FoodForThought:FebruaryCervicalCancerintheDevelopingWorld

InthisissueofFoodforThought:

♀ MonthlyTheme♀ MillenniumDevelopmentGoals♀ DiscussionQues;ons♀ Voices:InHerOwnWords

“Althoughitispreventableandtreatable,cervicalcancercon<nuestobeamajorkillerofwomen.Causedbysexually‐acquiredinfec<onwithhumanpapillomavirus(HPV),cervicalcancerclaimsthelivesofmorethan270,000womeneveryyear,mostofwhom(85percent)liveindevelopingcountries.”‐‐UnitedNa*onsPopula*onFund(UNPF)

“Canceriskillingus.PainiskillingmebecauseforseveraldaysIhavebeenunabletofindinjectablemorphineinanyplace.Please,Mr.SecretaryofHealth,donotmakeussufferanymore.”‐‐AclassifiedadplacedinElPaísnewspaperinCali,Colombia,onSeptember12,2008,bythemotherofawomanwithcervicalcancer.

“Thetragedyis,thisistheisthemostpreventablecancerintheworld.”‐‐Preven;onInterna;onal:NoCervicalCancer(PINCC)

MonthlyTheme:CervicalCancerintheDevelopingWorldReproductivehealthproblemsremaintheleadingcauseofillhealthanddeathforwomenofchildbearingageworldwide.Cancerofthecervix,onereproductivehealthproblem,isthesecondmostcommoncauseofcancer‐relateddeathinwomenworldwide,andinsomelowresource

countriesaccountsforthehighestcancermortalityinwomen.

Pre‐cervicalcancer(cervicalintraepithelialneoplasia)ischaracterizedbytheappearanceofabnormalcellsonthesurfaceofthecervix.Typically,mostcasesarerelativelystableandcanbeeliminatedbythebody’simmunesystem.However,asmallpercentageofcasesdevelopintocervicalcancer.

PhotoatleftcourtesyofPINCC

UnitedNa<onsMillenniumDevelopmentGoalsTheMillenniumDevelopmentGoals(MDGs)areeightobjectivesdesignedbytheUNtoimprovesocialandeconomicconditionsindevelopingcountriesbytheendof2015.EachmonthwefocusontheMDGsimpactedbyourthemeandourmonthlyfeaturedproject.

Atthe2005WorldSummit,worldleadersaddeduniversalaccesstoreproductivehealthasatargetinMillenniumDevelopmentGoalsframework.Thisincludescervicalcancerpreventionandtreatment.

ThismonthwehighlighttwoMDGs:

Goal6:CombatHIV/AIDS,MalariaandOtherDiseases“PreviousresearchhasshownthatHIV‐positivewomenarearoundfourtimesmorelikelytodevelopgenitallesionsandcervicalcancer,with20percentto60percentofHIV‐positivewomenshowingsignsofpre‐cervicalcancer.“(TheAIDSBeacon,www.aidsbeacon.com).

Goal5:ImproveMaternalHealthTheUNrecognizesthatmostmaternaldeathscouldbeavoided.Povertyandalackofeducationleadtohighadolescentbirthrisks,anduseofcontraceptionislowestamongthepoorestwomenandthosewithnoeducation.Amongwomenofreproductiveage,themortalityburdenduetocervicalcancerindevelopingcountriesis3.6timesashighasintheUnitedStates.(CervicalCancerAction,www.cervicalcanceraction.org)

WhoislikelytogetCervicalCancer?

Womenovertheageof35,womenwhohadsexbeforetheywere15,andwomenwithHIVhavethehighestrisk.Womenwhohavehadmanysexpartnersorwhosepartnerhashadmanysexualcontactsarealsoathigherrisk.

WhatisaCervix?Thecervixisthemouthoftheuterus(womb)thatsitsatthebackofthevagina.It'swhereaspermgetsintomakeababy,andhowthebabycomesoutlater.

Cervicalcanceriscausedbyaninvisiblevirusthatisspreadbyhavingsex,justlikeHIV.It'scalledHPV(humanpapillomavirus),andmorethanhalfofwomenhaveitbyage35.Mostmenandwomendon'tknowtheyhaveit,unlesstheygetthekindthatcauseswarts:li[lebumpsyoumayseeorfeelonthewoman'sorman'sgenitals.Wartsarenotcancer.

Howiscervicalcancerprevented?TheHPVvirusgetsintotheskinofthevaginaandcervixandlivesthere.Manyinfec;onsareclearedupbyyourownimmunesystem;butthebadkindscanstay,andslowlycausechangesinthecervixthatmaybecomecancer,overa5to10year;meperiod.Theseabnormalcellsarecalleddysplasia.Ifitisfoundandtreatedearly,itcanbecompletelyremoved.

‐‐ExcerptedfromPINCCh[p://www.pincc.org/cervical‐cancer/what‐is‐cervical‐cancer

CervicalCancer,HIVandAIDSOneofthemajorcausesofpre‐cervicalcanceristhesexuallytransmittedhumanpapillomavirus(HPV).HPV is the most common sexually transmitted virus in the United States. At least 50% of sexually active people will have genital HPV at some time in their lives. Around75percentto80percentofwomenwithHIValsohaveHPV.WomenwithHIVhaveaweakenedimmunesystem,whichallowsHPVtosurviveinthecervixandcausepre‐cancerouslesions.

Severalstudiespresentedatthe2010InternationalAIDSConferenceinVienna,Austria,examinedfactorsthatincreaseriskfordevelopmentofpre­cervicalcancerandcervicalcancerinHIV­positivewomen,aswellasfactorsinvolvedinrecurrenceofpre‐cervicalcancer.

Cervicalcancerpreventionshouldbepartofbroadersexualandreproductivehealthpreventionservices.Thismonth’sfeaturedprogram,PreventionInternational:NoCervicalCancer(PINCC)inElSalvador,alwaysmakessurethatthestafftreatingHIVpositivewomenaretrained,andthattheyeducatewomentogettheirscreeningexaminationseveryyear.

Becauseoftheirreducedimmunesystem,HIVpositivewomenprogresstocervicalcancermuchfaster,andanti­HIVdrugsdon’tinhibitthisgrowth.Thesimpleprocessofscreeningandtreatingearlydysplasiawillgivethesewomenalongerlife,allowingtheiranti‐viraldrugstokeepthemhealthy.

WorldwideCervicalCancerRates

BarrierstoCervicalCancerPreven<on&TreatmentintheDevelopingWorld

Asoftenseenindevelopingcountries,manywomendonottakemeasurestoprotectthemselvesfromharmbecauseitissociallyunacceptable.Culturalfactors,inwhichmenhavemultiplepartners,givewomenlittlepowertonegotiatesafesex,andleavemonogamouswomenatriskfordisease.In

remoteandunder‐servedareas,thereisoftenlittleornoaccesstohealtheducation,condoms,cervicalcancerscreening,ortreatment.Womenmayknowlittleabouttheirownreproductivehealth.Preventingcervicalcancerrequiresregularscreeningandfollow­up.

Previouschallengesinprovidingcervicalcancerscreeningthroughthe“Pap‐based”systemincludedexpense,poorresultsandfollow‐uprequirements.PINCCdiscoveredabetterwaytoprovidethousandsofscreeningseveryyearinremoteareasofElSalvador:theytrainlocalhealthcareworkersingynecologyexamination,visualscreeningwithaceticacid(VIA),cryotherapy(freezingofpre­cancercells)andLEEP(electrosurgicaltreatment).Alloftheseareperformedinsimpleoutpatientsettings,asustainableprogramthatwillcontinuetoservecommunities.TheirprotocolwasdevelopedbytheAllianceforCervicalCancerPrevention.Ithasbeenprovenbothmoreeffectiveandaffordable,andavoidstheproblemsofPap‐basedsystems.Womenfrequentlywalkmanyhourstobeseen,andPINCCisabletotreattheminonevisitwitha90%orbetterassuranceofcure.

AvaccinethatcanpreventHPVhasalsobecomeavailableinrecentyears,butmustbeadministeredbeforegirls(andboys)becomesexuallyactive.Thegreatestbarrierto

introducethisnewtechnologyintoprogramsisthecurrenthighcostofHPVvaccinesandtheHPVtest.Inaddition,sendingresourcestocountriesthatcannotorwillnotdistributethemwouldprovechallenging.Ontheotherhand,“NewvaccinesagainstHPVinthedevelopingworldcouldsavehundredsofthousandsoflivesifdeliveredeffectively,”UNWorldHealthOrganization(WHO)AssistantDirector‐GeneralforHealthTechnologyandPharmaceuticalsDr.HowardZuckertoldaninternationalconferenceinLondonorganizedbysixnon‐governmentalorganizations(NG0s)–StopCervicalCancer:GlobalHealthStrategies.

Ques<onsforDiscussion:1. AnewreportreleasedbytheNationalCancerInstitute_indsthathighratesofcervicalcancerin

certaingeographicareasandpopulationsare“indicatorsoflargerproblemsinaccesstohealthcare.”Whydoyoubelievethisisorisn’tso?

2. TheCenterforDiseaseControlintheUnitedStatesrecommendsthatallgirlswhoare11or12yearsoldgetthe3doses(shots)ofHPVvaccinetoprotectagainstcervicalcancerandpre‐cancer.TheCDCdidnotaddthisvaccinetotherecommendedimmunizationschedulesformalesintheseagegroupsbecause,“studiessuggestthatthebestwaytopreventthemostdiseaseduetoHPVistovaccinateasmanygirlsandwomenaspossible.”Boysdon'tgetcervicalcancer,buttheycantransmitHPV. Isthisrealistic?Sexist?Wouldyouexpectothercountriestomakethisrecommendation?

PINCCadoptedprotocoldevelopedbytheAllianceforCervicalCancerPreven7on.

VoicesThefollowingwomenweretreatedbyPINCC

ErlindaGuevara—ElSalvador,CentralAmerica

ErlindaGuevarais32yearsold,andworksinSanSalvador’sCentralMarket.Shenursedhermotherwhenshediedofcervicalcancer,andsosheknowsofitsterribleconsequences.WhensheheardtherewasascreeningandtreatmentprogramintheMarketClinic,shecamerightaway.“Itellallofmyfriendsandfamilythattheymustgetexamined”,shesaid.Shewasoverjoyedtobetoldthatherexaminationwasnormal.

MariaRodriquez—ZacamilHealthCenter“MayGodblessyoupeoplefromPINCCandalsoourowndoctorsandnursesforcaringforusandhelpingus.Iambringingmymothertomorrowsoshecanbescreenedtoo.Iwasscaredat_irsttocomebutnowIunderstandtheexamisnotsobadanditisimportant!MyauntdiedfromcervicalcancerbutIlearnedtodaythatIdonothaveto.”

LucyWanyonyi—Kitale,Kenya

Lucyisa45‐yearoldmotherof8andgrandmotherof5inKenya.Shehadneverhadanexaminationofhercervix,buthermotherhaddiedofacancerofhergenitalorgans,andsheknewhowterribleitcouldbe.Shecametoourteachingclinicfromavillagemanykilometersaway,arrivingthenightbeforeandsleepingneartheclinictobesureshecouldgetcare.PINCCdid_indcervicaldysplasia,andwasabletotreatherthesameday.Shehasa95%chanceofbeingcured!Shewasverygrateful,assheneedstocareforher3youngestchildrenand5grandchildrenwhiletheirmothersworkinthe_ields."IamsogratefulIwillnothavetosufferanddieasmymotherdid!",shetoldus.Shepromisedto

returnin6monthssohercervixcouldbecheckedbytheclinicdoctoragain.

Sources:www.aidsbeacon.comh:p://www.unfpa.org/rh/index.htmh:p://www.unfpa.org/public/home/news/pid/7075h:p://www.unmul*media.org/radio/english/detail/108077.htmlh:p://www.unfpa.org/public/cache/offonce/home/news/pid/7190;jsessionid=3E696E648D74E310EE2A0EAEB1D653DBh:p://www.cervicalcancerac*on.org/newsle:ers/2010‐07/CCA_news_July10.htmlh:p://www.un‐ngls.org/spip.php?page=ar*cle_s&id_ar