“These findings bring into sharp focus the need to implement the tools already available for cervical cancer, notably HPV vaccination combined with well-organized national programmes for screening and treatment”. – Dr Christopher Wild, Director of International Agency for Research on Cancer (IARC)
January is cervical cancer awareness month. Cervical cancer, or cancer of the cervix, is cancer of the neck of the womb. The baby grows in the body of the womb (the upper part). The cervix connects the body of the womb to the vagina (birth canal). In other words, the cervix is the door of life. Sadly, when cervical cancer occurs, this door of life becomes the door to death. Cervical cancer is the easiest of all cancers to prevent; yet it is the second most common cancer killer in Nigerian women.
This high mortality is partly due to some misunderstandings and false believes surrounding the disease. To mark this year’s Cervical Cancer Awareness Month, this article would attempt to demystify cervical cancer with focus on 20 common myths.
MYTH 1: We do not know the cause of cervical cancer. TRUTH: Infection with the Human Papillomavirus (HPV), is an absolute requirement for cervical cancer to develop. HPV is the root cause of more than 5% of cancers, including cervical cancer and cancers at other sites such as vagina, vulva (the outer part of the female genital organs), penis, scrotum, perineum, anus, head/neck, mouth, throat, nose, tonsil, skin, nail-bed, and conjunctiva (eye). There are over 150 types of HPV but the 4 that cause most of the diseases are Types 6, 11, 16 and 18. HPV is the most common sexually transmitted infection (STI) in the world, with the highest prevalence in sub-Saharan Africa.
MYTH 2: I am not promiscuous, so I can’t have cervical cancer. TRUTH: Although HPV can be spread during sex − including vaginal intercourse, anal intercourse, and oral sex − sex doesn’t have to occur for the infection to spread. All that is needed to pass HPV from one person to another is skin-to-skin contact with an area of the body infected with HPV. Therefore, even never having sex doesn’t guarantee that one cannot get infected. Recently, a woman presented at the National Cancer Prevention Programme (NCPP) with complaint of post-coital bleeding (bleeding after sexual intercourse). She was investigated and confirmed to have cervical cancer. The news was received by her with utter disbelief, because she has had only one sexual partner – her husband. This story buttresses the point that having only one partner does not preclude one from being infected with HPV. However, it is important to note that women who get sexually exposed at an early age and those with multiple sexual partners have higher risk of developing the disease.
MYTH 3: Cervical cancer cannot be prevented. TRUTH: Cervical cancer is virtually 100% preventable, through screening and vaccination. Vaccines are now available to protect against HPV infection. Preventing HPV infection dramatically reduces a woman’s risk of cervical cancer. In addition, cervical cancer usually develops slowly after persistent infection with HPV and will first appear as a precancerous condition called dysplasia or cervical intraepithelial neoplasia (CIN). It usually takes several years for cervical pre-cancer to change to cervical cancer, but it can happen in less than a year. Cervical Screening detects these precancerous conditions which could be effectively treated to prevent cervical cancer from developing.
Other protective measures include sexual discipline, non-smoking, balanced diet, and optimal feminine hygiene. Each of these behaviours relate to known risk factors for this disease.
MYTH 4: I don’t have intercourse, so I don’t need the HPV vaccine. TRUTH: to get the most out of the HPV vaccine, it needs to be taken before any type of sexual contact with another person and therefore, exposure to HPV. The recommended age-range for routine immunization against HPV is 9 years to 26 years. However, studies have shown that Gardasil also protects women between 27 years and 45 years.
MYTH 5: Cervical Cancer prevention does not concern men. TRUTH: As noted earlier, the disease is caused by infection with the sexually transmitted HPV. This implies that men are involved with its transmission. Besides, every woman that is affected by cervical cancer is a man’s wife, sister, aunt, daughter or niece. Therefore men should encourage and support their female relatives to take advantage of the available preventive measures.
MYTH 6: HPV vaccine is meant for females alone. TRUTH: There are three types of HPV vaccines – a bivalent vaccine (Cervarix), a quadrivalent vaccine (Gardasil) and a 9-valent vaccine (Gardasil 9). The bivalent vaccine protects against only 2 types of HPV (16 and 18) and is recommended for females alone for prevention of cervical cancer. The quadrivalent vaccine protects against 4 types of HPV (6, 11, 16 and 18). Gardasil 9 protects against the same 4 types of HPV as the quadrivalent vaccine, plus 5 other high risk types: 31, 33, 45, 52 and 58. The Gardasils thus prevent most cases of cervical cancer, and other cancers caused by HPV infection, including a proportion of genital, anal, oral and throat cancers. The Gardasils also prevent genital warts and Recurrent Respiratory Papillomatosis (RRP). The Gardasils are approved for both males and females. Vaccinating boys against HPV might also help protect girls from the virus by decreasing transmission. The vaccines are usually given in three doses over six months. The US Centre for Disease Control (CDC) recommends that people should get the same vaccine brand for all three doses i.e. Cervarix and Gardasil should not be used interchangeably.
MYTH 7: I use condoms during sex, so I don’t need HPV vaccine. TRUTH: The use of condom does not give full protection against HPV, since it could be transmitted through skin – skin contact. A person can get infected with HPV even with the correct use of condom. Condoms are more effective in protecting against other STIs like HIV/AIDS.
MYTH 8, I have had HPV vaccine, I do not need to get screened for cervical cancer. TRUTH: HPV vaccine does not protect against all the types of HPV that can cause cervical cancer, so it’s still important to continue regular screenings. According to the American Cancer Society, the most important thing you can do to prevent cervical cancer is to be screened.
MYTH 9: Family planning increases cervical cancer risk. TRUTH: The Intrauterine Device (IUD or coil) reduces the risk of cervical cancer. Conversely, Oral contraceptive pill can increase the risk of cervical cancer. The hormones in oral contraceptives may change the susceptibility of cervical cells to HPV infection, affect their ability to clear the infection, or make it easier for HPV infection to cause changes that progress to cervical cancer. However, cervical screening can detect cervical changes before they develop into full-blown cancers. And in women who have had HPV vaccination, the vaccine reduces the risk of developing cervical cancer by helping prevent infection by HPV.
MYTH 10: I don’t have symptoms of cervical cancer, so I don’t need cervical cancer screening. TRUTH: Cancer screening means testing for cancer before symptoms develop. Moreover, cervical cancer is usually asymptomatic in the early stage, hence it is known as the silent killer. Therefore, the fact that a woman is asymptomatic is not an excuse for not carrying out screening.
MYTH 11, I’m too young to worry about cervical cancer and its screening. TRUTH: Cervical cancer kills more 24-35years old women in developing countries than any other cancer in any other part of the world. HPV infection and the precancerous condition are common in younger women. In Nigeria, therefore, a woman’s first cervical screening should be done when she turns 18 or three years after she begins having sex, whichever comes first. We have seen teenagers with cervical cancer in Nigeria.
MYTH 12, I’m too old to need a cervical screening any longer. TRUTH: There is an increase in cancer incidence including cervical cancer in older populations.
MYTH 13, I can’t go for screening because if cancer is diagnosed, I can’t deal with it. TRUTH: Cervical screening can pick up the precancerous stages of cervical cancer which could be effectively treated with cryosurgery, a 15 minutes procedure. Screening can also pick up the early stages of cancer, which is also curable.
MYTH 14, I have been screened for cervical cancer, I don’t need to repeat the screening. TRUTH, in our environment, Cervical Cancer Screening should be repeated yearly. Although, some western countries no longer routinely carry out yearly screening, they used to, until they recorded significant decrease in cervical cancer death rate. The new guideline by the American Cancer Society is that women should have cervical cancer screening every 3 years. However, they recommended that women who are at high risk for cervical cancer may need to be screened more often.
Women in developing countries like ours, should be regarded as high risk since sub-Saharan Africa has the highest prevalence of HPV, and 26% of women in Nigeria are positive for the virus. Furthermore, low socioeconomic status has proven to be a significant risk factor for invasive cervical cancer. Besides, with longer intervals between screenings, there is the risk of women forgetting and missing their screening.
A case that illustrates the importance of yearly screening in our environment is that of a young lady in her thirties, who had been complying with her yearly cervical cancer screening at the NCPP centre since 2008. Her screening results were normal until 2013, when she had an abnormal screening result. Cervical biopsy revealed that she had the precancerous cervical changes. She was subsequently treated with cryosurgery. All her follow-up test have been normal since then.
MYTH 15: My cervical screening was abnormal, which means I must have cancer. TRUTH: This is not necessarily so. There is need for follow-up tests, including colposcopy and a biopsy to test for cancerous cells. An abnormal screening could indicate a precancerous condition that can be treated. Conversely, a negative screening does not always mean a woman is cancer-free. About 10 percent of all cervical screening return a false negative result, meaning the test did not identify a problem that is there. If there are problems such as bleeding or pain, further evaluation is necessary even if the screening was normal. This small chance of having a false negative result, also buttresses the importance of yearly screening in our environment.
MYTH 16: My cervical screening was abnormal; Vaccination can treat the problem. TRUTH: HPV vaccination helps to prevent pre-cancers and cancers of the cervix but does not treat HPV infection or the abnormal changes.
MYTH 17: Cervical cancer has no symptoms. TRUTH: While cervical cancer may show no symptoms at the early stage. Symptoms will occur later. These include bleeding after intercourse, bleeding between menstrual periods or bleeding after menopause. Other symptoms include an abnormal discharge or pain in the pelvic region. In 2012, a medical doctor presented at the NCPP centre with complaint of persistent vaginal discharge for which she had to be using panty liners. The discharge had persisted in spite of treatment with several medications. On evaluation, it turned out that she had cervical cancer. The lesson: not all vaginal discharge is “toilet infection”.
MYTH 18: If I am diagnosed with cervical cancer, I am going to die. TRUTH: Survival after cervical cancer caught in its earliest stage is 92 percent. The later it is diagnosed, the lower the chance of survival. Survival is lower in developing countries because of inadequate screening. Regular screening will help ensure cervical cancer is caught at an early, treatable stage.
MYTH 19: After I finish treatment, I will live the rest of my life worried about cancer returning. TRUTH: In most cases early cervical cancer never returns, once it is properly treated. However, if cervical cancer is going to recur, it is most likely to happen in the first two years after treatment. The risk of recurrence is extremely low after five years following treatment. However, it is important to continue regular screening.
MYTH 20: I must have a hysterectomy (surgery that removes the cervix and womb) to treat cervical cancer. TRUTH: It is true that early cervical cancer is typically treated with a hysterectomy. However, it is not the only option. Radiation and chemotherapy are used to treat more advanced disease and may also be options for women with early stage disease who cannot have surgery. Some women with early cervical cancer can also avoid hysterectomy with procedures such as a cone biopsy that removes only the cancerous tissue and a small margin of surrounding healthy tissue, or a procedure called radical trachelectomy, which removes the cervix but not the uterus.
More importantly, all of these expensive and traumatic procedures can be avoided by regular screening to pick up the precancerous stage which could be treated with cryosurgery.
Unfortunately, even if our women are aware of all these truths, most of them cannot take action because of the lack of adequate facilities for screening, diagnosis & follow-up in Nigeria, particularly in the rural areas. Obviously, there is an urgent need for a well-organized national system of cancer prevention that is accessible to all Nigerians.
To address this need, the National Cancer Prevention Programme (NCPP), a non-governmental initiative, pioneered community-based mass cervical cancer screening campaign in Nigeria, in 2007. Since then; over 100,000 Nigerians have been directly screened, vaccinated and treated so far, and through the awareness created, the NCPP is helping to protect millions of Nigerians from cancer.
This sacrificial effort has contributed to a 15% reduction of cervical cancer deaths in Nigeria from 26 women dying daily to 22 daily between 2008 and 2012 (World Health Organization data). The significance of this modest improvement is underlined by the fact that W.H.O. had projected a 25% increase in cervical cancer deaths within ten years, in the absence of widespread intervention.
However, we can do much better than that! The improvement in cervical cancer survivorship in Nigeria is proof positive that we can beat Cancer, if we could scale up the effort.
The BIG WAR Against Cancer is the current focus of Committee Encouraging Corporate Philanthropy (CECP-Nigeria). It is designed to establish the infrastructure for efficient and effective cancer prevention and treatment in the country. The short-term goal of the BIG WAR is to acquire and deploy 37 Mobile Cancer Centres (MCC), one for each state and FCT, Abuja; these will take cancer prevention and early treatment to the grassroots, by energizing the impact of NCPP. As a longer-term goal, the CECP is committed to spearheading the establishment of one Comprehensive Cancer Centre in each of Nigeria’s geopolitical zones.
According to the USA Network of Mobile Clinics, “The mobile clinic sector is an untapped resource for helping the nation reduce health disparities while improving care and saving healthcare costs.” A study by the Harvard Medical School found that for every dollar invested in the operation of the mobile clinic, $20 was saved in terms of management of chronic illnesses, avoided hospital visits, and prevention of diseases.
A single MCC in a state of Nigeria could make a huge positive difference. That state would be divided into smaller units such that every community would be reached by the MCC at least once a year.
We cannot achieve this unless we ACT! (Attack Cancer Together!). Fortunately, two Nigerian philanthropists have already pledged to donate the first Mobile Cancer Centre. This is a clarion call for all Nigerians of goodwill to support this movement and prevent unnecessary cancer deaths of our beloved compatriots. Together, we can! Yes, I can!
This article was published in BusinessDay Newspaper of Friday January 22, 2016, Guardian Newspaper of Thursday, January 28, 2016 and ThisDay Newspaper of Thursday, January 28, 2016
© 2016 Committee Encouraging Corporate Philanthropy (CECP- Nigeria)