Reducing the burden of cervical cancer in the developing world
Cervical cancer accounts for 1 in 10 of all cancers diagnosed and more than 273,000 deaths in women worldwide every year. (1) Nadine Cozens caught up with Dr. R Sankaranarayanan (Sankar), the author of a recent Lancet Article on the effect of visual screening on the incidence and mortality rate of cervical cancer in the Dindigul district in Tamil Nadu, India (2)
In developing countries, cervical cancer is the commonest cancer to affect women, and contributed to 85% of new cases and deaths worldwide in 2002. With so many women affected by cervical cancer, I was keen to find out the effect of cervical cancer in rural India. Dr Sankar believes that cervical cancer is the main cause of premature death among women in the Dindigul district. Due to the substantial loss of women in the reproductive age group, this has “devastating effects on the social, psychological and emotional well-being of the entire family,” he said.
Whilst in developed countries, cervical screening is performed mostly by cytology (Pap smears), this method of screening is less effective in developing countries: “There are many contributing factors, including sub-optimal performance of cytology, difficulties in maintaining the several steps required, inadequate investments into provider training and laboratory infrastructure, and lack of quality assurance,” Dr Sankar explained. He has found that Visual Inspection with Acetic Acid (VIA) is more advantageous than Pap smear in low resource settings, due to improved feasibility, reduced costs, immediately available results, and the possibility that screening, diagnosis and treatment can be offered in one session. Furthermore, doctors, nurses, healthcare workers and both medical and nursing students, can be easily trained to provide VIA, or even learn the skill themselves. (3)
A recent study of 1620 British women found that despite recent media coverage, only 2.5% of those questioned named HPV as the cause of cervical cancer. (4) But there has been little research about the aetiology of cervical cancer in the developing world. According to Dr Sankar, many women in developing countries believe the purpose of cervical screening is to diagnose sexually transmitted infections highlighting the need for further education: “The information that women currently receive is partial, very often inadequate and stigmatising,” he says.
There has recently been much press coverage of the new cervical cancer vaccines, however there are conflicting opinions concerning their benefits. According to Dr Sankar, “HPV vaccination is a very important approach for preventing cervical cancer.” However there are various factors that will hinder the vaccine’s efficacy in developing countries. With this being the most expensive vaccine in children for mass use, he worries about the cost to society in terms of resources that will not be devoted to other public health priorities especially considering that there are more affordable and effective screening techniques currently available. If vaccination were to be introduced in poor countries, it is vital that both the costs of the vaccine and its delivery are reduced. “Delivery costs are as important as vaccine costs, since in many settings new systems will be needed to reach young adolescents,” Dr Sankar explained. He added, “whilst HPV vaccination provides the hope for the future, screening provides the hope and means for the present time.”
In the US, certain states are trying to make the vaccine mandatory. (5) Objectors argue that this may increase promiscuity. I was eager to find out Dr Sankar’s view on this. “Objectors who argue that HPV vaccination might increase promiscuity can be divided between those who consider promiscuity from a moral point of view, and those who consider that promiscuity might increase unsafe sexual practices,” he said. “The moral approach is not within the scope of public health as different societies hold different beliefs with regards to what is considered ‘promiscuous behaviour.’” Dr Sankar acknowledged that if ‘promiscuity’ has a negative effect on the health of a population, then it is obviously a problem however Dr Sankar believes that vaccination may reduce promiscuity and have a positive effect on public health, by providing a unique opportunity for contact with health care professionals, allowing an opportunity to emphasise the importance of safe sex. But if no information is provided at the time of vaccination, the message could become confused and this may result in an increase in unsafe sexual practices. “Vaccine introduction should be accompanied by clear information about what the vaccine does and what it does not,” he said.
So as medical students, how can we contribute and help reduce the burden of cervical cancer in the developing world? According to Dr Sankar, first we must understand the scientific basis of disease prevention, and how best to utilise vaccination and screening programmes: “Medical and nursing students must learn to adequately provide speculum examination, collect cervical samples, and provide visual screening with acetic acid and Lugol’s iodine.” There are many ways in which students can gain such expertise, for examples visit the Screening Group, International Agency for Research on Cancer, website: http://screening.iarc.fr/. As Dr Sankar explains, “Only then can we create awareness among the public through appropriate messages and visual screening - the only feasible means to control cervical cancer for many years to come in several disadvantaged areas.”
As a final message, Dr. Sankar explains, “Today’s medical students are tomorrow’s healthcare providers. No program can be initiated and sustained without competent providers. I think medical students have a responsibility to become competent providers.”
Nadine Cozens
Fifth year medical student
Kings’ College London,
University of London, WC2R 2LS
nadine.cozens@kcl.ac.uk
(1) Cancer Research UK, Cervical cancer - international statistics. http://info.cancerresearchuk.org/cancerstats/types/cervix/international/
(2) Sankaranarayan R, Esmy PO, Rajkumar R et al. Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial. The Lancet 2007; 370:398-406
(3) Sankaranarayanan R, Gaffikin L, Jacob M, Sellors J, Robles s. A critical assessment of screening methods for cervical neoplasia. International Journal of Gynaecology and Obstetrics 2005; 89 Suppl 2:S4-S12
(4) Marlow LAV, Waller J, Wardle J. Public awareness that HPV is a risk factor for cervical cancer. British Journal of Cancer, 2007: 1-4
(5) The New York Times, A Necessary Vaccine. Available online: http://www.nytimes.com/2007/02/26/opinion/26mon1.html (accessed 01/10/07)
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