Cervical cancer, an African disease

Cancer is usually referred to as a disease of the Western World, but the truth is cancer affects people in poor countries more than anyone else.

Cervical cancer is particularly prevalent in developing countries, which count 80% of the cases. In Sub-Saharan Africa, where sexual risk behaviour also counts for high rates of sexually transmitted diseases (STD), cervical cancer is the most common cancer in women.

I interviewed Professor David Kerr, who is the President of the European Society of Medical Oncology and established the Africa Oxford Cancer Foundation (AfrOx). The charity aims to improve the delivery of cancer care in Sub-Saharan Africa. He told me how cervical screening programmes are being implemented in African nations.

Débora Miranda – How much is cervical cancer a priority in the Afrox work?

Professor David Kerr

David Kerr – It’s a key priority. We know that cervical cancer is the commonest cancer in Sub-Saharan Africa and indeed the whole of the developing world. Therefore it’s desperately important that we develop strategies for prevention, screening, early detection and treatment. It affects women at an important stage in life, it leaves families devastated and therefore it’s a top health priority. If we started vaccinating all girls in Africa today that would have an impact of 20 to 25 years, so we need to develop strategies which are not solely dependant on vaccination, but allow us to take care of women who are at risk over the next two decades – and of course women who are presented with a disease for treatment. In a way you’ve got to be able to deal with the whole pathway of the disease.

I assume you have to develop strategies not on an African level but in each country individually. How does that exactly work?

Indeed. We are focused predominantly in Ghana. We have very good relationships with the Ghanaian cancer society, excellent relationships with the Ghanaian health ministry, and very good relationships with the doctors and nurses that work with the health service there. What we hope is that the model and the experience that we develop in Ghana will help the rollout in other African countries.

Why Ghana?

Three years ago Afrox held a meeting in London with 32 health ministers there. All of them wanted to work with us but the Ghanaian were the ones who wanted to work with us first. Ghana is important because they’ve got some important existing cancer infrastructure – many African countries do get nothing whatsoever, there isn’t a single pathologist for example – but in Ghana there were some kinds of specialists, there were two centres, so there was a platform to build from and we thought that was the place to start.

Is there any vaccination programme running there?

At the moment there’s not, but we Afrox have just put together a pilot vaccination programme which will take us across three of the large districts of Ghana. We’ve just agreed this with the Ghanaian health authority. We believe that we’ll be able to get free vaccines from the manufacturers to roll this out and we’re seeking funding from international donours to provide the infrastructure, the healthcare workers, distribution and awareness raising so we can actually deliver the vaccine. We’re seeking funding just now and we plan to start rolling this out in the final quarter of this year.

Which one of the vaccines is it?

At the moment we haven’t decided. Both the vaccine manufacturers have open access programmes and they are keen to support African health ministers and NGO’s in getting the vaccines. But that’s a discussion that we’ve yet to conclude with the Ghanaian health ministry.

Vaccination programmes work better if they are school-based. Isn’t this hard to achieve in African nations?

Again, you’re making an important point and you are correct. But in Ghana we’re in a very strong position because 90% of Ghanaian children attend school. So again it’s an ideal place to pilot school-based model.

Which African countries are best in tackling cervical cancer?

There are open access programmes for vaccines working on Nigeria, Uganda and Rwanda, allowing countries which otherwise wouldn’t be able to afford the vaccine. There are good examples of what’s starting to take place. But of course none of the African nations has a comprehensive  national programme because there’s no funding available to be able to roll it out at that level.

Even if the manufacturers agree to help these countries it probably won’t last forever; at one point governments might have to invest themselves. And a vaccination programme only works effectively in a long-term basis.

Yes, sustainability is key and clearly the pilot programme we’re putting together for three years will cover 20% of the Ghanaian population. What we hope is that by doing this work, by understanding how to deliver the vaccine and how to raise awareness and reach schoolgirls, learning from that will allow us to roll it out. We hope that the price of the vaccine will come down. We hope that the international aid community will support GAVI, the Global Alliance for Vaccines and Immunisation, to help provide the vaccine to those nations that require it. In the next few years we’re hoping and guessing there will be an international aid programme to make the vaccine more widely available.

What are the biggest challenges to tackle cervical cancer in Africa?

We know that cervical cancer is caused by the human papillomavirus and is very prevalent in African women. The main problem is, when patients present the disease it’s at a very advanced stage. This is a problem with cancer generally in Africa. By the time patients (if ever) present in a conventional health system, like hospitals or GP’s, the cancer is usually reaching a very advanced stage which is much less likely to respond to treatment. So I think not only must we do work in terms of vaccination and prevention, but awareness raising and thinking how we can bring in a screening programme even if it’s just once in a lifetime screening. That’s been shown to save lives and reduce the death rates. We’re working up a plan for that to see if we can get the disease at an earlier stage when it might be treatable, but at the moment the vast majority of women come with a massive burden of cancer that is often impossible to treat other than pine it with painkillers.

Does it also depend on the type of screening that you adopt? Prof Peter Sasieni from Cancer Research UK told me HPV testing will be much more efficient in the developing world because it is realistic in almost any laboratory. It won’t require the same skills that liquid based cytology does.

I would agree with that. There’s a company called Qiagen who have got a point of care who does the DNA test for HPV. There are trials that have been performed in India showing that doing a just one in a lifetime screen, not asking women repeatedly (because you can’t afford that) does definitely reduce the death rate from cervical cancer. I think there’s two innovations, one is the DNA test and one that says let’s just start with a once in a lifetime test.

But if you need to start a screening programme from scratch, isn’t HPV testing the best choice?

I think there needs to be a transition. If you’re working in Africa we need to convince our colleagues of the utility of the test, that we can deliver in a rural, village setting in Sub-Saharan Africa, that we can keep the tests safe (especially if it’s a warm climate), etc. So there will be a phase of transition because for those countries which have got cytology services I think we need to move from one to the other. But I agree that the future is likely to be the DNA test.

Call and recall system is important. In countries where transport system is not the best, isn’t this a challenge?

We’ve been working with a Professor of Gynaecology in Cardiff, Alison Fiander, and her colleagues in Ghana. They develop a one slot shot because a call and recall thing doesn’t work. If we bring women to have the DNA test and if we spot that someone has an early cervical lesion or an early cancer we think it’d be possible to treat those in the field – using devices that would allow to burn the cancer out, painlessly in a rural setting. This seems a much better way to go for us.

What partners does Afrox work with?

We work with the two major professional cancer societies: the European Society of Medical Oncology – I happen to be the president of that – and the American Society of Clinical Oncology. This gives us access to tens of thousands of cancer professionals around the world who are keen to work with us and to support these programmes. We work with the pharmaceutical industry, which does want to make a difference and see what they can do to support cancer improvement generally in Africa. We’re working with the civil society because perhaps the most important message of all is awareness of cancer. Working with the Ghanaian cancer society allows us to make deep routes towards citizens. In developing countries the health ministries are really important and they need to feel ownership of these programmes and they need to be part of this early on.

Does the developed world still have to realise that cancer is a big reality in developing countries?

We know that in Africa there are more than 200 dialects spoken and the vast majority for them have no word for the disease cancer. Most Africans still live in a rural setting which delays treatment – there’s very little that can be done for those women with cancer. This increases the degree of stigmatisation that cancer is not a word but rather a death sentence. There’s a lot of work to be done there.

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