Cervical Cancer Worldwide

You have entered the Worldwide Cervical Cancer Issues section of the National Cervical Cancer Coalition (NCCC).

In this section you will find information on cervical cancer rates, programs and issues internationally. The Reproductive Health Outlook has provided the listed excellent introductory information on worldwide cervical cancer issues. [Reproduced from the Reproductive Health Outlook (RHO) Website (http://www.rho.org), 2000.]

 

Cervical cancer is an important women’s health problem in developing countries, killing some 200,000 women each year. It is the third most common cancer overall and the leading cause of death from cancer among women in developing countries. At least 370,000 new cases are identified each year; 80 percent are in developing countries. Rates are highest in Central America and sub-Saharan Africa. An important reason for the sharply higher cervical cancer incidence in developing countries is the lack of effective screening programs aimed at detecting pre-cancerous conditions (dysplasia) and treating them before they progress to invasive cancer.

 

It has been estimated that only about 5 percent of women in developing countries have been screened for cervical dysplasia in the past 5 years compared with some 40 to 50 percent of women in developed countries.

 

The vast majority of cases are caused by human papilloma virus (HPV), a sexually transmitted agent that infects the cells of the cervix and slowly causes cellular changes (dysplasia) that can result in cancer. These changes can be relatively mild ones which often do not progress, or regress. Larger, deeper lesions (severe dysplasia) are more likely to progress to cancer. Women generally are infected with HPV in their teens, 20s, or 30s, although the disease can take up to 20 years after HPV infection to develop. Cervical cancer starts with an in situ stage that can be treated, but then progresses to invasive disease which, where surgery and radiation therapy are unavailable, is always fatal.

 

The Traditional Approach to Prevention

 

Cervical cancer prevention efforts worldwide have focused on screening women at risk of the disease using Pap smears and treating precancerous lesions. Where screening quality and coverage have been high, these efforts have reduced invasive cervical cancer by as much as 90 percent. Most developing counties, however, have been unable to implement comprehensive Pap smear screening-based programs. In countries where Pap smear screening is available, it often is accessible only to a relatively small proportion of women attending private sector providers, or, is offered primarily to young women through maternal/child health or family planning clinics where the population that is screened is not generally at high risk. These approaches have had little effect on morbidity and mortality and are not as cost-effective as centrally organized screening programs implemented by the public sector ( Fahs et al. 1996 ).

 

Emerging Strategies

 

Some countries have re-designed their cervical cancer screening programs to be more successful and effective. Strategies have been developed to limit screening to women at highest risk of high-grade dysplasia, to reduce the frequency of screening among women who have had at least one normal smear, and to recommend regular follow-up rather than treatment for young women with mildly abnormal smears. Modified screening and treatment strategies, an increased emphasis on improving the accuracy of the tests, planning for follow-up of clients, and evaluation of the program are key to program success.

 

A recent regional workshop on the prevention and control of cervical cancer in East and Southern Africa discussed these issues and developed local plans of action. (Full text of the meeting report is available online.) Several alternative approaches to cervical cancer screening also have been proposed and are being evaluated in research studies. These include: visual screening (both magnified and unmagnified visual screening) to identify cervical lesions without reliance on cytology; human papilloma virus tests that may be able to identify women at high risk for cervical cancer, and automated Pap screening machines to identify subsets of Pap smears that should be examined by cytologists. These approaches are being evaluated for clinical effectiveness, acceptability to clients and providers, and cost-effectiveness.

 

Lessons Learned

 

In order to reduce cervical cancer morbidity and mortality, experience shows that programs need to plan to achieve the following minimum program goals:

 

Increase awareness of cervical cancer and preventive health seeking behavior among high risk women (30 to 50 is a reasonable target age group for a new cervical cancer control program with limited resources).

 

Screen all women aged 30 to 50 at least once before expanding services to other age groups or decreasing the interval between screening.

 

Treat women with high-grade dysplasia, refer those with invasive disease where possible, and provide palliative care for women with advanced cancer.

 

Collect service delivery statistics that will facilitate ongoing monitoring and evaluation of program activities and outputs.

 

Other lessons learned include:

 

It is crucial to ensure strong management and support for program strategies at all levels of the health care system;

 

Gaining management policy support can be made easier by clearly demonstrating the need and demand for a cervical cancer control program;

 

Analyses of the estimated costs and impact of suggested program approaches are important; potential providers and clients should be involved in program design to ensure that their perspectives are considered and their needs are met;

 

Bottlenecks to program functioning (for example, logistic barriers) should be identified and addressed at the start; train providers to improve sensitivity to client concerns and needs.

CERVICAL CANCER: PROMISING APPROACHES

Human Resources Development and Operations Policy

 

Number 46 - March 27, 1995

 

In the developing world, more women die from cervical cancer than any other cancer. Worldwide, there are at least 350,000 new cases of cervical cancer per year, of which 80 percent occur in developing countries. As the incidence of HIV infection increases (women with HIV-induced immune-suppression are at high risk of developing cervical cancer), and as developing country populations age during the coming decades, the number of cervical cancer cases can be expected to increase.

CERVICAL CANCER SCREENING PROGRAMS

Because cervical cancer generally develops slowly and has a readily detectable and treatable precursor condition (severe dysplasia/carcinoma in situ [CIS]), it can be prevented through screening and treating women at risk. In many Western countries, invasive cervical cancer incidence and mortality has been reduced by as much as 90 percent through screening programs based on routine cytological examination of Papanicolaou (Pap) smears and treatment of precancerous conditions.

 

It has been argued that cervical cancer screening services are not feasible in developing countries because cytology treatment and services are largely unavailable. Furthermore, many have assumed that the cost of implementing an effective program would be prohibitive.

FEASIBLE APPROACHES FOR LOW-RESOURCE SETTINGS

Such concerns are often based on the assumption that successful screening programs must follow a Western model of regular screening of all sexually active women with aggressive follow-up and treatment of women with moderate and even mild dysplasia as well as severe dysplasia/CIS. In fact, a large proportion of cervical cancers can be prevented through a much more limited approach. Key elements of a more limited, feasible, and cost-effective approach include:

 

Targeting older women (age 35 and older).

 

Screening all at-risk women relatively infrequently (for instance, every 10 years) or even once in a lifetime.

 

Treating only women with severe dysplasia, based on the recognition that most mild dysplasia does not progress to more severe disease.

 

Using relatively inexpensive outpatient treatment techniques to eradicate cervical lesions.

 

The cost-effectiveness of screening programs will be highest in regions with the highest incidence of cervical cancer, in programs targeting especially high-risk groups (women over 35 who have never had a Pap smear), and where cervical screening services are integrated with programs that have ready access to sexually active women in their thirties (for instance, surgical sterilization programs, maternal-child health clinics, and perhaps STD clinics).

 

Through the Special Grants Program, the Population, Health and Nutrition Department is currently funding research on feasible cervical cancer dysplasia treatment approaches for developing countries. The study includes an inventory of current treatment practices, an assessment of training requirements and service delivery logistics, and analysis of the cost-effectiveness of various approaches.

SCREENING APPROACHES AND TREATMENT OPTIONS

In some settings, implementation of even limited cytology screening programs (based on Pap smears) present formidable challenges in terms of laboratory facilities, trained personnel and client follow-up, among other factors.

 

Alternative approaches that reduce the need for extensive cytology services would make cervical cancer screening and treatment much more feasible.

 

Promising approaches include the following:

 

Visual inspection Preliminary results of recent studies have shown that two-thirds of women with early cancer could be identified using a speculum and light source to observe the cervix. A disadvantage to this approach, however, is that it most easily detects invasive cervical cancer, which is costly and difficult (or impossible) to treat.

 

Aided visual inspection (AVI) Use of a simple magnifying lens to view cervices treated with acetic acid solution to highlight abnormal tissue, alone or in conjunction with back-up cytology, may provide an easier, less costly way to identify high-grade dysplasia/CIS and make simple treatment decisions.

 

HPV Screening Accumulated data from several decades of work strongly support the view that the primary causal agent of cervical cancer is genital infection with human papillomavirus (HPV). Many of the commonly accepted risk factors for cervical cancer, including history of sexually transmitted diseases (STDs) and history of multiple sex partners (or a partner with multiple sexual partners), are probably indicators of HPV infection.

 

Cytology and diagnostic services could be focused on women positive for the HPV types strongly associated with cancer development. Although an inexpensive, accurate HPV test appropriate for low-resource settings is not yet available, research on various tests is ongoing and HPV screening could become a viable option within the next several years.

 

These or other screening approaches, however, will be of value only if women who are found to have cancer have access to treatment. Of the treatment options available, cryotherapy and loop excision will be of particular interest for use in low-resource settings due to their relatively low cost and simplicity. With cryotherapy, abnormal cells are destroyed by freezing the affected area, most commonly with liquid nitrogen or carbon dioxide. Loop excision involves removing the diseased tissue with a sustained electrical spark.

RECOMMENDED APPROACHES

Policy makers need to be aware of the problem of cervical cancer in their countries and about how feasible, public health-oriented approaches to prevention can reduce incidence and mortality. In general:

 

In low-income countries where resources are extremely limited, efforts to improve family planning, maternity care, and STD management will likely have higher priority. As those basic services become stronger, research and pilot projects can be initiated to test feasible cervical cancer screening and treatment approaches.

 

In lower-middle-income countries, efforts should focus on establishment of limited screening/treatment programs that reach women at least once between the ages of 35 and 40.

 

In middle/upper-middle-income countries, programs should aim to expand available screening and treatment services, with the ultimate goal of screening all women aged 30 and over every 3-5 years.

 

Prepared by Anne Tinker, based on "Cervical Cancer in Developing Countries: A Situation Analysis."

Community Community 2nd Annual NCCC Conference Visit our store iGive.com Register with iGive.com and help support our goals NCCC on Facebook NCCC on Myspace