Cervical Cancer We Can Prevent It!

Cervical cancer is one of the most common cancers occurring in women, and a leading cause of women’s death worldwide. As per the latest WHO reports, in 2018 alone, there were more than 500,000 deaths due to cervical cancer, with majority of cases occurring in Asia and African sub continent. In developed countries, the annual occurrence of new cervical cancer cases has been on a decline since the last decade because of effective screening programs, but in under developed and developing nations, the disease burden is still high, or on the rise.
In the context of Nepal, it is estimated that more than 2,000 women die annually due to cervical cancer, and more than 10,000 new cases are detected annually. Higher deaths are because of late arrival to health facility, reluctance to seek health facilities, ignorance about the disease, or late detection. This article is aimed at providing general information about cervical cancer, but focused more on preventive strategies, which is the crux to prevention.
Cervical cancer is a disease of young women, common between ages 35-55 years. Human papilloma virus (HPV) infection, multiple sex partners, immune-suppression, smoking, and HIV infection are all acclaimed risk factors of the disease, but HPV 16 and 18 infections are the major causes in more than 98% of the cases. Post-coital bleeding, smelly discharge from vagina, and heavy menstrual bleeding are the early signs suspicious of cervical cancer, so women having these symptoms are advised to seek medical attention. Surgery, chemotherapy, and radiotherapy, either single or combined, are the different modalities of treatment available, depending on the stage of disease at detection. Earlier the detection, better and longer the chances of survival.
In spite of such high brutality of this disease, it is preventable by means of screening. Screening is application of test in apparently healthy subjects for early detection of a disease. With particular regard to cervical cancer, screening is very effective, because there is a long gap of 15-20 years, a pre-cancer phase called CIN, where screening can detect the disease and treatment can be done by effective means. PAP tests, VIA, VILI, HPV DNA testing, cervicography, colposcopy, and HPV vaccination of young girls between 9-13 years are different screening methods of cervical cancer. Selection of one or other methods of screening depends on the country’s policy and national screening guidelines.
Among the different screening tests, PAP test, HPV DNA testing, and colposcopy are the tests with higher detection rates, and used as a screening tool in most countries, but these tests require sophisticated laboratory and expert manpower, so they are not popular means in developing nations. In developing nations, WHO recommends VIA, VILI as screening tools for mass screening. Screening intervals differ from country to country, but majority have guidelines state screening for all women from the start of sexual activity or 30 years up to 60-65 years on yearly basis or once every two years. Colposcopy is a method of screening where a magnified image of cervix is seen after application of 5% acetic acid and any abnormalities are detected. The most recent advancement in cervical cancer prevention is HPV vaccination, in which girls of 9-13 years are vaccinated with HPV vaccination presumed to prevent cervical cancer in the future. Some countries have already incorporated HPV vaccination in their national schedule.
In Nepal, the National Cervical Cancer Screening and Prevention (NCCSP) program was launched in 2010 with the aim of screening all women to prevent cervical cancer. The guideline recommends testing by VIA to all women 30-50 years at 5 yearly intervals. The aim of the program is to provide VIA testing facility at the community health center level, and the government has put in a lot of effort on this program since the last few years. HPV vaccination program is also on trial phase in a few districts of Nepal.
The author of this article, with a team trained in providing VIA screening services, has screened more than 20,000 women of eastern Nepal till now. The hospital OPD setup and mobile screening camps, conducted with the help of different women welfare organizations, social organizations, NGOs, and municipalities of eastern Nepal covering remote areas of province number one, were used during the screening. During screening, around 50 women without any symptoms were detected to have advanced cervical cancer and were referred for radiotherapy, and around 1,400 women were detected to have CIN during screening and were successfully treated. These women in whom screening test was positive were the high risk candidates for developing cervical cancer. The details of this project have been partially published in Nepal Journal of Obstetrics and Gynecology.
To conclude we can say that, although cervical cancer is a disease leading to mortality, with effective and timely screening by any means, it is preventable and treatable at a very early stage. Increasing awareness of all women about screening can help early detection and prevent late diagnosis. Since it is a major public health concern, the effort from the government in scaling up programs on screening nationwide is of importance. Nevertheless, women’s self awareness and voluntary screening at regular intervals is of utmost importance for early detection and bringing down deaths caused by this disease.