Despite effective screening and prevention methods, late-stage diagnoses remain common among Malaysian women.
CERVICAL cancer is often described as one of the most preventable forms of cancer.
Unlike many other cancers, it develops slowly, has a clearly identified cause, and can be detected early through effective screening.
Consultant obstetrician and gynaecologist and gynae-oncologist Dr Nirmala CL Kampan observes that despite this, many women in Malaysia are still diagnosed only when the disease has reached an advanced stage – when treatment becomes more complex, outcomes are poorer and lives are profoundly disrupted.
Preventable condition
From a medical perspective, cervical cancer is highly preventable because it is almost always caused by persistent infection with high-risk types of human papillomavirus (HPV).
Dr Nirmala emphasises that cervical cancer is the only cancer in the female reproductive tract that has a primary prevention method – the HPV vaccine.
The progression from HPV infection to cervical cancer usually takes about 10 to 20 years. This long window creates multiple opportunities for prevention – through HPV vaccination and regular screening that can detect precancerous changes before cancer develops.
Despite this, cervical cancer remains one of the leading cancers affecting Malaysian women.
“In the past, approximately 75% of women presented with stage 3 or stage 4 cervical cancer. This has dropped down to about 46%. This shows that there has been some awareness about prevention and early detection,” notes Dr Nirmala.
The Malaysia National Cancer Registry Report (2017-2021) revealed that the age-standardised incidence of cervical cancer in Malaysia is about six per 100,000. Dr Nirmala notes that while women ages 15 to 65 years are most commonly affected, those between 15 to 44 years have the highest incidence.
In the 15 to 44 year cohort, cervical cancer incidence is the second highest in Malaysia, and its ranked fourth in the highest causes of death in women in the country.
So despite the availability of preventive measures, the incidence is still very high.
According to Dr Nirmala, at the later stages of the disease, treatment often involves a combination of surgery, radiotherapy and chemotherapy, with survival rates that are significantly lower compared to early-stage disease.
Late diagnosis also means greater physical, emotional and financial strain – not only for patients, but for families as well.
For the disease’s early stages, “we are able to surgically remove the cancer without any other intervention required. Survival rates are very high, and the surgery doesn’t affect fertility,” she compares.
Reason women delay testing
HPV causes 99.8% of all cervical cancers, says Dr Nirmala. The virus is usually – but not always – transmitted through sexual contact and can cause abnormal changes in these cells.
This can gradually lead to precancerous lesions and, eventually, invasive cancer.
“One of the challenges is that early cervical cancer often causes no symptoms. When symptoms do appear, such as abnormal vaginal bleeding, bleeding after intercourse, pelvic pain, or unusual discharge, the disease may already be advanced,” notes Dr Nirmala.
Because these symptoms can be mild or mistaken for other conditions, many women delay seeking medical advice. “If you have persistent menstrual irregularities, vaginal discharge, it’s best to always get it checked,” she advises.
Cervical cancer screening has been available in Malaysia for decades, yet uptake remains suboptimal. Traditionally, the Pap smear has been the most commonly used screening test.
“For the Pap smear, if you’re undergoing it for the first time, you’ll need to repeat (it) the next year. If that’s normal, then you need to repeat every three years. So in all, a woman gets about 15 Pap smears in her lifetime.
“HPV DNA testing marks a significant advance in cervical cancer screening,” says Dr Nirmala.
“It is more sensitive than the Pap smear and can detect HPV infection before abnormal cell changes develop. The test is recommended every five years for women aged 30 to 65.
“According to WHO guidelines, at least two HPV tests in a woman’s lifetime – at ages 35 and 45 are sufficient – regardless of HPV vaccination status,” she says.
There is no single reason why women delay screening or present late with cervical cancer. Instead, it is a complex interplay of personal, social and cultural factors.
“There appears to be a divide between urban and rural communities. Urban women appear to be more aware, but they may not have the time to go for testing, often juggling career and home responsibilities that take up all their time.
“Fear may also play a major role. Some women are afraid of the screening procedure itself, while others fear a possible cancer diagnosis. There is also embarrassment around pelvic examinations, especially in conservative communities,” says Dr Nirmala.
Misconceptions are another major barrier. Many women believe that screening is unnecessary if they feel healthy or have no symptoms. Others are wary of the social stigma, thinking that cervical cancer only affects those with multiple sexual partners, leading them to underestimate their own risk.
Geography and access matter too. Women in rural or underserved areas may face logistical challenges, including distance to healthcare facilities, limited appointment availability, and difficulty returning for follow-up visits.
HPV Vaccination
Malaysia’s national HPV vaccination programme for schoolgirls has been a major public health success. Vaccination significantly reduces the risk of infection and is expected to lower cervical cancer rates in the future.
However, vaccination does not eliminate the need for screening. Many adult women today were not vaccinated as adolescents. For this reason, screening remains essential for all women, regardless of vaccination status.
Adult women who were not vaccinated earlier can still benefit from HPV vaccination. While that does not treat existing infections, it can provide protection against future strains.
Reducing late diagnoses of cervical cancer in Malaysia will require action at multiple levels. Public education must improve, not just about cervical cancer, but about prevention, screening intervals and available options.
Education should extend beyond women themselves to include partners, families and communities, helping to normalise conversations about reproductive health.
“HPV testing offers a more convenient solution for screening. Although it has been approved by the government, awareness has not been widely spread. In government hospitals, they are provided free of charge where available, and they are relatively inexpensive in private settings.
“In many developed nations, HPV testing has changed the landscape of cervical cancer incidence and mortality. For example in Australia, where HPV testing is used for screening, they have almost eradicated cervical cancer,” observes Dr Nirmala.
The most important message is simple: Cervical cancer does not have to be this way. Screening is not about looking for cancer, it is about preventing it.
A few minutes of discomfort can prevent years of suffering. Avoiding screening out of fear only allows the disease to progress silently.
Early detection saves lives, preserves fertility options, reduces the intensity of treatment and protects families from unnecessary loss.
With the tools already available, cervical cancer could become a rare disease in Malaysia, but only if prevention is embraced.
“Primary prevention is important. If we can vaccinate our children in schools, and implement catch-up programmes to vaccinate those who have left school, this would largely prevent cervical cancer from occurring in future generations,” says Dr Nirmala.
“We need to use all screening tools, such as HPV testing, and if it comes back positive, we proceed to tissue diagnosis and treat accordingly to prevent cervical cancer.”
Positive outlook
With continued commitment to vaccination, improved screening strategies that include both Pap smears and HPV testing, and open conversations about women’s health, cervical cancer elimination is an achievable goal.
“Husbands, partners and families need to be supportive and encourage screening. Women themselves need to take care of their own needs before taking care of others. You are not being selfish. You are being responsible to your family, and to yourself,” exhorts Dr Nirmala.
The challenge now is turning knowledge into action, before it is too late.
