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COVID-19 hits cervical cancer program
Prior to the COVID-19 outbreak the medical community had pinned high hopes on efforts to tackle the prevalence of cervical cancer, which remains among the deadliest forms of the disease in the country despite it being the most preventable. However, the pandemic has disrupted mass screening and vaccination programs.
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span id="docs-internal-guid-b186f169-7fff-ee8b-5ed6-f5c3a89ab124">Prior to the COVID-19 outbreak, the medical community had pinned high hopes on efforts to tackle the prevalence of cervical cancer, which remains among the deadliest types of malignant growth for women in Indonesia despite it being the most preventable. However, the pandemic has managed to disrupt mass screening and vaccination programs.
A four-year ongoing study of cervical cancer, carried out by Gadjah Mada University’s Center for Reproductive Health and the University of Melbourne’s Nossal Institute for Global Health, found that the number of patients seeking treatment in the capital Jakarta has declined.
The researchers started conducting interviews with dozens of workers from community-based organizations, clinics and hospitals in March, when the outbreak first erupted in the country, to find out why. They discovered that some medical services were adjusted as a result of the epidemic. As it turns out, there were fewer screenings for women, particularly pap smear and acetate acid (IVA) tests, which are used to diagnose cervical cancer. There were also fewer vaccines available for treating an infection of the human papillomavirus (HPV), which is the main cause of this type of cancer.
"If fewer women are going to be screened, then we won't be detecting cancer early, which means [...] women present for treatment [...] at the latest stages where it’s harder to save them," Nossal research fellow Belinda RM Spagnoletti, who focuses on sexual and reproductive health, told The Jakarta Post recently.
The high-risk HPV is a virus transmitted through sexual contact that is linked to 99 percent of cervical cancer cases, and with its vaccine, most of these cases are preventable.
The vaccination, however, is considered costly at around Rp 1 million (US$70.40), or a quarter of the Jakarta minimum wage, and is not part of the national immunization program.
Six cities and regencies across the country had joined the national HPV vaccination pilot program by including it in their Schoolchildren Immunization Month (BIAS) program, in which fifth- and sixth-graders are administered the vaccine twice. But this program has stalled due to a lack of funding, the researchers said.
Gynecologic oncologist Oni Khonsa, who works at Persahabatan Hospital, one of the main referral hospitals for COVID-19 treatment in Jakarta, predicted that coverage for HPV would further decline as schools closed down and parents became fearful of contracting the SARS-CoV-2 virus at healthcare facilities. And this is not to mention the issues with data and the unpunctual administering of vaccines.
"We have only begun to reach higher prevention coverage, not only by screening but also vaccination; [...] and originally it was expected that [cases] could decline, but apparently there's a bit of [trouble] because of the pandemic," said Oni.
Symptoms for cancer of the cervix are often absent or hard to spot in its early stages, making it more common for women in Indonesia to be diagnosed late. After breast cancer, it is the most common and the most deadly type of cancer among women.
According to 2018 Globocan statistics, the incidence rate for cervical cancer in Indonesia stood at 23.4 percent and the mortality rate was 13.9 percent. That year, some 32,469 new cervical cancer cases were recorded, accounting for the second-largest share of new cancer cases for both sexes and all ages in the country at 9.3 percent.
On Nov. 17, the World Health Organization launched its global strategy to accelerate the elimination of cervical cancer by vaccination, screening and treatment. If the campaign is successful, it could reduce new cases by more than 40 percent and save as many as 5 million lives by 2050.
The agency said the launch marked a "historic milestone" – it was the first time that 194 countries, including Indonesia, committed to eliminate a cancer.
The strategy sets out to achieve, among other targets, 90 percent of girls fully vaccinated with the HPV vaccine by the time they reach 15 years old; 70 percent of women screened using a high-performance test by age 35 and again at 45; and 90 percent of women identified with cervical cancer receiving treatment.
However, several challenges still stand before the country is able to pursue these goals.
In Indonesia, married women between 30 and 50 years old have free access to screening under the National Health Insurance (JKN) program. But the COVID-19 outbreak had also affected financing for early detection efforts. Researchers found that the Indonesia Cancer Foundation (YKI) had lost two thirds of its annual funding from the Jakarta administration for 2020. As a result, the quota of free pap smear tests made available to women over the next 12 months had fallen from 4,000 to 1,000.
Even prior to the epidemic, the expansion of screening coverage had been rather sluggish. Experts attributed this to the lack of education on sexual and reproductive health, as well as the fear and stigma associated with cervical cancer. Up until 2019, Health Ministry data showed that screening coverage had only reached 12.2 percent, far below the target of 50 percent that was set for the previous year.
Researchers said they had not seen a clear prevention roadmap for cervical cancer from the government, so they suggested that communities at the neighborhood level be involved in spreading information. They also recommended that more female health workers should be involved to conduct screenings and provide safe and timely prevention services, even during the pandemic.
"The thing is, the government is shifting some funds from the [national health services] to be able to respond to COVID-19. So instead of doing that, why not increase the overall funds for COVID-19 and maybe not move around [funding] from one part of the health sector to another?" Nossal research assistant Hanum Atikasari said.
Separately, the Health Ministry's director for non-communicable diseases, Cut Putri Ariane, said that the central government had provided local administrations with the optimum in regulations, support and funding. Regarding the HPV vaccination, she said the government had yet to expand the program, noting that the vaccine's halal status also remained an issue for Muslim-majority Indonesia.
