here’s how to save 60 million lives

Providing the Pap smear to detect cervical cancer to all women requires a complex infrastructure, which has made it prohibitively expensive in poorer countries.

The World Health Organization estimates that cancer is the leading cause of death worldwide. The burden of cancer is on the rise, putting increased pressure on already strained systems in low- and middle-income countries. These regions are the least prepared to deal with the growing number of cancer patients. People in the world’s poorest countries have not benefited in the same way from recent advances in cancer screening, prevention and treatment. Inequalities also exist between patient profiles and within countries, even the wealthiest – not everyone has the same chance of achieving a good outcome. Lynette Denny is a world expert on cervical cancer, the fourth most common cancer in women. She spoke to The Conversation Africa about the drivers of cervical cancer and how to close the care gap.

Most (90%) new cervical cancer cases and deaths occur in low- and middle-income countries. What are the key factors behind this?

Cervical cancer is a disease of unequal access to care. It is an almost entirely preventable disease. Here’s why.

The natural history of cervical cancer begins with infection of the cervix with certain types of human papillomavirus (HPV). Over 200 types of HPV have been described over the past 40 years.

About 40 are associated with infection of the genital tract in both men and women. Of these 40 types, about 14 types are associated with cancers of the anus or genitals, particularly cervical cancer. These are known as the high risk types. HPV types 16 and 18 are the most common and account for more than 70% of cervical cancers worldwide.

The majority of people who get an HPV infection will have no symptoms and will overcome the infection without serious problems. But they can still transmit the infection to others.

In a minority of cases, the HPV infection becomes persistent. And over time, this infection causes changes in the cells of the cervix. These are known as precancerous changes. Untreated or undetected, they will progress to invasive cervical cancer over time – ranging from five to 20 years.

If these precancerous changes can be detected, however, they can be surgically removed, preventing progression to cervical cancer. Detecting them is what the Pap test has been doing since the 1940s.

When implemented in national programs, at 3-5 year intervals among all women in society over the age of 25-30, there was a dramatic decrease in the incidence of breast cancer. cervix and mortality.

But offering the Pap test to all women requires a complex infrastructure. This requires the ability to perform Pap smears, to transfer the smears to the laboratory, where they must be prepared and interpreted by laboratory technicians and from there returned to patients.

These requirements have made cervical cancer screening programs based on the Papanicolaou test prohibitively expensive in low- and middle-income countries. Failure to implement these programs is the primary cause of the high incidence and mortality from cervical cancer in these settings.

Where screening does exist, it is opportunistic and confined mainly to urban areas and to women with health insurance.

What are the most effective and affordable ways to prevent cervical cancer?

Ideally, at least 70% of women between the ages of 25 and 30 should be tested, with a system that has adequate human and consumable resources, excellent infrastructure, built-in quality control and strong management systems. orientation. The Pap test is affordable and cost-effective in most high-income countries, but not in low- and middle-income countries.

Preventing HPV infection is tricky. The most effective method is vaccination against HPV. The other is total abstinence from all sexual activity (not very realistic).

There is, however, some protection offered by condom use (every time you have sex), which is estimated at around 70% (compared to more than 90% protection against HIV transmission through correct condom use).

Vaccination against HPV was introduced in 2006. There are currently three vaccines against different types of HPV. Current WHO recommendations for cervical cancer prevention include HPV vaccination in girls (and boys if resources permit) aged 9-12, combined with effective screening for women aged 30-49, at least twice in a lifetime using a high-quality screening test. .

The tests currently recommended are those capable of detecting HPV DNA on the cervix. These tests detect precancerous lesions of the cervix. A doctor can collect the sample or teach women to collect their own sample and deliver it to the nearest clinic for evaluation.

Services for the early detection and treatment of cervical cancer are essential, as well as the provision of palliative care for people with advanced disease.

Treatment for early-stage cervical cancer is removal of the uterus and, if present, removal of the upper vagina and removal of the pelvic lymph nodes. For more advanced cancers, the treatment of choice is radiation therapy to the pelvic region.

What hinders the implementation of these interventions?

The most significant barriers to establishing national cervical cancer control programs are:

  • Failure of government health sectors to prioritize cervical cancer and therefore failure to allocate resources.

  • Competing health needs among women in low- and middle-income countries. Maternal mortality and the high incidence of HIV, malaria and tuberculosis divert funding from cervical cancer prevention. Other basic needs to be met include drinking water and adequate sanitation. Civil unrest and widespread poverty also hamper meeting the needs of the population.

  • Lack of political will and lack of understanding of the impact on individuals, families, communities and society as a whole of women dying prematurely. This has widespread socio-economic costs at the national level.

  • A powerful investment case is being made, urging governments to prioritize preventing cervical cancer and eliminating it by at least 2030. If all countries join in effort, it is estimated that more than 60 million women’s lives will be saved.

Lynette Denny, President and Professor of Obstetrics and Gynecology, University of Cape Town

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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