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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.


The more Pap tests, the worse

The reason why this website is called Cancer Screening reflects the issue that intrigues me the most in the cervical cancer debate. As I said before, in many countries, including Portugal where I come from, screening for cervical cancer usually starts as early as women become sexually active. In England it doesn’t start until the age of 25.

Different factors should be considered when judging the quality of a screening programme, regardless the type of cancer it applies to. Budget, culture and private health services are just some of them, which partly explains why there isn’t a common cancer screening programme, for example, on a European level.

Portuguese GP
Dr Armando Brito de Sá

I spoke to one expert who is particularly concerned about such discrepancies. Dr. Armando Brito de Sá is Professor of General Practice and Family Medicine at the Medical School of Lisbon University.

He agrees with the screening programme adopted by the NHS. Both the age to start screening and the frequency (every three to five years) are recommended for the Portuguese primary care services, following the British model.

Some important bodies, such as the U.S Preventive Studies Task Force (USPSTF), still recommend screening once a woman becomes sexually active. But the Portuguese expert highlights the position taken two years ago by the American College of Obstetricians and Gynecologists (ACOG):

Screening before age 21 should be avoided because women less than 21 years old are at very low risk of cancer. Screening these women may lead to unnecessary and harmful evaluation and treatment.

According to Dr. Brito de Sá, “this is a surprising statement given that it comes from an organisation of specialists [and not of a wider range of health professionals], which is very good news”. In his opinion, such organisations tend to be more aggressive.

ACOG also states cytology should be made every two years – a frequency that “prevents cervical cancer just as well, has decreased costs, and avoids unnecessary interventions that could be harmful.”

There is no scientific evidence that supports doing a Papanicolaou test every year, the GP adds.

The more medical exams, the healthier: a wrong message

One of my questions was that although the Portuguese health service takes the NHS as an example, both systems can never be totally similar since the private sector plays an important role in the country.

According to Portuguese database Pordata, 1,485 gynaecologists/obstetricians and 5,160 GPs were active in the country in 2009.

"Pap" test

Dr. Armando Brito de Sá points out that, although most people are consumers of the national health service (SNS in Portuguese), there is an overuse of medical exams in the private sector – not only in Portugal but worldwide. “This happens because of this general and wrong idea that the more exams we do, the better health we have.”

In line with this, I know many people who ask their private gynaecologist to be screened every year – sometimes even twice a year. So I asked Dr. Brito de Sá whether patients understand that paying for an exam could be more harmful than attending a national programme that recommends less frequent smear tests.

“Patients are not idiots,” he answers. “When you tell them the facts, they understand and are capable of making their own decision”.

Overscreening is a direct breach of “Primum non nocere”, an ethic principle taught in medical schools which means “First, do no harm”

And the facts are clear in his words: “The problem caused by early, frequent screening is not only the very small number of lives it would save but mainly the thousands of young women that are unnecessarily overwhelmed with additional exams whenever they have an abnormal test.”


Making medical students aware of different evidence-based policies

While lecturing the future generation of doctors, one role of Dr. Armando Brito e Sá is to make them understand that governments do not always follow the latest, best scientific advice.

He points out the dangers of overprevention and overmedication – an idea that was highlighted in 2001 when the American Family Physician journal published these Screening Guidelines.

Numerous medical organizations have developed cancer screening guidelines. Faced with the broad, and sometimes conflicting, range of recommendations for cancer screening, family physicians must determine the most reasonable and up-to-date method of screening.

Finally, the Portuguese expert shows conviction in saying that government’s policies are just partly determined by scientific evidence. The implementation of the HPV vaccines in different national programmes was “inevitably political, because of the excessively heavy disease-awareness produced in the media by the vaccine manufacturers.”

Cancer Research UK

Video: What cervical cancer is about

This video helps understand the main issues that this project aims to investigate. I spoke to Professor Jack Cuzick from Cancer Research UK, who highlighted the importance of changing cervical screening methods and the understanding of the human papilloma virus (HPV). I also heard the opinion of three women in the streets of London.

Video Transcript:

Débora Miranda: According to the World Health Organisation, over 12 million people are diagnosed with cancer every year. Two in five cancers are potentially preventable. The Human Papillomavirus or HPV causes cervical cancer, and is the second biggest cause of female cancer mortality. There are two main weapons against the disease. Screening for cervical cancer, which has been widespread in developed countries for many years, and newer techniques aimed at the virus that causes the disease.

Prof Jack Cuzick: There clearly is not very much understanding about the human papillomavirus. I think most people know that they should get screened and get an invitation. There has been a drop in acceptance of invitations in younger women. There is a lot of misunderstandings and fears about the virus because it is a sexually transmitted virus and it raises all sorts of issues about behaviour and partners behaviour which need to be handled with quite sensitively so doctors and people in general do need to understand more about this virus. It’s a very common virus. Like the common cold in most cases it leads to very minimal changes.

Voxpop 1: I’m not one of those organised people who makes a note of when the next smear test should be. I wait to get a letter from my GP or from the hospital.

Voxpop 2: When I got the letter I didn’t read it that well. I just sort of knew that I had to go. My friend had recently got a letter because she had just turned 25 as well, so we decided to book our appointments for the same day so we could both go to the doctor surgery together. That was quite nice to have the moral support. And even though I didn’t read the letter that much the nurse was really nice and she explained everything really well. The whole experience was much better because of that.

DM: Different countries implement different cancer screening programmes. It is important to understand the scientific evidence on which worldwide governments are based to make their decisions.

Voxpop 3: I grew up in another culture, where you get a yearly smear test if you’re on the pill. When I was in my early twenties I was taking the pill and so I would have the test every year and that was part of the culture. I grew up in the south of France and I think people are probably a bit more laid back about their sexuality or anything which involves your body It’s not seen as a taboo as maybe in an Anglo-Saxon culture.

Voxpop 1: I think it’s become better since there’s been so many high-profile cases. And I think Jade Goody’s case really brought to the general population the importance of testing and that it can happen to you at a very young age.

JC: The most important thing in screening programmes (and it’s been clearly demonstrated in cervix cancers) is high coverage. Screening can only work if people that can be screened do it. The coverage is very very important. The second most important thing is having an effective test and we’re seeing now that the HPV testing is more effective, more sensitive than cytology. So we do need to move to HPV testing as a method of screening.

DM: Cervical cancer raises controversial questions. Why does the age to start screening change from one country to another? Is there enough information about the vaccine? And what are the harms of screening?

JC: As with all screening there may be some harms. The main harm associated with cervical screening is, there is increasing evidence now that the treatment associated with lesions at a young age leads to increase miscarriage, early pregnancy rates because you basically have to loop out a piece of the cervix and that makes the cervix weaker.

DM: But before these questions are answered, follow the advice:

Voxpop 2: It wasn’t pleasant, I don’t think it would ever be pleasant to have that sort of thing but it was fine. It’s uncomfortable but it’s five minutes of your day compared to possibly the rest of your life if you catch something early. It’s a necessary evil but it’s really not that bad.