Ranked as one of the leading causes (fourth) for cancer among women in Sri Lanka, the number of those with Cervical Cancer is on an upward spiral despite the awareness raising programs, vaccination and screening programs by the Ministry of Health.
National Cancer Control Program (NCCP) officials have repeatedly said that it is also one of the most preventable cancers, provided those most vulnerable to becoming its victims lead healthy lifestyles, vaccination and get screened regularly.
Human Papilloma Virus (HPV) infection which is transmitted to female as a sexually transmitted infection is the most commonest risk factor leading to Cervical cancer and can be easily avoided with proper precautions, said an Oncologist from the NCCP.
The Sunday Observer spoke to Consultant Community Physician at the National Cancer Control Program (NCCP) of Ministry of Health Dr Suraj Perera to find out more about how the disease originates, how it spreads, and how it can be prevented.
Excerpts
Q: Cervical cancer has been identified as one of the leading causes for cancer among women worldwide. What is the incidence rate among Lankan women?
A: According to the National Cancer Registry Sri Lanka in 2019, 1,114 cervical cancer patients were detected in Sri Lanka. In 2005, 881 new patients with cervical cancers were detected. Over the years, the number of those with cervical cancer detected yearly varies between 732 cases and 1246 cases.
Q: Is this high compared to a decade ago?
A: According to Crude incidence rate (CR) per 100,000 population, over the years, there is a slight increase of the cervical cancer incidence rate. In 2005, the cervical cancer incidence rate was 8.9 per 100,000 people and in 2019, it was 9.9 per 100,000 as shown according to the National Cancer Registry Sri Lanka
Q: What is the most vulnerable age group to get this cancer? Why?
A: According to the National Cancer Registry Sri Lanka when five year age specific rates were calculated for the newly diagnosed cervical cancers in five recent successive years, it has shown that the majority of women with cervical cancers were detected after 45 years of age and the highest number of those with cervical cancers were detected between 65-69 and 70-74 five year age groups.
Q: According to the mortality data published by the Registrar General Department, about 200 deaths occur due to cervical cancer every year. It has been said that the actual number may be higher due to under reporting of such deaths to the registration system. Could most of these deaths be prevented if detected early and treated in time? If so how?
A: Yes. Cervical cancer is preventable. It is treatable and curable if detected at the pre cancer stage or early stages of cancer.
Q: What are the causes that drive this cancer in women?
A: Human Papilloma Virus (HPV) infection is the commonest risk factor leading to the initiation of cancer. HPV is transmitted to women as a sexually transmitted infection.
When HPV is transmitted, the infection is resolved over time. When there are factors such as persistence of other sexually transmitted infections, immmuno suppression, HPV persists in the cervix. When HPV persists, it can progress into initiation of cervical pre cancer. Over the years, this pre-cancer may turn into early stage cervical cancer if not intervened.
Q: Is there a vaccine to prevent this cancer?
A: Yes. HPV vaccine is available.
Q: I understand that the HPV vaccine is being administered to girls at the age of 11 years. What is HPV? How does it affect young girls? Why was it introduced to school girls?
A: Yes. The HPV is given at the age of 10-11 years at the 6th grade of the school. The Human Papilloma Virus vaccine is given to prevent cervical cancer.
Q: Are there side effects? If so, what are they?
A: Minor and transient side effects may be there.
It may be categorised into two types. (i) Minor transient local reaction – redness, swelling, pain at the injection site. (ii) Systemic transient effects – fatigue, headache, myalgia and fever. Major side effects, such as anaphylaxis or anaphylactoid reactions are extremely rare
Q: How successful has this school program been? Do you have a feedback? Are those vaccinated monitored?
A: The school vaccination program was successful. It is coordinated by the Epidemiological Unit of the Ministry of Health nationally. The program is also monitored at the district level and the Medical Officer of Health (MOH) level.
Q: What about older women? I understand that all women over 35 years and 45 years with cervical cancer or pre cancer cells attending Well Women Clinics throughout the island are being given comprehensive screening by way of pap smear and cervical screening tests free. What is the feedback? Are these women now more willing to have these tests than earlier? Are these tests mandatory?
A: Cervical cancer screening is offered at the Well Women Clinics throughout the country coordinated by the Medical Officer of Health in each area. Married women are invited by the public health staff to attend to cervical cancer screening at the age of 35 and 45. The service is free.
Q: Young mothers are admitted to hospitals for delivery or pregnancy related complications. are they also tested for pre-cancerous cells?
A: Not during pregnancy.
Q: Is there a monitoring system to keep track on these women once they return home?
A: The cervical cancer screening program is offered through the Well Women Clinic program of the Ministry of Health. It is coordinated nationally by the Family Health Bureau in collaboration with the National Advisory Committee on Well Women Clinic Program. Screening positive women are monitored through a follow up registry by the staff of the Medical Officer of Health in the area.
Q: What happens if they move to another district?
A: Ideally, the woman needs to be followed up at the new setting too.
Q: Is stage 3b cervical cancer curable? How? What is the survival rate? Any studies on this?
A: Stage 3b cervical cancer is a locally advanced cancer. For those patients, external beam radiation to reduce tumor mass intracavitary application radiotherapy (Brachytherapy) is needed. Survival rates in 3b cancers are relatively low. A study conducted by Dr. Chiranthika Vithana and team revealed that deaths due to cervical cancers is 3.5 times higher among women diagnosed with Stage 3 and 4 cancers compared to those with stage 1 and 2 cancers in the Western Province.
Q: What are the symptoms of advanced stages of cervical cancer?
A: Cervical purulent discharge, vaginal bleeding, difficulty in micturition and defecation.
Q: What happens in the last stages of cervical cancer?
A: In the advanced stage, cervical cancer may spread to adjacent organs including urethra, bladder, rectum and regional lymph nodes.
A: What stage of cervical cancer do you need a hysterectomy? Radical hysterectomy and excision of pelvic lymph nodes for Stage I and II cervical cancer
Q: The World Health Organization (WHO) has declared a ‘Global initiative on elimination of cervical cancer as a public health problem’ and has advised member countries to achieve interim targets by the year 2030. Is this a realistic goal considering the current health issues in the world including Sri Lanka? What is the NCCP doing to achieve this target?
A: Following interim targets need to be achieved in 2030 under the global initiative on elimination of cervical cancer as a public health problem’
1 90 percent of girls fully vaccinated with the human papilloma virus (“HPV”) vaccine by 15 years of age 2 70 percent of women are screened with a high-precision test (Pap smear test /HPV test) at 35 and 45 years of age 3 90 percent of women identified with cervical disease receive treatment and care by 2030 Target 1 is already achieved through ensuring HPV immunisation coverage by the Epidemiological Unit of the Ministry of Health. The cervical cancer screening program is enhanced to achieve 70 percent coverage of cervical cancer screening.
The target 2 and Target 3 need to be monitored through establishing colposcopy units covering the entire country and ensuring good management information system within the colposcopy unit, pathology laboratory, gynaecology unit and cancer treatment centres.
Q: Is there a link between Sexually Transmitted diseases ( STD’s) and Cervical cancer?
A: Human Papiloma Vius (HPV) infection is a sexually transmitted disease. In most women, the HPV infection clears by the immune system.
Q: Are screening tests for Cervical Cancer available at the STD clinics that dot the island?
A: Yes. Pap smear tests are offered at STD clinics.
Q: Tell us the main activities of the NCCP with regard to cancer prevention in general?
A: The National Cancer Control Program (NCCP) is the national focal point of the Ministry of Health for prevention and control of cancers in the country. It is also responsible for policy, advocacy, planning, monitoring and evaluation of prevention and control of cancers including surveillance of cancers and facilitating research related to cancers. The NCCP coordinates activities related to prevention and control of cancers according to the ‘National Policy and Strategic Framework on Cancer Prevention and Control-Sri Lanka’ which was approved in 2015.
Q: Your plans for the future?
A: Yearly all activities are based on the National Strategic Plan on Prevention and Control of Cancers 2020-2024. (www.nccp.health/gov.lk)
Q: Have you a message for our women readers with regard to cervical cancer prevention?
A: Avoid unsafe sexual practices. Avoid smoking. Vaccination at the age of 10-11 years.
All married women and those with sexual exposure need to attend to the cervical cancer screening program through the Well Women Clinic Program organised by the local Medical Officer of Health (MOH). All symptomatic women need to be investigated to detect cervical cancers.