ACCORDING to the GLOBOCAN cancer statistics for 2020 released by the International Agency for Research on Cancer, 5,008 Pakistani women were diagnosed with cervical cancer, while 3,197 succumbed to the disease, making the death rate for cervical cancer in the country a staggering 60 per cent. Of the new cancer cases diagnosed each year, cervical cancer is the third most common cancer in women in Pakistan.
In developed countries, thanks to the introduction of effective screening and vaccination programmes during the last three decades, cervical cancer has become largely preventable. However, to date, low- and middle-income countries (LMIC) account for more than 80pc of the cervical cancer burden. This occurrence can be attributed to a lack of awareness, poverty, inadequate infrastructure, and disenfranchisement of women. While cervical cancer has garnered significant attention within the medical sphere, efforts need to be expanded to raise awareness about this disease among the general public.
Human papillomavirus is considered the most important risk factor for cervical cancer. It is a commonly occurring infection in sexually active women of reproductive age. Most individuals will have a transient infection and remain oblivious to it since it does not cause any symptoms. However, persistent HPV infections can progress to precancerous and/or cancerous changes within the cervix.
Cervical cancer is not only a preventable disease but also a highly curable one if caught in the premalignant or early stages with the help of regular screening. Screening consists of a relatively simple office-based test called a Papanicolaou (Pap) smear test in which cells from the cervix are scraped and examined under a microscope. Regular screening through Pap smears and HPV tests every three to five years can adequately aid in the identification of any precancers. Once such changes are detected, successful treatment can be carried out, alongside the preservation of fertility if required.
January is Cervical Cancer Awareness Month. But Pakistan does not have a national guideline for cervical cancer screening.
As per World Health Organisation, American and European guidelines, Pap smear tests and HPV tests remain the most common screening tools for the detection of cervical cancer. Unfortunately, Pakistan does not have a national guideline for cervical cancer screening though Pap smear tests are available throughout the country; the HPV test, albeit less common, can be done at specific laboratories.
A population-based screening programme using Pap smear tests, with or without HPV tests, would be ideal. However, multiple factors make this unfeasible: it is expensive, dependent on trained healthcare personnel, requires the transport of samples to centralised labs, and needs follow-up, which is a challenge in resource-limited settings such as Pakistan.
In addition to financial constraints, several barriers prevent the uptake of cervical cancer screening in Pakistan. First and foremost, the discussion of sexual health is considered a social taboo; hence, topics concerning sexual and reproductive health are often neglected. Women may not opt for screening due to fear of discomfort associated with the procedure, and the likelihood of being examined by a male doctor. Furthermore, rampant health illiteracy leads to a poor understanding of the disease and the significance of screening resulting in a lack of perceived necessity. Various superstitions/ myths in our society have also contributed to a negative perception of cervical cancer screening. Lastly, since most Pakistani women are socially and economically disadvantaged, they may pay less heed to their health and/ or be unable to access preventative care.
Global cancer incidence is expected to rise by 75pc over the next 20 years. LMICs are expected to account for greater than 95pc of deaths due to cervical cancer by 2030. The gap in cervical cancer incidence and mortality between developed nations and LMICs is driven by persistent financial, infra-structural and educational limitations. There is an urgent need for countries such as Pakistan to implement screening and vaccination programmes for cervical cancer prevention. To ensure the success of these programmes, misconceptions about sexual health and cervical cancer screening need to be addressed simultaneously. This can be achieved through community mobilisation, health education and counselling. An organised, informed and culturally sensitive approach towards cervical cancer prevention is essential if we want to curb the rising disease burden in Pakistan.
Dr Uzma Chishti, the main author of this article, is an assistant professor in the Department of Obstetrics and Gynaecology at the Aga Khan University, Karachi. Dr Afshan Manji, the co-author, is a research associate in the Department of Medicine at Aga Khan University, Karachi. Maheen Zakaria, the second co-author, is a medical student at the Aga Khan University, Karachi.
Published in Dawn, January 18th, 2022