By Associate Professor Dr Ganesh Ramachandran, Head of School of Medicine, Taylor’s University
November 17, 2021, marks the 1st anniversary of the declaration by the World Health Organization (WHO) to eliminate cervical cancer.
This is a laudable aim as cervical cancer is one malignancy for which there are reliable screening methods and effective vaccination.
The Burden of Disease
As socio-economic standards improve around the world, life expectancy also increases and with that, comes an increased risk of non-communicable disease—one of which is cancer.
In 2018, the World Cancer Research Fund reported a total of 18 million new cancer cases around the world of which 47% involved women (1).
In women, the most common cancers were breast, colorectal, lung, and cervical cancer. Of more than 8 million new cases in women, almost 600,000 were new cases of cervical cancer.
Cervical cancer is the fourth most common cancer among women, and the eighth most common among men and women combined. The burden of disease is largest among poorer countries.
HPV and Cervical Cancer
Almost all cervical cancer is associated with the Human Papilloma Virus (HPV). Other cancers associated with the HPV infection include anal, vulvar, vaginal, penile, and oropharyngeal cancer.
Not all HPV cause cancer, and most women and men will not develop cancer following an HPV infection. The transmission of this virus is largely associated with the sexual behaviour of an individual. For example, multiple sexual partners and early-age sexual intercourse. Other risk factors include smoking, the presence of other sexually transmitted infections and an immunocompromised state.
There are almost 100 subtypes of HPV, HPV 16 and 18 are seen in 70% of all cervical cancers (2). Other common cancer-causing subtypes are HPV 31, 33, 45, 52 and 58.
Cervical cancer does not occur immediately after exposure to HPV; in 90% of women, recovery is the norm, while in others, depending on the type of HPV progression to a pre-cancerous lesion and subsequently, cancer is a possibility. Generally, this takes about 15 to 20 years in otherwise healthy women. In women with a weakened immune system, this may take up to 5 to 10 years.
The Malaysian Scenario
The World Health Organization 2020 report derived from the Malaysian National Cancer Registry and the Penang Cancer Registry reported 48,639 new cancer cases, with 29,530 cancer deaths (3).
Overall, among men and women, the most common cancers were breast, colorectal, lung, nasopharyngeal, and liver cancers. Among women again the most common were breast, colorectal, ovarian, cervical, and uterus cancer.
Concerning cervical cancer, there is a national screening programme in place which recommends regular screening between the age of 20 and 65. Despite this programme existing since the 1960s and being offered free since 1995, only 45.7% of Malaysian women have been screened compared to the minimum target of 80% (4). Factors that have proven to be an obstacle include individual-based factors such as fear of cost, embarrassment, lack of knowledge or time, and fear of the procedure (5). Systemic factors that have impeded screening include long wait times for an appointment, lack of a call-recall system, patient overload, lack of resources, manpower and educational material.
The silver lining, though, is the inception of the cervical cancer vaccination programme in Malaysia. The vaccine was approved for use in Malaysia in 2007 and was incorporated into the national vaccination programme in 2012, and the population coverage exceeds 80% (6).
Another innovation is the Removing Obstacles to Cervical Screening (ROSE) programme, which was launched in Malaysia back in 2019, allowing women to self-test for HPV and overcome the barrier of seeing a health care professional for a pap smear. This test, apart from being self-administered, requires less testing and is also more sensitive in picking up the risk of cervical cancer.
Can we eliminate cervical cancer?
Cervical cancer is a good example of cancer that can be eliminated because there is a clear cause in many patients, a relatively long period before cancer develops, effective screening methods, and most of all, an effective vaccine.
It has been reported that the number of HPV infections and pre-cancerous lesions has dropped in countries with a vaccination programme, and in time this should lead to a drop in new cervical cancer cases.
Adopting a healthy lifestyle, vaccination against HPV, regular pap smears, and the recent availability of self-testing kits for HPV play an important role in preventing cervical cancer. Pre-invasive lesions caught on screening can also be treated relatively easily and effectively. It has been suggested that more than 99% of future invasive cancer may be prevented by screening for and treating pre-invasive lesions (7).
The evidence of the usefulness of screening programmes, the availability of safe and effective vaccines together with self-screening kits, and the improvement of socio-economic and educational status will serve to empower women to manage their health in time to possibly eliminate this disease.
Associate Professor Dr Ganesh Ramachandran is the Head of School for the School of Medicine, at the Faculty of Health & Medical Sciences, Taylor’s University. He is a fellow from the Royal College of Obstetricians & Gynaecologists, London, United Kingdom, and his area of expertise is in Obstetrics and Gynaecology. He is a clinician turned medical educator, nurturing soft skills in medical students by making full use of technology today.