As South Africa marks the end of cervical cancer awareness month, experts have urged women to get screened often and avoid becoming a statistic.
The country has a high prevalence, with 1 in 42 women having a lifetime risk of developing cervical cancer.
According to the ICO/IARC Information Centre on HPV and Cancer, current estimates indicate that every year 10, 702 women in SA are diagnosed with cervical cancer and 5 870 die from the disease.
This makes the disease the second most common cancer among women and the most frequent among those aged 15 to 44.
Importance of regular pap smears
Lorraine Govender, CANSA’s National Manager, said that myths, misconceptions, and misinformation surrounding cervical cancer could be highly damaging. It contributes to stigma and impacts negatively on the decisions women taken when it comes to prevention and seeking treatment.
During Women’s Month in August, Govender stressed the importance of having regular pap smears and following up on abnormal results.
“Unfortunately, most women diagnosed with cervical cancer today have not had regular pap smears or followed up on abnormal results. It’s also important that women do not stay away when they receive abnormal results”, she said.
According to Govender, the gap between screening and treatment is very high in South Africa. Around 50% of women who present with pre-cancerous signs are referred for further follow-ups such as a colposcopy and biopsy.
“Factors such as lack of financial resources, transport and child-care play a huge role in preventing women from accessing care,” said Govender.
What is HPV?
Human Papillomavirus (HPV) is a common virus that is spread through skin-to-skin contact, body fluids and sexual intercourse. There are many different types of HPV.
Some strains lead to cervical cancer. Other strains may cause genital warts, while others do not cause any problems at all. Pap smears detect abnormal cells in the cervix that could develop into cervical cancer.
However, Dr Rakiya Saidu, lead clinician at the Khayelitsha Cervical Cancer Screening Project (KCCSP), said that even though pap smears have worked very well in developed countries, it hasn’t worked as well in developing nations and low-middle income countries (LMIC).
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The downside of pap smears
In 1994, the KCCSP, in collaboration with Columbia University, set up to find alternatives to the pap smear.
“Pap smears started became popular in the 1940s, and by the 1960s, it was available all over the western parts of the world. It is the fastest screening method and has worked well in those parts of the world”, said Saidu.
But according to Saidu, pap smears require a lot of logistics, are expensive and need specialist personnel to be able to do some of the required work.
“You need a lab with quality control so that the pap smears are of top quality. A specialist then looks at the results, and the entire process takes about six weeks,” said Saidu.
LMIC and pap smears
Another reason why pap smears aren’t as efficient in LMIC is the daily socio-economic issues that women face.
“Most of the time, the women who are screened don’t come back. Home addresses aren’t always stable either”, said Saidu.
According to Govender, The National Department of Health’s Cervical Cancer Prevention and Control Policy allows women aged 30 and older to have three pap smears in their lifetime. This happens in 10-year intervals at 30, 40 and 50 at public health clinics at no cost (non-symptomatic).
“If women experience abnormal symptoms, they can request a pap smear at local government clinics. HIV-positive women are eligible for a pap smear at diagnosis and every three years thereafter if negative for cervical cancer. If positive, they can screen yearly,” she said.
Why women stay away
Saidu also believes that the fear of getting a positive cancer result drives them away. She said that proper counselling would help with overcoming this fear.
“Apart from doing the pap smear, you must be able to link those with abnormalities to treatment. If you find an abnormal pap smear and cannot treat the patient, you have done nothing,” she added.
In between that linkage, there is also a drop where women do not come back. That linkage means you are sending them to a secondary or tertiary facility. Not every woman can afford the bus fare to go to those clinics”, she said.
Saidu said that KCCSP, the World Health Organisation (WHO) and many other organisations, have been working towards finding alternatives to the pap smear because of reasons like this.
“The concept of ‘screen and treat’ is that when you see a woman, you screen her, and if she has an abnormal result, you treat her in one visit so that she doesn’t have to come back.
She explained a WHO initiative called cryotherapy, which uses extreme cold to freeze and remove abnormal tissue.
According to the National Cervical Cancer Prevention and Control Policy, cryotherapy is offered in limited settings in South Africa. It can be performed by trained nurses and is often used as part of a same-day screen-and-treat programme following visual inspection with acetic acid (VIA) for screening.
Cryotherapy can also be used for treatment after cytological or HPV DNA screening, however, this will involve a two-step process.
According to Dr Saidu, cryotherapy involves using nitrogen oxide gas to treat any abnormalities that may be picked up during screening. The gas freezes the abnormal cancer cells and kills them.
However, this method proved problematic because many LMICs do not have gas availability.
The visual inspection screening method also has obstacles because it is very subjective. It involves the use of a colposcopy machine. A colposcopy is a type of cervical cancer test. A vinegar-like solution is used to find abnormal cells in your cervix.
This screening methodology is currently in use in very limited settings in South Africa, usually supported by NGOs.
Saidu said portable colposcopies had brought much relief, especially in rural areas.
“These portable devices can take images of the cervix, and some are based on the smartphone device design. For example, the images are uploaded onto the server, and I will be able to remotely assist the nurse in the field and tell her what to do,” she explained.
Other companies are trying to further improve portable colposcopies by using artificial intelligence (AI). Instead of having to wait for a diagnosis from a doctor, the nurse in the field can take a photo of the cervix and, through AI, get a diagnosis and be able to treat the patient immediately.
However, Saidu said the use of AI with portable colposcopies is not in the market yet.
Another method of cervical cancer treatment being used is thermal ablation. This procedure uses a heated probe tip to the cervix to destroy the precancerous cells. The probe tip is heated to between 100°C and 120°C and is a painless procedure.
“Technology is now improving, and we have companies making what is called the ‘point of care test, which is what we are currently using here,” said Saidu.
Saidu also encourages women to speak to a healthcare professional if they have any fears about getting a pap smear.
“If you feel any pain or discomfort, tell the provider, and they can remove the speculum used for the pap smear and find one suitable for you. Speculums come in different sizes because all women are different. The most important thing is that you come and get screened”, Saidu concluded. – Health-e News