According to Uganda national cancer registry, cervical cancer kills about 2,275 women annually and 3,915 new cases are diagnosed every year, especially in women aged 15 to 44.
By comparison, 1,100 women die of breast cancer every year, according to the Uganda Women’s Health Initiative (UWHI). Cervical cancer occurs when abnormal cells on the cervix (lower part of the uterus which opens into the vagina) grow out of control. It is caused by the sexually-transmitted human papillomavirus (HPV).
Specifically, about five types of HPV (16, 18, 31, 32 and 45) among about 100 known strains have been linked to cervical cancer. Estimates by the World Health Organisation (WHO) suggest that types 16 and 18 account for 70 per cent of all cervical cancers in Africa.
“Cancer of the cervix was traditionally a disease for older women, above 40 years, but nowadays, younger women are being diagnosed with the disease because of early sexual debut,” Dr Judith Ajeani, consultant obstetrician and gynecologist, says, adding that the cancer is also common among women who have multiple sexual partners.
The national trends seem to reflect the global milieu. According to WHO, there are an estimated 530,000 new cases of the disease each year, leading to at least 270,000 deaths, most of them in developing countries. Of the 20 countries with the highest incidence worldwide, 16 are African, including Uganda.
Despite this confrontational situation, many girls and women in Uganda go without routine cervical cancer screenings because of lack of a national screening program.
“More than three quarters of patients report with advanced stage cancer, which takes more than six months to treat. The survival rate in the advanced stages is usually about 40 per cent. If detected at a pre-cancerous stage (when the cells are not normal but not yet cancerous), this cancer is 100 per cent curable,” Dr Ajeani says.
RISK FACTORS & SYMPTOMS
Early onset of sexual activity predisposes girls to cervical cancer. Other known risk factors for the disease include persistent HPV infection, family history of cervical cancer, having multiple sexual partners and HIV/Aids infection.
According to the International Agency for Research in Cancer (IARC), cigarette smoking, long-term use of hormonal contraceptives and co-infection with other sexually transmitted infections such as genital chlamydia trachomatis, HIV and the herpes simplex virus contribute to development of cervical cancer after infection with HPV.
Dr Ajeani says there are no initial symptoms and signs of cervical cancer in its early stages. However, during the later stages (stage 3 to 4), abnormal vaginal bleeding between regular menstrual periods, pain in the pelvic area and pain during sex are noticeable.
DIAGNOSIS & TREATMENT
Ajeani notes that it may take up to 15 years for precancerous cells to transform into cancerous cells. In order for one to detect these precancerous cells, one needs to do a pap smear.
“During a pap smear, the doctor scrapes a small sample of cells from the opening of the cervix and examines them under a microscope to look for cell changes.
If a pap test shows abnormal cell changes, your doctor may do other tests to look for pre-cancerous or cancer cells on your cervix,” she explained.
One may also do a visual inspection with acetic acid (VIA) where a health care provider applies acetic vinegar such as apple cider vinegar to the cervix and indentifies areas that change colour. Normal cervical tissue remains unaffected while pre-cancerous or cancerous tissue turns white.
“After diagnosis, depending on how much the cancer has grown, one may have one or more treatments. The commonest types of treatments for cervical cancer in Uganda are radiation and chemotherapy.
CHALLENGES & PREVENTION
Despite increasing cervical cancer cases, Uganda is still playing catch-up in the critical areas of awareness, diagnosis and treatment of the disease. According to Dr Ajeani, many women in Uganda still go without routine screening because of lack of awareness of the disease. Additionally, there is only one radiotherapy machine for the whole country, located at Mulago hospital.
“The work load on it is heavy and sometimes patients have to wait up to about three weeks to receive treatment. Meanwhile, we admit about two patients on the ward everyday and it takes about six months for the older ones to leave,” Ajeani says, adding that the national referral hospital does not have a linear accelerator, which is used for external beam radiation treatments.
Prevention of HPV is two-fold: primary and secondary prevention. Primary prevention can be achieved through behavioral change such as abstinence and using a condom when having sexual intercourse. It can also be achieved through biological mechanisms such as HPV vaccination.
“Vaccination against HPV has been proven to prevent the types of HPV that cause the majority of cervical cancer cases. We have an important responsibility to improve access to vaccines worldwide, as they are still beyond reach for low-income countries,” Farouk Shamas Jiwa, the director public policy, MSD, told The Observer.
To strengthen the vaccination move, Dr Robert Mayanja, the program manager, Uganda National Expanded Programme on Immunization (UNEPI), says vaccination of all primary-school-going girls against cervical cancer is set to begin in August this year.
Under secondary prevention are measures such as regular screening and early treatment. Currently, screening services can be found at Mulago, Mbale, Mbarara, Masaka, Ibanda, Soroti, Gulu and Kisoro hospitals. It is also available at Nakasongola Health Centre IV.
However, screening services are still lacking, contributing to low screening rates and unequal distribution of services in the country.