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Taking a snapshot of CERVICAL CANCER

  • Writer: Polelo Mawela
    Polelo Mawela
  • Sep 21, 2022
  • 7 min read

Cervical cancer (CC) is a type of cancer that occurs in the cells of the cervix and is the 2nd most common cancer among the ‘Big Five’ cancers affecting women in South Africa (SA). It affects women of reproductive ages 15-44 years of age. Various strains of the human papillomavirus (HPV), a sexually transmitted infection, play a role in causing most CCs.


Cervical cancer prevalence in Low to Middle-Income Countries (LMICs)/Developing Countries

Cervical cancer is one of the leading causes of cancer death in women all over the world, but especially in LMICs/Sub Saharan African (SSA) countries. In SSA, CC encompasses 20–25% of all cancers among women. In 2018 it was estimated that there were about 570 000 new cases of CC worldwide, with 80% of these cases occurring in LMIC countries. Cervical cancer remains the leading cause of female cancer deaths in SSA with mortality rates reported as high as 40 per 100 000 in Uganda.


Overall, developed countries such as the United States of America and United Kingdom, 40 and 42% of the women diagnosed with CC respectively, die from it, while in Africa and South Asia, the equivalent death rates are nearly twice (78%) as high as the rates experienced in high income countries. Approximately 90% of CC deaths are in LMIC which often lack the resources and funding to provide adequate treatment. Furthermore, LMIC carries 83% of the global CC burden, but only achieve an average successful screening coverage of 19%, compared to 63% in high-income countries.


Cervical cancer often affects the most vulnerable women: those in low socio-economic groups who have inadequate health literacy, poor access to reproductive health care and screening and, who face many socioeconomic challenges. Lack of resources limits coverage of CC for these women, and notably, for those from rural communities compared with urban areas.


Cervical Cancer Prevalence in South Africa (SA)

Cervical cancer in SA accounts for 15.85% of all female cancers annually. This prevalence figure doubles to 30.29% when separating the statistics for Black African women. Together these prevalence rates result to more than 6000 deaths annually.

According to the 2017 South African National Cancer Registry Report, there were 5630 new histologically confirmed cases of CC amongst black women with a lifetime risk (0–74 years) of 1 in 33 women. The main risk factor for CC is a persistent infection with high-risk HPVs. About 21.0% of women in the general population of SA are estimated to harbour cervical HPV infection and that 62.8% of invasive CCs are attributed to HPVs 16 or 18.


Signs and symptoms

Early-stage CC generally produces no signs or symptoms; however more-advanced CC signs and symptoms include:

  • Abnormal vaginal bleeding between periods

  • Continuous watery, bloody vaginal discharge (heavy and have a foul odour)

  • Menstrual periods becoming heavier and lasting longer than usual

  • Vaginal bleeding or pain during and after intercourse

  • Vaginal bleeding after menopause


Risk factors

· Failure to always use protection during sexual intercourse

· Multiple sexual partners and high-risk sexual activity

  • Early sexual debut

  • Other sexually transmitted infections (STIs) e.g., HIV

  • Immunocompromised health conditions

  • Smoking

· Poor genital hygiene (conditions)

· Lack of education

· Prolonged use of hormonal contraceptives

· Consumption of alcohol (could lead to high-risk sexual activity)

· Being overweight/obese with low physical activity levels

· Residing in a rural area


Human Papilloma Virus (HPV) and HPV Vaccines


Almost all CCs are caused by Human Papilloma Viruses (HPVs). This virus is common and spreads though skin-to-skin contact, body fluids and sexual intercourse.


Studies have estimated that over 80% of sexually active women will be infected with genital HPV at some point in their lifetime. Although vaccines are available to prevent CC, financial and political barriers contribute to their underutilization and inaccessibility. These barriers contribute to women in LMIC populations seeking care for this cancer late in the course of their disease (when symptoms occur). Consequently, a large emphasis is put on CC screening. Traditional cytology-based screening, such as Pap smears, has been successful in reducing CC rates in high-income countries, but it is less accessible and efficacious in LMIC due to the requirement for a robust infrastructure.



Types of HPVs

The oncogenic high-risk HPV genotypes include strains 16,18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59. Of the 12 known oncogenic types, HPV 16 is linked to most high-grade CC, followed by HPV 18.


HPV vaccines

Human Papilloma Virus (HPV) vaccines cannot prevent infection which is why immunization is recommended before sexual debut. The Cancer Association of South Africa (CANSA) has an HPV School Vaccination Programme. This vaccination if offered to grade 5 girls only in all public (government) schools and special schools, to girls 9-12 years of age. This six-month vaccination campaign is offered in February/March and again in September/October annually to ensure completion of the two doses for full protection.


The identification of HPV as the agent responsible for CC lead to the development of three FDA-approved multivalent prophylactic HPV vaccines. The first-generation vaccine, HPV quadrivalent, (types 6, 11, 16 and 18) recombinant specifically targets 70% of infections that may lead to CC, while the second-generation, HPV nine-valent (types 6, 11, 16, 18, 31, 33, 45, 52 and 58) recombinant vaccine targets those additional 15% to 25% potentially oncogenic infections not addressed by the HPV quadrivalent and HPV bivalent (types 16 and 18) vaccines, thus offering the potential to prevent almost 90% of CC.


Pap Smears


Cervical cancer screening via the Pap test has made it possible for this cancer to be a treatable disease if detected and diagnosed early. The literature reveals that 50% of women diagnosed with CC never had screening done, and 10% had not been screened within the last five years.


Women aged 18-25 years who have been sexually active, should have Pap smears every three years or two years later after first sexual activity (whichever is later) and continue until age 70.


The South African Department of Health developed the Cervical Cancer Screening Programme which allows three Pap smears per lifetime, at 10-year intervals, starting at the age of 30. This screening policy programme was designed for target coverage of at least 70% of women nationally.


Prevention (reducing the risk)

  • Having routine Pap smears

  • Enquiring about and receiving the HPV vaccine available

  • Practising safe sex

  • Abstain from smoking

The National Department of Health has partnered with CANSA on the training of Traditional Health Practitioners and runs workshops across the country to provide education around cervical and other prevalent cancers (including cervical and HPV awareness), treatment, side effects, the importance of early detection and quick referral for treatment, in the hope that the Traditional Health Practitioners will empower the local community with this information.


Cervical cancer is a prevalent STI with the causative agent being mainly the HPV. The incidence of CC is higher in LMIC. Education drives, accompanied with the provision of free testing, are required to improve the sexual wellbeing of the women. Community health outreach initiatives in collaboration with non-government organizations set in accessible locations could be a possible course of action.


Organisations and Associations

  • Cancer Association of South Africa (CANSA) offers Pap smears at their CANSA Care Centres at affordable rates

  • Toll free: 0800 22 66 22, www.cansa.org.za; WhatsApp: 072 197 9305 (English/Afrikaans)/071 867 3530 (Xhosa/Zulu/Sotho, Siswati)

  • The African Women Awareness of Cancer (AWACAN) public involvement project

  • Cervical Cancer Screening Programme initiated by the SA Department of Health

  • The Gynaecological Cancer Intergroup (GCIG)

  • The World Health Organization (WHO) strategies for cervical cancer prevention and control


References


Cancer Association of South Africa (CANSA). 2022. Cervical Cancer, available at: https://cansa.org.za/cervical-cancer/ accessed: 6 September 2022


Cancer Association of South Africa (CANSA). Eliminate Cervical Cancer Through Early Detection. 2022, August 4. Available at: https://cansa.org.za/eliminate-cervical-cancer-through-early-detection/ accessed: 6 September 2022


Cancer Association of South Africa (CANSA). CANSA Promotes #OneLessWorry HPV Awareness. 2022, February 23. https://cansa.org.za/cansa-promotes-onelessworry-hpv-awareness/ accessed: 6 September 2022


Cervical Cancer. Mayo Foundation for Medical Education and Research (MFMER). 2022. Available at: https://www.mayoclinic.org/diseases-conditions/cervical-cancer/symptoms-causes/syc-20352501 (accessed: 6 September 2022)


Cervical cancer. Mayo Foundation for Medical Education and Research (MFMER). 2022. Available at: https://www.mayoclinic.org/diseases-conditions/cervical-cancer/diagnosis-treatment/drc-20352506 (accessed: 6 September 2022)


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Compiler: Dr. Liesl Brown, BPharm, MSc (Pharm) Cum Laude, PhD



 
 
 

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