In most Nigerian Gynaecology clinics, you may predict the answer ‘NO’ following an enquiry into Pap smear for Cervical cancer screening! The question remains, why is the awareness of cervical cancer screening so poor among our Nigerian women folks? The most disheartening of them all is that even though the awareness is not lacking in healthcare setting, however, the uptake is still abysmally poor among the healthcare workers.
Cervical cancer is the commonest cause of gynaecological cancer in Nigeria. It is the second most common cancer in females after the breast cancer. As at 2018, 70,327 deaths were recorded following cancers, with cervical cancer contributing 14.8% of these deaths.
Cervical cancer is one of the few cancers that has a known cause: the Human Papilloma Virus (HPV)! This virus is sexually transmitted and cannot be fully protected by the regular male and female condoms except with the new panty condoms. The reason for this incomplete protection with regular condoms is because, labioscrotal contact (contact with skin of female/male genitals) is just enough to transmit this virus. There are up to 120 serotypes with few serotypes known to cause cancer (high risk groups). Therefore, HPV infection is not necessarily a death sentence! Immunocompetent individuals can clear this virus, however, the immortalized viruses will persist and are the ones that will cause disease based on the serotype.
Other forms of HPV transmission are via human contacts with contaminated fomites. HPV can also infect other sites of the body causing cancer too e.g., pharynx, anus.
How can one be infected with HPV? Some of the well documented methods are as follows – multiple sexual partners, having unprotected sexual intercourse with high-risk females (commercial sex workers, etc.) or high-risk males (uncircumcised males, males whose wives died of cervical cancer, males with penile cancers) etc.
How then can we change this narrative? Fortunately, when compared to all other gynaecological cancers, cervical cancer is one among other cancers that has a well-defined pre-malignant state (some cervical changes which can detect that cancer is imminent). Discovering these pre-cancerous lesions which can be amenable to treatment and ultimate clinical cure is crucial. This therefore gives the opportunity for treatment and follow ups.
What are the possible suggested reasons why the uptake of cervical cancer screening is low among ladies in Nigeria and Sub-Saharan African as a whole? Awareness and poor coverage is central. Majority of the women in Nigeria have not heard of cervical cancer at all, those who are aware might not know how to seek for this healthcare screening. At times, it may be that the services are not available in most districts of the country.
Interestingly, some ladies avoid cancer screening due to perceived risk of ‘pain’ or ‘extreme discomfort’ following the procedure. This is false. Others may not assess this screening because it involves removal of the under wears to access the cervix. While majority will not go for screening due to personal reasons best known to them!
Why cervical cancer screening? A very well organized, self-sustaining cervical cancer screening has been achieved in most of the Western world. This has changed the narratives of cervical cancer incidence in these countries. There are complex reminder systems that track women who are yet to perform these cervical screening among the general population. The essence is to curb the transmission rate of HPV infection across board.
Different recognized health authorities have suggested the age bracket for cervical cancer screening. Most societies recognize age 21 as the earliest age for screening among the sexually active group. Cervical screening in the form of pap test only is suggested for ages 21 to 29 years while ages 30 to 65 years will benefit from pap test with reflex HPV testing. Screening usually stops at age 65 unless otherwise specified. Special cases like HIV infection, ladies on steroid and those who have removed their womb for any reason are considered separately and have their own individualized follow up scheme.
Recommendations and prevention:
There is need to immunize our girl children with vaccines against cervical cancer. Cervarix®, Gardasil®, and Gardasil-9® are some of the recommended vaccines with the most available in Nigeria being Cervarix®. The recommended timing for this vaccination is before sexual debut (between ages 9 and 12 years), though can be extended up to 26 years of age. This vaccination has no added advantage when one has been infected with targeted HPV strains.
Cervarix® vaccine is advocated for females only, but Gardasil and Gardasil-9 HPV vaccines can be used in both males and females. The Centers for Disease Control and Prevention (CDC) recommends HPV vaccine for all boys and girls aged 11 or 12 years old, teenage boys and girls who have not already received the vaccine or have not completed all booster shots of HPV vaccine can be vaccinated also.
The congress of Gynecologists world over advocate that all eligible women must have cervical cancer screening based on a robust, well organized local protocol. Abnormal pap test result should be treated. Those eligible for microscopic cervical examination with or without targeted cervical biopsy should have such procedure(s) and their histology results discussed with them without delay.
Individuals, both male and female should modify any lifestyle that encourages multiple sexual partners. The girl child up to 26 years must be immunized with the appropriate vaccine.
All these enumerated interventions will reduce the incidence and death due to cervical cancer especially in our country and the entire Sub-Saharan Africa. A robust organized system that encourages contact tracing of eligible women for this screening should be put in place.
Government and non-governmental agencies should employ well trained personnel for awareness creation, sample collection, discussion of labouratory results, preferred treatment(s) and well-organized follow up visits. Media houses via TVs, internets, tertiary institutions through the vice chancellors and dean of different faculties, churches involving the lord’s spirituals, mosques with the help of the Imams, marketplaces via the use of posters, hand bills should help in creating this awareness.
In all, individual awareness creation will go a long way in helping out during face-to-face everyday conversations.
No one will love to see a relative go through the harrowing experiences of excruciating waist pain, terrible foul-smelling vaginal discharge that may necessitate social distancing from patients’ contemporaries or possible torrential vaginal bleeding which can occur spontaneously or following cervical contacts.
Let’s all brace up and change this narrative in our country, just by asking your wife, daughter, sister, mother, aunt, in-laws, girlfriend, date, fiancée, ladies in your workplace, during religious and social or academic or financial gathering if she has had pap test done or better put cervical cancer screening done!
Dr. Chukwuemeka Philip Igbodike, MBBS, FWACS, FMCOG
Consultant Obstetrician, Gynaecologist & Minimal Access Surgeon
+234 9090940011; firstname.lastname@example.org