Cervical cancer is a growing cancer in Pakistan. It is one of the few cancers that are contracted, in more than one ways. It is, however, more often than not, contracted through unprotected sexual contact with a carrier. The human papillomavirus (HPV), a sexually transmitted infection (STI), in its various strains, is what mostly causes cervical cancer. Thus, a sexually active woman is at risk of contracting the virus. Married or not.
Often the carrier, if a man, will not be affected by the virus himself, but will transmit it to the woman. The vaccine that protects against it, though still being studied upon, is available in Pakistan. Expensive, yes, but potentially life-saving. The best time for a girl to get the vaccine is before the years she becomes sexually active. Hence, teenage years are a good time to get vaccinated against HPV. But in Pakistan, we see a resistance to the idea of getting teenage girls getting this vaccine.
The reason for this resistance, according to Dr Azra Ahsan of the National Committee for Maternal Neonatal and Child Health (NCMNH), is this: “We like to idealistically believe that in Pakistan, sexual relations take place only within marriage. Thus we brush aside the issue of safe sex. And even within a marriage, a woman may be at risk of contracting STIs from her husband. Thus, we encourage that the vaccine be given to girls before them becoming sexually active.”
HPV types 16 and 18 are thought to be the causes of nearly 70 per cent of all cervical cancer cases that occur globally. There HPV may also be a cause of other anogenital cancers, and head and neck cancers.
As it can be sexually transmitted, the incidence of cervical cancer in Pakistan is probably much more than we like to believe. The taboos linked with screening for STIs and the lack of awareness even among educated, urban women that a simple Pap Smear test can be a life saver points in this direction.
When asked which groups of women are most likely to develop cervical cancer, Dr Ahsan says, “Women from poor socio-economic status are the most common victims. Reason could be an absence of early detection. Women with multiple sexual partners also fall in the higher-risk group. Also, women who have had many children tend to be more at risk, as each child birth can cause injury or trauma which can trigger a dormant disease.”
In a country where nine per cent of young women aged 15-19 have begun age bearing, and uneducated young women are more than ten times as likely to have started child bearing by age 19 (according to the 2007 Pakistan Demographic Health Survey — PDHS), the clear indication is that a sizable chunk of the female population, especially in rural or underprivileged areas, becomes sexually active at a young age. Within marriage or outside would hardly be a debate of consequence with reference to the HPV vaccine.
The Total Fertility Rate (TFR) in Pakistan, though has declined, still holds steady at 4.1 children per woman on an average (PDHS).
Fortunately for Pakistan, prevalence for HIV is extremely low with only one-tenth of one per cent of the population affected (Reproductive Health at a Glance, April’11, The World Bank). But use of contraceptives, especially as protection against acquiring STIs which includes HPV, remains low, with only 20 per cent of ever married women (age15-49) using condoms (PDHS). However, even condoms do not provide 100 per cent protection against the highly contagious HPV. Apart from monogamous relations with a single uninfected partner, early detection is the key where cervical cancer is concerned, because by the time the patient starts showing signs, it has already progressed considerably. Once a woman is infected, it can take between five and 20 years for the virus to develop into full cancer, with no symptoms in a lot of cases.
Around six decades ago, a doctor from Cornell University discovered that precancerous cells from the cervix could be identified before they turned lethal. The finding made scientists re-think the screening and treatment of cervical cancer. Dr George Papanicolaou’s “Pap Smear” test became popular. Within the following 20 years, deaths from cervical cancer in the USA decreased by 74 per cent.
The situation, however, is drastically different as far as the developing world is concerned. In today’s world, cervical cancer is primarily a disease found in low-income countries. Annually, nearly 500,000 new cases occur, and out of these, 83 per cent are in the developing world. 85 per cent of the 274,000 deaths associated with cervical cancer are from the developing world. South Asia alone is home to one fourth of the cases of cervical cancer.
According to a World Health Organisation (WHO) study from 2008, Pakistan’s incidence of cervical cancer in 2008 was 19.5 per 100,000, compared to less than 9 per 100,000 in 2002.
The study reported that cervical cancer deaths stood at 12.9 per 100,000 nationally, said Dr Muhammad Tayab, speaking at a press conference organised by the Health Awareness Society (HAS) in October 2010.
A solution came to my attention in a bigger way on a recent visit to Ethiopia, as part of a team called “Women’s Edition” of female journalists from developing countries. Population Reference Bureau (PRB) which organises the Women’s Edition is a Washington DC-based organisation that informs people around the world about population, health, and the environment.
On a visit to St Paul’s Hospital’s Cervical Cancer Prevention Unit working under Pathfinder, a starkly simple solution for early detection of cervical cancer in an economical and effective manner stared at me. The Unit consisted of three tiny rooms with the simple most equipment, and an old steel bed for patients. A senior nurse professional met us, who heads the small team responsible for detection of the earliest signs of cervical cancer of so many women, and in turn saving their lives.
Pap Smears can detect it, but Pap Smears are expensive. And people in Ethiopia or Pakistan are often underprivileged. At St Paul’s, they are using a far less expensive method to screen women for signs of cervical cancer. The method is one of direct visualisation with acetic acid and has gained popularity and proven itself as an adequate alternative to PAP smears in developing countries.
In visual inspection with acetic acid (VIA), 5 per cent acetic acid is applied to the cervix with a large cotton swab and left for 30-60 seconds, after which the cervix is visually examined with the naked eye and a lamp. Pre-cancerous lesions, with a higher ratio of intracellular proteins, turn white when combined with acetic acid. Normal cervices without any precancerous lesions, do not change colour. It is low-cost, requires fewer visits to the physician and the efficacy is about 5 years.
“VIA in Pakistan is done in small pockets, but not enough. In Pakistan, there is no structured screening programme for cancers. VIA is a low-cost method. Medical technicians, if trained, can also do it. Thus, it is a good solution. It should be encouraged that VIA units be set-up in public hospitals,” says Dr Ahsan.
It is time that we seriously think about methods like vaccination against cervical cancer, as well as Pap Smear or VIA, depending on affordability, for early detection. Brushing issues of diseases spread through STIs under the rug will not help solve these growing problems. Acceptance and then looking for solutions — that is the key.
Originally published in The News: http://jang.com.pk/thenews/aug2011-weekly/nos-07-08-2011/dia.htm#5