer. These vaccines are best administered to young girls aged nine to fourteen years, before onset of sexual activity, although older women may also benefit from the vaccine. This represents a very attractive approach, especially in areas where widespread screening may not be achievable.
Potential challenges exist though: first, in achieving vast vaccine coverage to adolescent girls for whom it was primarily developed; and second, in achieving effective coverage of the target population i.e. adolescent girls. Potential pitfalls exist as to its acceptance, as in the Nigerian experience with the polio vaccine which was mired in controversy and misconceived as a surreptitious attempt to interfere with the fertility potential of recipients. A successful vaccination programme holds immense promise for the eradication of the disease in Nigeria.
Greater public awareness
Regarding public awareness, a welcome development over the past two decades or so has been the noticeable plethora of activities surrounding cancer. Where hitherto, cancer had been a subject of taboo, it is good to see that Non-governmental organizations, corporate organizations and philanthropists have emerged, willing to contribute their quota. This synergy of activities is crucial to the prosecution of an effective cancer prevention and control. Much misconception exists towards screening activities which causes people to hold a fatalistic view. Individuals are able to make rational choices about their health when they have information. They are able to make lifestyle changes to reduce their risk of cancer as well as utilise available screening procedures.
It has been a long road to curtailing the scourge of cervical cancer even in advanced countries. There is hope however that developing countries have learnt from these experiences for a variety of reasons, especially the globalisation of the world through modern communication modalities – internet social media etc.
Evidence is accumulating that Nigeria is on the positive trail through knowledge, awareness and willingness to engage in health seeking behaviour. Gender discriminatory beliefs are being jettisoned by a modern generation as cultural divides are gradually demolished through this globalisation. All these factors portend a beacon of hope that with proper synergy of activities backed by strong political will, the battle against cervical cancer will be won.
Dr. Yinka Olaniyan is a Chief Consultant Obstetrician & Gynaecologist, Gynaecare Clinic, Abuja.