Cervical Cancer in Low Resource Countries
In Canada, if you were to receive a couple of abnormal PAP tests, a follow up would take place in a clinic or medical center. If your abnormal results do in fact point to the occurrence of cervical lesions, appropriate steps are taken. You would be informed that you have likely contracted human papilloma virus (HPV), the virus responsible for genital warts and precancerous lesions of the lower genitals which, if left untreated, may lead to cervical cancer. You will also be told that this is luck of the draw and there very little could have been done to prevent contracting this virus, as it is usually passed through sexual skin to skin contact. The usual safer sex protocol is not an effective means for prevention and readily accessible tests are not available for partner testing. Condoms have a limited impact on contraction. You would likely hear that most cases of HPV infection clear up on their own; however, some do not. Next, the appropriate actions would be taken. For example, a colposcopy might be done, which involves looking at your vagina and cervix through a magnifier, to detect and treat abnormal lesions and to ensure that these lesions do not progress into anything harmful. You would then be required to have regular follow-up visits and monitoring to ensure that these lesions do not reappear and, if they do, are treated in a timely manner. While inconvenient and perhaps worrisome, this process prevents the development of cervical cancer, one that kills many women who do not access to this lengthy, but effective, process. Certainly inconvenient and worrisome, the burden of cervical cancer impacts entire communities in the developing world by taking the lives of their women.
Screening is the front line in the battle against cervical cancer; but let us imagine the resources involved. An ideal screening program includes, in no particular order: good coverage of the target population, referral services, patient follow-up, adequately trained staff, essential equipment, treatment protocols, quality control of screening tests, timely and adequate care, effective public education and outreach campaigns, documentation, and patient notification systems, just to name a few. Low resource countries whose health centers and hospitals commonly lack infrastructure, equipment, personnel, funding, resources and training often can hardly serve the needs of the emergency ward. While many of the make-do solutions discussed below don’t require such an extensive list of resources, the difficulties are apparent. In cases where the health care system is strained, limited, or expensive, it is common for people to only seek medical attention in times of emergency. A holistic and preventative approach to health care, with regular check-ups and active management of primary symptoms, remains a goal even in the most well-equipped and effective health care systems. In middle and low resource countries people tend to seek health care only when problems arise; in the case of cervical cancer, this usually proves devastating for the woman, as at this point the cancer has frequently reached an advanced stage. If not already too late, treatment will usually require invasive surgery or radiation therapy which, even without taking into account the significant impacts on the woman and her family, may not be available in these countries. If the cancer is untreatable, it will result in a painful, even agonizing, death.
Regular PAP tests? What are those?
Cervical cancer is the second most common cancer affecting women worldwide. 288,000 women died from cervical cancer in the year 2000 alone. Over 80% lived in developing countries. In low resource countries it is the most common cancer affecting women, and is a significant factor in the numbers on female mortality. Families, communities, and countries all suffer when women die. Women are usually the primary care givers in low resource countries, managing the home and doing their best to provide for their children. The loss of a woman has many impacts, from the macro to the micro. Those who suffer the most, being the most vulnerable, are the youngest children. For women struggling to make ends meet, spending money on preventative check-ups is hardly a priority. The PAP test and how to get one is nearly unheard of, not to mention unaffordable.
Death by Cervical Cancer: Long and Painful
Women who are suffering the advanced stages of cervical cancer tend to present at hospitals and clinics reporting bleeding, pelvic pain and urinary symptoms. Even with excellent medical care, if the cancer has spread to areas outside of the reproductive zone to other organs such as the bladder, rectum and pelvis, treatment is successful in less than 5 percent of cases. When untreated, the growths on the cervix enlarge, pushing in through the vagina and into other areas of the body causing irregular bleeding and obstruction of the urinary tract. Women will essentially bleed to death and die from anemia and uremia. Little discussed is the pain. To die of cervical cancer, without access to medication, is excruciating. In HIV/AIDS prevalent countries, many HIV-positive women are unable to combat an HPV infection, leading to an eventual death of cervical cancer enabled by AIDS.
Once in a lifetime screening. Luckily many solutions yielding significant results don’t require the extensive list of screening program needs mentioned above, and creativity along with research has indicated more simple screening methods.
The WHO estimates that a one-time screening among women around the age of 40 could reduce the chance of fatality due to cervical cancer by 25-30% if adequately followed up. Since cervical cancer usually progresses slowly, this once-in-a-lifetime screening could prevent abnormal cells from becoming fatal.
The wonders of vinegar - VIA. The most recommended and accessible method of screening for cervical cancer in low resource settings is called Visual Inspection with Acetic acid (VIA). A comparatively cost-effective method, this test involves swabbing the cervix with vinegar (acetic acid), which will highlight differences in cell structure and absorption rates, turning the precancerous cells white. Health care providers can use this method without magnification, using a light source and their eyes to identify a need for further investigation. Studies have demonstrated that this is a very effective method of identifying the precursors or existence of cervical cancer, with different studies indicating that VIA is able to detect between 65 and 95 percent of cases requiring further examination. While not as in-depth as a PAP test, and less effective on post-menopausal women due to physiological changes, the accessibility of VIA makes it a great solution for low resource settings. With adequate training, this test can also be performed by nurses and midwives in various locations, better ensuring that women are screened. In some cases, VIA has added a low power magnification to the procedure, indicating even more accurate results. Requiring comparatively minimal infrastructure, this low-tech approach provides a great opportunity for low resource countries and countries in transition to detect cervical cancer – one step toward stopping it from needlessly taking women’s lives.
HPV Vaccine- A Matter of Time?
Recently, developed countries have seen the advent of the HPV vaccine, now accessible to girls and women as an effective means of preventing cervical cancer. Although not without controversy, the vaccine has been accepted as a method to protect people from cancers related to HPV. Will this vaccine trickle down and be accessible in low resource countries? Likely not without pressure on governments, institutions and pharmaceutical companies.
It is a matter of injustice to have a large part of the solution to the majority of cervical cancers presented only to the population who suffers its burden the least.
The vaccine is seen as one of the best and most realistic methods of preventing cervical cancer in developing countries. While building the infrastructure and capabilities for a system that could provide PAP testing and other comprehensive exams remains ideal, the vaccine would rapidly reduce the numbers of women contracting HPV each year, which currently totals over half a million cases annually. While the vaccine works best in combination with screening, it provides an opportunity for prevention. Research is currently underway to determine the requirements and best practices for lobbying for and implementing a vaccine program in low resource countries.
Impossible? No Way!
While overcoming the barriers for women in low resource settings to access quality screening programs and the HPV vaccine might seem difficult under the circumstances, we must remember battles that have made significant gains when armed with justice, motivation and good planning. When antiretroviral drugs (ARV’s) were first developed and accessible in high resource countries to prolong the lives of HIV-positive people, the concept that they would be accessible for those in developing countries was considered impossible. People said the prices were too high, and that the dissemination programs could not be organized effectively. While there is still a long way to go to get everyone the ARVs they need, skeptics would likely have never imagined the progress gained with the advocacy, mobilization and action on part of people and organizations everywhere, which have insisted that all people should have access to life-enhancing medications. In our push to get better care for women with cervical cancer, let us remember these important lessons learned.
“We call on industry to provide adequate supplies of these new technologies at radically tiered prices”
— Global Call to Stop Cervical Cancer
“Cervical cancer accounts for a high percentage of cancer deaths in women in Latin America and the Caribbean — as high as 49.2% in Haiti, compared with 2.5% in North America. These high rates result from problems in access and quality of services.”
— DR. MIRTA ROSES
Director, Pan American Health Organization / WHO-ACCP
Now what? What can be done?
- Governments, donors, development partners, and other stakeholders should dedicate the needed financial resources to allow life saving technologies to be accessible to all.
- Industry can provide appropriate pricing and minimize barriers in accessing new technologies.
- Raise public awareness and encourage the community to put pressure on their health care systems to get availability of the HPV vaccine.
- The medical community can learn and educate each other and their patients about cervical cancer and its prevention as well as approve and issue guidelines about new prevention and treatment technologies.
- Foster better use of existing knowledge, resources and research for more effective partnerships and rolling out of treatment.
- Governments, health agencies and others working in the health domain can prioritize cervical cancer and dedicate the necessary resources for sustained impact.
- Civil society organizations can work in partnership to create global change and place and maintain cervical cancers place on the agenda.
- Monitor and hold stakeholders accountable.