INTRODUCTION:
Cervical
cancer is a preventable genital tract malignancy, with majority of the patients
presenting in the advanced stages in the developing countries of the world due
to poor screening.1-4 However in the developed countries of the
world through organized screening modalities of cervical cancer over 80% of
mortalities are prevented annually.2-4
Cervical cancer is the fourth most common cancer among women worldwide, but in
developing countries like Nigeria, it is second only to breast cancer.2-5
There are estimated 570,000 new cases and 311,000 deaths in 2018..2-6
Approximately
85 to 90% of cervical cancer new cases and deaths occur in low and middle
income countries (LMIC) 3;
whereas, in the high-income countries, cervical cancer has relatively declined
steadily and significantly for several decades. 3,4
This is largely attributable to organized cytology based cervical cancer
screening initiatives and effective cancer treatment services. In many LMICs,
including Nigeria, cervical cancer screening services are either opportunistic,
sporadic, or nonexistent with inadequate treatment services.5,6 As a result, most women living
in LMICs present with advanced-stage invasive cervical cancer, resulting in
high morbidity and mortality.7
Prophylactic
use of human papilloma virus (HPV) vaccine as primary prevention strategy is
also employed in reducing the burden of cervical cancer. Over 90% of cervical
cancer is attributable to several oncogenic HPV serotypes. Broad-spectrum
vaccines such as Gardasil which is quadrivalent
against the virus can potentially prevent cervical cancer by about 84 to 90
percent.8,9
In
most LMICs, HPV vaccine is still inaccessible, and vaccination coverage is less
than 3% compared to over 63% in high income regions.8,9,10 In addition, the only available
HPV vaccine in some countries including Nigeria is bivalent and provides only
partial protection. As a result, even immunized women still have to undergo
screening.11,12
Secondary
prevention strategy consequently remains the key to reducing the cervical
cancer burden in LMICs.13
Across
Nigeria, there were 14,943 new cases and 10,403 deaths in 2018. 13,14 The high disease
incidence and mortality rates are largely
due to nonexistence of organized cervical cancer screening and scarce treatment
services.15 Other contributory factors, however, include: advanced
disease presentation, insufficient awareness and knowledge, literacy, poverty,
and socio-cultural factors. 7,16
AIM/OBJECTIVE:
The
primary objective of secondary prevention of cervical cancer is the accurate
detection and timely treatment of precancerous lesions. Cytology (Pap), visual
inspection with acetic acid/ (VIA/VILLI) and HPV-DNA testing are three
screening strategies for cervical cancer.
The
aim of this analysis is to highlight the poor uptake/acceptability of these
screening methods in LMICs, especially Nigeria.
The
objective of the program is to create awareness about cervical cancer risk
reduction strategies in addition to promoting a positive attitude towards
screening.
METHOD:
This study is a retrospective
analysis of the cervical cytology (Pap Test) reports
of 200 women screened over a period of 11 years (2007-2018). The Community
Cervical Cancer Awareness and Early Detection Programme
carried out by Preventive Health Care Initiative, a nongovernmental
organization in Rivers-state, Nigeria. We looked at Bio-data, including the
cytology reports, of all the women screened for cervical cancer over the period
under review. The method of screening was as described by Dr. George Papanicolaou.17,18 The report was based on the
Bethesda system for reporting cervical cytology. Each of the women screened was
appropriately followed up based on their cytology report and recommendation of
SOGON Nigeria guideline. The information was analyzed by simple
statistical method.
EXCLUSION CRITERIA
Women
who were menstruating or pregnant were excluded from this screening.
RESULTS:
TABLE: PAP SMEAR TEST RESULT
(CYTOLOGY)
|
Total Number of Women Screened
|
200
|
|
Negative for Precancerous Lesions
|
190 (95 percent)
|
|
Positive for Precancerous Lesions
|
10 (5 percent)
HSIL – 1
LSIL – 8
ASCUS – 1
|
|
Inflammatory Smears
|
7
|
200
women aged between 25 and 73 were screened. Majority fell within the reproductive
age group (40 to 49 years). Prior to the program, about 80% of the participants
have never heard of cervical cancer. 98 percent were screened for the first
time. The cytology reports indicated that 190 (95%) were negative for
precancerous lesions. Ten (5%) of the women, however, had precancerous lesions
which included: Low Grade Squamous Intra-epithelial Lesion (LSIL),8 (4%), High Grade Squamous Intra-epithelial Lesion (HSIL)
1 (0.5%), and Atypical Squamous Cells of Undetermined Significance (ASCUS) 1
(0.5%). No case of invasive cervical cancer was found. Other conditions found
include: seven inflammatory smears, with two suggestive of candidiasis and one
atrophic smear.
DISCUSSION:
The study
revealed that the awareness of cervical cancer was 80% of the respondents.
Although this was above average but not good enough when compared to some other
cities in Nigeria. The cervical cancer awareness was higher than 80% in Lagos as shown
in the table in this study. 2-5
However, in some rural areas in Nigeria, the awareness of cervical
cancer was lower than 80% as seen from this study.4-6
Infection
with high-risk HPV e.g. serotype 16 or 18 may cause persistent disease,
precancerous changes such as mild dysplasia (low-grade lesions), or moderate to
severe dysplasia (high grade lesions). The high-grade SIL, nevertheless, has a
greater potential to progress to cancer than the 5 low-grade SIL. Studies
indicate that if left untreated, about 20% of HSIL will progress to invasive
cervical cancer.2-8 However,
for LSIL approximately 57 percent will regress spontaneously, while 32 percent
will have persistent infection, and 16% may progress to HSIL.4-9
Persistent HPV infection takes a latent period of about 10 to 20
years to progress to invasive cervical cancer.10-14,16-18 This allows for the secondary
prevention through screening of asymptomatic women for precancerous lesions.20
Early detection and prompt treatment of identified cases prevents progression.1,16-18
CONCLUSION:
Cervical
cancer are preventable genital tract malignancies, but
remains a serious threat to the health of women globally. Cervical cancer
screening coverage is dismal in our environment even though an organized
screening program can effectively reduce the cervical cancer incidence and
mortality. The current national cervical cancer screening is essentially
opportunistic and sporadic. Significant impact in the secondary prevention of
cervical cancer is achieved only by increasing screening coverage. Majority of
the women diagnosed with invasive cancer in our environment never had the
opportunity to be screened. The functional nationwide cervical cancer screening
program is critical for effective decline in incidence of morbidity and
mortality of cervical cancer.
Other
important factors in ensuring an effective screening program include community
education with emphasis on the benefits of screening. Our experience with the
cervical cancer awareness and early detection program demonstrated the ability
of an educational intervention to reduce barriers and elicit positive cervical
cancer screening behavior. The health talks about cervical cancer risk factors,
symptoms, and screening procedure, often motivated the women to consent to
screening. We were however limited by the high cost of cytology-based tests.
Alternating less-expensive screening methods such as Visual Inspection with
Acetic acid (VIA) or Visual Inspection with Lugol’s
Iodine (VILI) as recommended for low and middle income countries.
RECOMMENDATIONS:
There is need for awareness and enlightenment
for cervical cancer prevention by Government and Nongovernmental organizations
to the general public to prevent mortalities from the disease burden.
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