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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Dr. Yinka Olaniyan: Preventing Cervical Cancer in Nigeria

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

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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.

Screening programme
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.

Low-technology screening
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.

Vaccination
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.
Contact: dryinka@gynaecarenigeria.com

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