Early detection, screening and vaccination can reduce the risk of getting the cancer by 70%. Yet, the disease remains the second most common cancer among women in Malaysia. Why?
There isn’t much good news when it comes to cancer. In the case of cervical cancer, however, the prognosis is good, potentially.
Cervical cancer is not only curable if detected early, but is also largely preventable. Through regular screening tests – namely the pap smear and the HPV DNA test – and the groundbreaking HPV (human papillomavirus) vaccination (which reduces the possibility of getting the cancer by 70%), there is no reason women should die from cervical cancer.
Yet, cervical cancer remains the second most common cancer among women in Malaysia and the fourth leading cause of death in women aged between 15 and 44.
According to Globocan statistics (2012), there are about 2,145 new cases and 621 die from the disease in Malaysia every year.
National Cancer Society Malaysia (NCSM) president Dr Saunthari Somasundaram believes the high incidence of cervical cancer in Malaysia is largely because of a lack of awareness among women about how preventable the disease is, as well as the importance of screening in preventing the disease from developing.
“When we talk about screening for breast cancer, for example, we are talking about catching the cancer at its early stages and treating it. The cancer is already there but it’s about catching it early.
“With cervical cancer, screening identifies abnormalities in cells before they become cancerous. A pap smear will show abnormalities which could potentially lead to cancer. When abnormalities are detected, action can immediately be taken to remove those cells and prevent the cancer from developing.
“What’s unique with cervical cancer is that we know what causes it and we have the tools to stop it from developing,” says Dr Saunthari.
The HPV vaccine, introduced in Malaysia in 2010, promises to reduce the chances of cancer even further, she points out.
“With the HPV vaccine, we can address the issue even before a person has been exposed to the risk factors associated with cervical cancer. We aren’t able to do that with any other cancer,” she says.
Dr Saunthari points out that in developed countries like the United States and Britain, cervical cancer has been reduced by 70% in the last 30 years because of good screening programmes.
“There is no reason we can’t see that kind of progress here,” she says.
Malaysia was among the first countries in Asia to introduce a national HPV vaccination programme for 13-year-old girls in schools about five years ago.
“So far, the coverage has been more than 70%, which is good. On top of that, LPPKN (the National Population and Family Development Board) has a catch-up programme for those aged 18. We have a very good programme in place and we will see the results of this in 20 years.”
The HPV vaccine has to be administered in three doses within a six month period.
For now, the Government needs to go down to the ground and educate the public on the importance of prevention.
Vaccinations are available at all government hospitals and clinics and pap smears can be done at any clinic at a very minimal cost, she says.
“What we need is a robust programme to raise awareness among women, girls and men on the importance of screening. Though the HPV vaccine reduces the risk of cervical cancer greatly, you need to do a smear test periodically,” she says.
About 99% of all cervical cancers are caused by sexual contact with a person who has been infected with HPV, a common sexually transmitted virus.
The HPV is a skin virus that is easily transmittable through sexual intercourse or genital skin-to-skin contact.
“It is important to note that it is transmittable through any form of sexual contact – there doesn’t have to be intercourse for the virus to spread. You can get HPV infection through any contact with genitalia which is why using condom is not an effective preventive measure,” cautions Dr Saunthari.
The HPV, she explains, is a virus which thrives in certain environments.
“It thrives in moist, warm and dark environments and so the cervix is the perfect place, particularly the transformational zone at the opening of the cervix. Other areas that are prone to infection are the mouth and the anal area,” she says.
Most HPV infections are transient (they resolve themselves and go away within a couple of months) and carry no symptoms. Therefore, those infected are often unaware that they have the virus and are carriers.
There are over 100 strains of HPV, 15 of which can cause cervical cancer. The two main strains are HPV 16 and HPV 18 – responsible for 70% of the cases of cervical cancers.
“HPV is a very common virus. In developed countries, statistics show that two-thirds of the population have had HPV at any one point of their lives. In Asia, the estimate is about 50%. However, just because you have HPV, doesn’t mean you will get cervical cancer. In most cases, the virus goes away by itself after a while. However, it is when it persists that we should check to see if there are abnormalities which could lead to cancer,” explains Dr Saunthari.
Fortunately, cervical cancer is slow growing. The latent period for the abnormal cells to develop into cancer is about 10 years.
“If the HPV is persistent and is not resolving on its own, we know that it could potentially become cancer. These are pre-cancerous lesions but they take about 10 years before they become cancer. This is when we can do something about it and this is why regular screening is important,” she says.
Stigma surrounding cancer
Another big barrier to the prevention of cervical cancer is the stigma surrounding the disease, says Dr Saunthari.
“Many shy away from it (screening) because you get cervical cancer from the HPV virus which is a sexually transmitted virus. Women feel embarrassed about how they would be perceived if they have HPV. But the truth is even though having multiple sexual partners increases your risk, you can be infected by HPVs even if you are currently monogamous but have had sexual contact someone who has been infected. All women who are sexually active are at risk,” she says.
Stigma aside, Dr Saunthari adds that the nature of pap smear screening also puts women off.
“Many fear pap smear screening as they feel it is invasive and uncomfortable. They are also embarrassed to go for one. But if they were aware of how important it is for the prevention of cervical cancer, this may change,” she asserts.
Public awareness programmes are crucial in getting the message across and they should also be targeted at men.
“ln countries like Malaysia where men have a large sway in decision making, they should be made aware of the importance of screening and the possibility of prevention,” she says.
Whether spouses or partners are supportive or not makes a large difference in whether women come for screening, she opines.
A study conducted by gynaecology oncologist Dr Zaridah S from Hospital Tuanku Fauziah in Kangar Perlis revealed “extremely poor knowledge” about cervical cancer and HPV, leading to resistance to women getting the HPV vaccination.
According to the study, reasons for vaccine refusal included doubts about its safety and efficacy (27.4%), perceived embarrassment about receiving an STI vaccine (20.7%) and a belief that they were not at risk for HPV (20%).
More than 90% of the 400-odd women interviewed (rural women across the country) indicated that they required more information about the vaccine. The study also indicated how unpopular pap smear screening is among the women interviewed.
Dr Saunthari estimates that only 38% of Malaysian women have ever done a pap smear – and most of those do it because they are required to by their gynaecologists for post-reproductive reasons.
With the ongoing research in the field, Dr Saunthari is confident that screening and testing processes will be less invasive and more accessible in the future.
The World Health Organisation’s new guidelines for prevention and screening of cervical cancer released at the World Cancer Congress late last year are already indicative of progress in the area.
“With regards to the HPV vaccine, girls aged between nine and 13 are now only required to have two doses of the HPV vaccine instead of three.
“Studies in the past 12 years since the vaccine was introduced show that girls at that age don’t need three doses because they have such good antibody response to the vaccine. However, those over 15 still have to adhere to the present three-dose schedule,” explains Dr Saunthari adding that this will not only make it easier to administer the vaccine but also reduce costs.
Additionally, if a woman’s pap smear test does not indicate any abnormalities, she would not be required to be screened again for at least five years.
“Presently, national guidelines encourage women to get a pap smear done within two years from the time she becomes sexually active. An annual pap smear is then recommended for the subsequent three years and if the results are normal, it can be done every three years or so. With the new guidelines, women don’t have to be screened so often,” she says.
She also highlights new testing methods which aren’t as invasive as the pap smear.
“In high-resource countries, the pap smear is no longer the number one screening tool. There is now HPV DNA testing which is considerably less invasive. There is also the possibility of doing self tests – where a woman can take a swab herself and send it to a lab for the results. These are all less intimidating and more accessible, provided there are enough labs to do the testing. At present, the self tests are not available in Malaysia although the HPV DNA testing is,” she says.
FACTS AND MYTHS ABOUT CERVICAL CANCER -->
Important facts and common myths about cervical cancer.
1. Cervical cancer is nearly 100% preventable.
2. Cervical cancer is caused by the human papilloma virus (HPV), which is transmitted via sexual contact. There are over 100 types of HPV virus, but not all cause cancer.
3. Most HPV infections resolve themselves within a couple of months and carry no symptoms. Therefore, those infected are often unaware that they have the virus and are carriers. Screening is therefore crucial.
4. A HPV vaccine can lower your chances of cervical cancer by 70%. Regular pap smears can detect abnormal cells which may lead to cancer. These cells take about 10 years to develop into cancer; therefore there is ample time to remove the abnormal cells and prevent cancer.
5. Other factors that cause cervical cancer include multiple sexual partners, tobacco, birth control pills, engaging in early sexual contact and multiple pregnancies.
1. Only Promiscuous Women Get HPV
Fact: Any woman who has had sexual contact have been exposed to HPV. It is a common virus and statistics show that in developed countries, about eight out of 10 women would have had HPV at some point in time by the age of 50. In Asia, the estimate is one in two women.
2. If you have HPV, you will probably get cervical cancer.
Fact: Not all forms of HPV can lead to cervical cancer. For most women, HPV infections will go away on their own. If the infection persists and causes abnormal cells to form, there is a risk of cervical cancer.
3. Check for HPV when you experience symptoms.
Fact: HPV infections usually do not have any symptoms. Although some “low risk” types of HPV can cause genital warts, the “high-risk” types associated with cervical cancer often go completely undetected. This is why routine screening with pap smear and HPV testing is so important.
4. There is nothing I can do to prevent cervical cancer.
Fact: Apart from the HPV vaccination and getting a pap smear done periodically, you can reduce the risk for cervical cancer by avoiding smoking, multiple sexual partners and early sexual contact. The presence of other sexually transmitted diseases is another causative factor.
5. If a woman gets the HPV vaccine, she no longer needs to be screened.
Fact: Even with the HPV vaccine, women need to get pap smears and HPV tests as the vaccine only protects against two of the more than a dozen types of cancer causing HPVs. The vaccination is only fully effective when given to women who have not yet been exposed to HPV.