By Dominic D. Gadeka
In my practice as a member of the oncology team at the Sweden Ghana Medical Centre and as a Public Health Specialist and a Health Advocate, I have encountered many cancer cases including cervical cancer patients, who come to seek professional help at various stages of the disease. The sad story is that more than 70% of these purposeful women come to know of the disease at the later stage, a stage where cure is not possible but to manage or hope for a miracle. I have witnessed many sell all they had and even went in for loans just to save the life of a loved one, and to help ease the pain even a little bit for an unavoidable passage to the next life. I have seen others become care takers to take care of their sick person, above all, I have seen tears, tears of pain, condemnation and a wish for a second chance, tears that nothing can wipe away. Many of these women age from early 30s to 50s, have their whole life ahead of them, but for this disease. Despite these, there exists no national health promotion, screening nor vaccination programs to reduce the burden of the disease while there exist complex cultural barriers.
Good health is priceless! As put by Arlen Specter: “There’s nothing more important than our good health – that’s our principal capital asset.”It is therefore not surprising that the Goal three (3) of the Sustainable Development Goals (SDGs) categorically is to ensure healthy lives and promote well-being for all at all ages by the 2030. However, to achieve this, there is the need for awareness on health and ill health since awareness influences early health seeking behavior and even among the apparently healthy. The purpose of this article therefore is to create awareness of cervical cancer, its burden in Ghana and how to prevent it.
Introduction Cervical Cancer occurs when the body is not able to control the growth of abnormal cells in the cervix. The cervix is the area between the vagina and the womb (uterus). Cervical cancer normally starts on the surface of the cervix (epithelial cells) and can spread to other parts of the body (metastasize) if not detected and treated early. Cervical cancer is mainly caused by the Human Papilloma virus (HPV). There are more than 100 types of HPV of which at least 13 are cancer causing. The abnormalities caused by HPV in the cells of the cervix may turn malignant and cause death over a period of 5-20 years. Progression of HPV to cancer requires: modifiable & non-modifiable risk factors. HPV also causes cancer of the anus, vaginal, vulva, penis and oropharyngeal (head & neck) and genital warts
Cervical cancer burden in Ghana
In Ghana, Cervical Cancer remains a major burden. According to the GLOBOCAN report, the incidence rate of cervical cancer in Ghana (24.3%) is higher compared to West Africa (17.2%) and the world (15.1%) at large. In Ghana, it is the first leading cause of female cancer deaths although being the second leading cause of female cancer. Every year, more than 3,000 women are diagnosed of cervical cancer and more than 2,000 die from it in Ghana with mortality rate of 67.2%. Compounding this is the younger age at which the disease develops coupled with late-stage of presentation and the increasing rate of the major risk factors. However, it does not only cause death but also psychosocial and physical burdens, decrease / loss of productivity at workplaces, diminish resources within families and burden society and health system.
The death rate of cervical cancer patients (a curable and highly preventable cancer) in Ghana which occurs in just a section of the female population is higher but unattended to as compared to road traffic accident which occurs across the entire Ghanaian population (male, female, adult, children) all inclusive. As a nation, there exists no national screening or vaccination program to reduce the HPV infection and cervical cancer in the Ghanaian women. Compounding this inadequacy is the lack of awareness /knowledge of the risk factors (which are alarming), mode of transmission, symptoms, screening and most importantly the HPV vaccination among these women and the general population.
HPV is transmitted through skin-to-skin contact during sexual activity with an infected person, either through skin-to-skin genital contact or through sexual intercourse. This transmission can occur through oral, vaginal, or anal sex. HPV infected individual is asymptomatic. It can also be gotten through enema (‘bentoa’ ) which is contaminated by the virus or by touching the genital part with HPV contaminated hands.
All women are at the risk of developing cervical cancer. This is dependent on the following risk factors
- If a woman/girl starts having sexual intercourse at an early age (normally before age 17).
- If a woman/ girl has/ had multiple sexual partners (past/ present/future)
- Women whose partners have multiple sexual partners
- Women who had several pregnancies
- Women who gave birth at a very young age (before age 17)
- Long term and indiscrimate use of oral / hormonal contraceptives (5 or more years)
- Women whose partner had sexual contact with a woman with cervical cancer (at the pre-cancer stage when the woman is not aware she has cancer)
- Women who smoke tobacco / shisha
- Women with weak immune system especially as a result of infection – HIV, STIs/STDs, TB, chlamydia and previous gynaecological infections
- Psychological stress
- Women who drink alcohol
- Women with uncircumcised sexual partner
- Women with low socioeconomic status
- Exposure in utero to diethylstilbestrol (DES)- women whose mothers were given DES during pregnancy to prevent miscarriage
- Women who take in diet low in fruits and vegetables
- A family history of cervical cancer where women are genetically less able to fight off the HPV infection.
- Vaginal douching, tampon use, use vagina spray, feminine wash, vaginal tightening methods including the use of salt, kerosene, herbal stuffs, etc
Signs and symptoms
Cervical cancer usually does not show symptoms until it’s in the advanced stages. Women who are fortunate enough experience some symptoms. However most of these symptoms are related to other gynecological issues. This means that a woman should make it a point to see her Gynecologist or General Practitioner (GP) early should in case any of these shows up:
- Irregular vaginal bleeding or bleeding during or after sexual intercourse
- Bleeding after menopause
- Bleeding between periods
- Bleeding after douching.
- Menstrual periods that last longer and are heavier than before
- Back, leg or pelvic pain
- Increased vaginal discharge or odorous discharge
- Pain during sex
- Fatigue, weight loss, loss of appetite; vaginal discomfort and single swollen leg
At the advanced stage, the following may occur: severe anemia, incontinence, renal failure, fistulae and lymphedema.
Cervical cancer prevention/eradication
There are two major ways through which cervical cancer can be prevented/ eradicated: vaccination against the HPV and early detection through regular (3-5 years) screening.
The HPV vaccine which has been approved by the World Health Organization (WHO) and national governments in many countries is proven as an effective public health intervention against cervical cancer. There are two types of the HPV vaccines: Merck’s quadrivalent Gardasil and GlaxoSmithKline’s bivalent Cervarix which can be taken by both girls and boys (9-14years) before first sexual experience. Two shots of the vaccine within space of zero and six months are needed for this category of people. Those above the age of 14 years to 26 years, three shots are recommended (0, 1 and 6 months). However, it is paramount that screening be carried out first before the vaccination.
Routine HPV vaccination comes with several benefits to individuals, societies and the nation as a whole: it prevents HPV infection and cervical cancer, decrease genital warts, establishes herd immunity against HPV and it removes the negative physical and psychosocial impacts. Its cost of effectiveness also ensures considerably huge cost savings in terms of the money spent on diagnosis and treatment.
Likewise cervical cancer screening helps in identifying high-grade, pre-cancerous cervical lesions which can easily be treated and thereby preventing cervical cancer. A research published by Campos and colleagues in 2015 showed that women who screen twice or three times, between ages 30 and 45, can lower their lifetime risk of cervical cancer by 50%.
Screening can be done through the following means:
- Visual Inspection with Acetic acid (VIA).
- Cytology (pap smear).
- Primary screening with mobile colposcopy (EVA system). EVA- Enhanced Visual Assessment
- HPV DNA testing
Most of these screening methods are very fast and affordable. The self-sampling technique allows the women to take their own samples at their convenient time then send to the hospital for analysis without difficulty.
Early Treatment for cervical cancer
The main aim for cervical cancer awareness among women above the vaccination age category, is to help detect the disease at the early stage. Because, at the early stage, treatment is effective, cure rate very high and it is very affordable or cost effective as well. The treatment can take the following forms: Cryotherapy (-60º -90º C), Thermocoagulation (100-120º C) and Loop Electrosurgical Excision Procedure (LEEP) –with cure rates ranging from 80-99%. The rest include: simple hysterectomy and radical hysterectomy depending on the disease stage.
The fact still remains, that cervical cancer when detected late steals a woman’s joy and negatively affects her, her family and loved ones physically, economically, psychologically and socially and eventually causes premature death. Worse-of are the less privileged who are rejected, ignored, forsaken and unloved because of the disease that others have labeled as a ‘curse’ or a punishment from God.