A preventable disease, cervical cancer continues to claim lives
ervical cancer is the third most frequent cancer among women after the breast and oral cavity. Morbidity and mortality rates for cervical cancer are very high in Pakistan as this type of cancer is mostly ignored in terms of screening, prevention and vaccination. More than 70 percent of patients report with very advanced stage of malignancy, and this results in a high mortality rate in our country. The World Health Organisation has predicted that by 2030, almost half a million women will die of cervical cancer. More than 98 percent of these deaths are expected to occur in developing countries such as Pakistan. According to the GLOBOCAN cancer statistics for 2020 released by the International Agency for Research on Cancer, 5,008 Pakistani women were diagnosed with cervical cancer, with mortality being 60 percent. Pakistan has no government healthcare policy regarding screening and preventive measures for cervical cancer. In the absence of structured screening, opportunistic screening occurs mostly in private practice, missing out on most underprivileged women.
There are more than 100 types of human papilloma virus, some of which are associated with genital and anal cancers. HPV Types 16 and 18 cause approximately 70 percent of cervical cancers and 90 percent of all anal cancers.
How can we pick early changes in the cervix?
Cervical screening is not recommended till the age of 21 years. Women aged 21-29 years are advised to undergo cervical screening every three years. It is a fairly simple test called a pap smear where the doctor visualises the cervix using a small instrument in clinic and uses a plastic spatula to take cell scrapings from the cervical wall. It is a pain free procedure. For ages 30-65, it is recommended to get pap smears done every three years or hrHPV DNA testing every five years. Co-testing with both pap smear and hrHPV can be performed every five years too. No test is required after the age of 65 if previous screening tests have been normal.
Those diagnosed with previous precancerous cervical changes, HIV or any other immunocompromised state may require more frequent screening.
Risk factors for developing cervical cancer include multiple sexual partners, early sexual activity, weak immune system and smoking.
Where to go for screening tests?
Family physicians and gynecologists can be consulted for this purpose. The laboratory charges for pap smear are around Rs 500-1,000 in Pakistan.
Preventive measures include safe sex practices, regular screening tests, HPV vaccination and cessation of smoking tobacco. The Centre for Disease Control and the World Health Organisation recommend vaccination for girls and boys before they become sexually active.
How can this disease be prevented?
Preventive measures include safe sex practices, regular screening tests, HPV vaccination and cessation of smoking tobacco. The Centre for Disease Control and World Health Organisation recommend vaccination for girls and boys before they become sexually active. HPV vaccination prevents new HPV infections but does not treat existing HPV infections or diseases, so it is very important to vaccinate children and teens before they become sexually active. It is recommended to get two doses of vaccine 6-12 months apart before the 15th birthday. Three doses of HPV vaccine (0, 1-2 and 6 months) are recommended for those who start the series at ages 15 through 26 years and for immunocompromised persons such as those infected with the HIV.
The vaccine should not be administered in case of a prior severe allergic reaction to a previous dose or in case of severe acute illness. However, it can be safely administered in case of minor illness or diarrhoea.
It should not be administered during pregnancy. If one finds out about pregnancy after getting a dose, there is need not panic. If any dose is due during pregnancy, the patient should wait till the pregnancy is over. Reputed pharmacies in Pakistan have vaccines available; Cervarix and Gardasil. Cervarix protects against HPV 16 and 18. It is administered in the shoulder muscle. It costs around Rs 4,000.
Gardasil has broader coverage. It protects against HPV 6, 11, 16 and 18. It is also administered in the shoulder muscle. It costs around Rs 9,000. Adverse reactions by either vaccine include injection site reactions – redness, swelling, itching and pain, headache and body aches. These effects resolve in a day or two. Sometimes kids faint after getting an injectable shot, so it is better that they keep sitting for a few minutes after receiving the vaccination.
Can the HPV vaccine affect fertility in future, and do males need it?
There is no evidence of any effect on fertility.
HPV vaccination can help prevent future infections that can lead to cancers of the penis, anus, and back of the throat in men. These are the same recommendations as for girls.
The healthcare system in Pakistan is now trying to address the serious issue of cervical cancer as it is entirely preventable if adequate measures are taken timely. Healthcare workers - doctors, nurses and public health teams - need to spread awareness door-to-door through physical meetings, print media, radio, television and social media. Schools and other educational institutions should spread the message far and wide to protect our children and adults from deadly diseases. The United States Congress has designated January as Cervical Health Awareness month. Hence, every year represented by teal blue colour, cervical cancer awareness campaigns get more robust, and fundraising programmes are conducted to educate communities and encourage them to get screened and vaccinated.
The writer is a family medicine consultant [MBBS, FCPS, MRCGP(INT)] at Khatoon Hospital, Block F, Police Foundation, Islamabad