Urging cervical cancer prevention program in RI

The Jakarta Post , Jakarta | Wed, 04/25/2007 3:23 PM | Life

Tommy Dharmawan, Contributor, Leiden, The Netherlands

Imagine that globally, a woman dies of cervical cancer every two minutes.

According to one research from Ferlay et al, almost 500,000 new cases of this cancer is identified each year. Eighty percent of these cases occur in developing countries, where at least 200,000 women die of the disease each year.

These facts rank cervical cancer as the second most prevalent form of female cancer in the world.

Today, cervical cancer is becoming the number one female cancer in Indonesia. It accounts for 34 percent of female cancers and at present, 48 million Indonesian women are at risk.

According to 1998 data from Central Jakarta's Cipto Mangunkusumo General Hospital, cervical cancer was the leading cancer among the 10 most prevalent primary female cancers it recorded.

Meanwhile, research conducted in August 2006 by the Female Cancer Programme Foundation -- a non-governmental organization funded by the Netherlands government and the Europeaid cooperation office -- shows that the prevalence of cervical cancer in Indonesia numbers approximately 100 cases per 100,000 people. In comparison, the Netherlands records a prevalence of only 9 cases per 100,000 people.

Indonesia is thus facing a new era of disease: On the one hand we are still combating infectious diseases such as tuberculosis and avian flu, and on the other, we must face degenerative and malignant diseases such as cervical cancer.

The main reason this cancer has a high mortality rate is because patients come to medical attention in the late stages of cancerous growth; around 65 percent of patients are diagnosed in the late stages -- that is, beyond stage IIB.

One of the causes of this late diagnosis is due to the fact that 90 percent of cervical cancer cases in the early stage are asymptomatic, so the patient is not aware of the disease. In addition, patients -- particularly in Indonesia -- go in for a check-up only after they have experienced spontaneous vaginal bleeding. But this symptom might indicate that the cervical cancer is already in the late stages of development.

Another problem in combating cervical cancer in Indonesia is the very low screening coverage for this cancer.

Screening is one way to detect precancerous lesions and cancers in the early stages, but Indonesia records less than 5 percent screening coverage for cervical cancer; the ideal coverage is about 80 percent. As a result, 70 percent of cervical cancer patients are diagnosed in the late stages.

Such conditions make for a low survival rate and thus a high mortality rate for the patient. The problem is compounded because the government does not have a formal cervical cancer mass screening program, a national registry of cervical cancer cases, or data on screening results.

This is an irony, because early diagnosis (screening) and treatment is easily accessible to cervical cancer, which can drastically reduce the mortality rate. More importantly, cervical cancer is to a large extent a preventable disease.

Cervical cancer develops in an area of the cervix known as the transformational zone. This zone is more prone to the loss of cellular differentiation and can develop precancerous changes that may turn into cancer, depending on the presence of cervical cancer risk factors.

Some of these risk factors are: multiple sexual partners, a male partner who has had multiple sexual partners, multiparity (having more than four full-term pregnancies), early age of first intercourse, immunosuppressant usage, genital infections, imbalance of free radicals and antioxidants, smoking and low social economy.

A major risk factor is Human Papilloma Virus (HPV) infection. Cervical cancer can develop up to 10 years after an HPV infection. Further, an HIV infection increases the risk of an HPV infection by up to 10 times because of the decline in immunity.

The clinical manifestations of cervical cancer are: vaginal discharge, bleeding between menstrual cycles, postmenopausal bleeding, spontaneous vaginal bleeding, vaginal bleeding during defecation, pain during sexual intercourse and bleeding after intercourse.

Several strategies exist to lower the prevalence of this cancer.

The first method is primary prevention, which includes educational programs to reduce high-risk sexual behavior, measures to reduce or avoid exposure to sexually transmitted diseases including HPV, avoiding or minimizing other risk factors like early marriage (under 20 years old), early child bearing (teenage pregnancy) and smoking.

The HPV vaccine also falls under primary prevention methods.

According to the 2006 De Boer research, the virus -- particularly types 16 and 18 -- was detected in 95 percent of cervical cancer cases. This research also found that HPV type 18 is more dominant in Indonesia; the dominant virus in other Asian countries such as India and Korea is HPV type 16.

Thus, HPV vaccination is one solution in a cervical cancer prevention program, as the HPV vaccine widely used by doctors -- such as the quadrivalent and bivalent vaccines -- can be used against both HPV types.

But costs for mass vaccination remain high, so another strategy is needed against cervical cancer in Indonesia, namely secondary prevention methods.

Secondary prevention includes detection and treatment of precancerous lesions, which are simple, easy to administer and effective. The key to secondary prevention is a mass screening program to detect precancerous lesions. Indonesia needs a good screening test that is effective, safe, practical, affordable and readily available.

Some methods of early detection are the pap smear and visual inspection acetic acid (VIA).

The pap smear is the gold standard, and all women should have pap smears from an age before the onset of sexual activity until 65 years of age. If undertaken annually, and consecutive results from 2 to 3 smears are negative, then the pap smears can be undertaken at intervals of 3 to 5 years.

While pap smears are widely used as a screening test for cervical cancer, it has its limitations. In Indonesia, one such limitation is the availability of trained human resources that can conduct the test.

Another method of early detection is the VIA, which can differentiate between a normal and abnormal cervix. Although this type of screening is not new -- it was introduced by Hinselman in 1925 -- the technique fits with conditions in Indonesia: it is the most affordable, cost-efficient and fastest method (PATH, 2000) of identifying precancerous cervical lesions.

VIA is a visual cervical examination conducted by swabbing acetic acid (3-5 percent concentration) on the cervix and observing the effect over 20 to 30 seconds. Precancerous lesions temporarily appear white after staining with acetic acid.

VIA can be implemented in a wide range of settings, as no laboratory processing is required, the results are immediate, and treatment can be provided on the same visit.

In this case, one thing the government must do is provide VIA training for health workers, especially in rural areas.

A final strategy is tertiary prevention, or cancer treatment, such as surgery and radiation therapy, depending on the stage of cancer.

It must be stressed that a strategic approach to cervical cancer prevention in Indonesia -- triangulating between women, the health services and technology -- should be developed urgently.

According to the World Health Organization's 2002 prevention program development, the steps involved are to: confirm political commitment, engage high-level stakeholders, conduct a situation analysis, develop policy and maximize access to health care providers.

The focus of the cervical cancer prevention program should be to maximize coverage of screening and treatment services, as the overall mortality rate will decrease if more patients are diagnosed in the early stages of the disease.

Prevention -- rather than curative methods -- remains the best way to take this opportunity to protect women from this dreadful disease, and to stop the rapid growth of cervical cancer cases in Indonesia.

The writer is a University of Indonesia medical student on an exchange program to Leiden University -- sponsored by the Female Cancer Programme Foundation -- where he is researching cervical cancer prevention and treatment in developing countries with a focus on Indonesia.

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