This month of January marks a new year on the calendar, a month to make resolutions for a better and healthier you. January is also designated as International Cervical Cancer Awareness Month. This is a great opportunity to make a resolution where women’s health is concerned.
In Trinidad and Tobago (T&T), cervical is the second leading cause of death due to cancer among women. The Human Papilloma Virus (HPV) is the main cause of cervical cancer. Cancer is essentially a disease in which cells in the body grow out of control and is always named for the part of the body where it starts, even if it spreads to other body parts later. When cancer starts in the cervix, it is called cervical cancer. The cervix connects the vagina (birth canal) to the upper part of the uterus (or womb). The uterus is where a baby grows when a woman is pregnant.
All women are at risk for cervical cancer, and this because HPV is a quite common and a very infectious virus. The HPV passes from one person to another during sex, which leaves a statistic of at least half of sexually active people having HPV at some point in their lives, but few women will get cervical cancer.
Almost all cervical cancers are caused by HPV, that is most often than not, contracted during sexual intercourse. There are many types of HPV. Some HPV types can cause changes on a woman’s cervix that can lead to cervical cancer over time, while other types can cause genital or skin warts. HPV is also related to oropharyngeal, anal and penile cancers
HPV usually causes no symptoms so you cannot tell that you have it. For most women, HPV will go away on its own however, if it does not, there is a chance that over time it may cause cervical cancer.
Other things can increase your risk of cervical cancer:
Having HIV (the virus that causes AIDS) or another condition that makes it hard for your body to fight off health problems for example from organ transplant or long-term steroid use
Women with Polycystic Ovarian Syndrome (PCOS)
Using birth control pills for a long time (five or more years).
Having given birth to three or more children.
Having several sexual partners.
Cervical cancer was once the number one cause of cancer death among women because in its early stages it is asymptomatic. This is a key stage to identify cancer. If caught at this early stage, curative treatment is possible. There was no way to pick it up before it became symptomatic in the advanced stages, by which time curing it would have been virtually impossible and all that is left to do is to offer palliative care. Palliative care involves just treatment of the symptoms, so that the patient is comfortable for the remaining short time of their life before the cancer spread leads to death.
However, today cervical cancer is very much preventable because of the availability of a screening test that picks up the HPV infection and cervical cancer in the early asymptomatic stages, and an HPV vaccine. The most important thing you can do to help prevent cervical cancer is to have regular screening tests from 21 to 65 years, at least every three years. The screening test for cervical cancer is the Pap smear, which is one of the best screening test developed for any cancer. It is very simple, effective and sensitive in identifying not only cancer, but identify precancerous changes in the cervical cells, five to 15 years before the diagnosis of cancer. When cervical cancer cells or precursors to cancer are found this early, it is highly treatable and associated with long survival and good quality of life.
The Pap smear is a procedure used to collect cells from the cervix so that they can be looked at under the microscope to find cancer or pre-cancer cells. These cells can also be used for HPV testing. A Pap smear test can be done during a pelvic exam, but not all pelvic exams include a Pap test. An HPV test can be done on the same sample of cells collected from the Pap test. Pap smears are available by appointment at most of the over 100 health centres throughout Trinidad and Tobago and is managed by the Population Programme Unit of the Ministry of Health. If pre-cancer cells are found via a Pap smear, patients are referred for a special test called colposcopy at the hospital to determine their status with respect to cancer and determine the appropriate treatment. Referral services for colposcopy, treatment of pre-cancer and cancer is available at all public hospitals.
Who should get a Pap smear and how often?
All women should begin Cervical Cancer testing (screening) at age 21.
Women aged 21 to 29, should have a Pap test every 3 years.
Women aged 30 to 65 should get tested every 3 years.
Women over 65 years of age who have had regular screening in the previous 10 years should stop Cervical Cancer screening as long as they haven’t had any serious pre-cancers.
Women who have had a total hysterectomy (removal of the uterus and cervix) should stop screening (such as Pap tests and HPV tests).
Women who have had a hysterectomy without removal of the cervix (called a supra-cervical hysterectomy) should continue cervical cancer screening according to the guidelines above.
Women who are at high risk of Cervical Cancer because of a suppressed immune system (for example from HIV infection, organ transplant, or long-term steroid use) or because they were exposed to Diethylstilbestrol (DES) while in the womb, may need to be screened more often. They should follow the recommendations of their health care team.
Women who are at high risk of cervical cancer because of PCOS
Not only is it possible to catch the disease early, but also the disease can be prevented with the vaccine developed against HPV. Because we know that HPV causes cancer, at the turn of the century, a vaccine was developed against the HPV types that predispose to the development of cancer. HPV vaccine is available free at the public system from preteen male and females. This reduces not only cervical cancer but also oropharyngeal, anal and penile cancers. It also prevents anogenital warts. The ideal time to administer the vaccine is before the start of sexual activity, this is because the vaccine will be most effective once administered before contracting the virus. However, it can still be administered after sexual activity starts or even in women who are diagnosed with an HPV infection. It is recommended that women be given the vaccine between nine and 26 years of age. Women who have been vaccinated against HPV should still follow these guidelines recommended for regular Pap smear screening.
All services as noted above are available free to the public. However, are severely underutilized by women in Trinidad and Tobago- this is evident by the statistics presented in the first line of this article. If cervical cancer is very preventable and the services to prevent it are readily available in the public sector, then why are the incidence and prevalence still so high in T&T? There are population factors and healthcare factors that are at play to create this scenario. Because the risk cervical cancer is associated with HPV and sexual activity, there is much stigma attached to a diagnosis of cervical cancer, which may deter woman from seeking a Pap smear. Also, in T&T, there was a slow uptake where the vaccine was concerned, as many orthodox perspectives equated having the vaccine as a nod to young people to indiscriminately indulge in sexual activity. Such issues are not unique to cervical cancer, but also pose a challenge to curbing other illnesses. To lay sole blame on the population’s reluctance to access its facilities is counterproductive. Just as the corporate sector has perfected the art of using effective publicity to promote their products, in the same way the health sector can learn this art for effective health promotion and health education. Encouraging those with or who have survived cervical cancer to share their stories with the public and highlighting how simple it is to avoid such experiences by just having a Pap smear, can be very effective with a proper public relations plan which includes using primetime media advocating healthy behavior practices.
There is however a glimmer of hope on the horizon. According to Dr. Adesh Sirjusingh, Director of Women’s Health, at the Ministry of Health (MOH), new policies and programs are currently being launched by the Directorate of Women’s Health in collaboration with the National Cancer Control and Coordinating Committee of the MOH, PSI Caribbean (the marketing organization for healthy lives), and international partners from MD Anderson Cancer USA.
Cervical cancer incidence is the international surrogate objective marker for how well a health sector is doing. Current statistics of cervical cancer incidence in T&T reflects poorly on our health sector. The country looks forward to these initiatives by the MOH in 2019 to positively change this trend.
After all is said and done nothing beats the slogan ‘Don't let cervical cancer stop you, please get vaccinated and have your Pap smear screening test!’
For more information please contact your healthcare provider privately or at your local health centre or the T&T Cancer society at http://cancertt.com/ or call 800-TTCS (8827) or 226-1221.
Dr. Visham Bhimull,
Diploma in Family Medicine(UWI)