The government has finally established guidelines to screen women for this disease
Khadija Magardie
For the first time ever the Department of Health has a policy on the single biggest cancer killer of middle-aged, but also younger, black South African women cervical cancer.
Approved in the middle of last year at national level, the guide- lines fall within the government’s National Cancer Control Programme and are now being dispatched to provincial health departments to start fleshing out their implementation. The aim is to screen at least 70% of women nationally in a target age group within 10 years of initi- ating the programme. A series of activities have been planned within the National Guidelines for the Cervical Cancer Screening Programme, including primary prevention, screening, treatment, palliation (pain relief) and auditing of the fatal disease.
According to statistics from the Cancer Association of South Africa (Cansa), cancer of the cervix is the most common cancer among women, affecting thousands every year. It represents more than 35% of all cancers in black women, who have a lifetime risk of one in 26 of contracting the cancer. White women’s lifetime risk for this particular cancer is only one in 83. It is also the most common cancer in coloured women, the second most common in Indian women and, after breast cancer and skin cancer, the third most common cancer in white women.
And, with the numbers steadily increasing each year, the govern-ment has decided to step in.
“The saddest thing about this cancer is that unlike other cancers it’s totally preventable,” says Dr Sharon Fonn, director of the Women’s Health Project (WHP) at the University of the Witwatersrand, and a leading expert on cervical cancer in South Africa. She says this is partly due to the fact that, like immunisation programmes, the awareness and preventative treatment is best when the individual is healthy.
“It’s always a problem to encourage people to get screened and checked when they’re in perfectly good health,” she says.
Studies by experts like Fonn indicate that if women are screened there is a likely chance of picking up the cancer in its early stages and completely curing it, by cutting out the lesions.
The programme will target women aged 30 years and older for screen- ing. These women will be entitled to three free cytological (pap) smears at least three years apart. If a woman requests additional smears she will have to cover the cost.
Though there have been critics of the government’s slow reaction the proposals for establishing cervical cancer screening guidelines were mooted by Fonn and the WHP more than eight years ago various NGOs and researchers in the field have described the move as a welcome indication of the government’s commitment to women’s health issues.
Though the prevalence of the cancer is generally known, statistics have been, by and large, outdated and inaccurate, especially in the rural areas. The previous government was not particularly partial to investing money and resources in saving black women from the disease. This was exacerbated by what insiders say was Cansa’s “Western orientation”, which saw it devoting most of its energy and resources on campaigns from the United States, especially around breast cancer.
A major obstacle in the way of effectively treating the disease is that, like HIV/Aids, there is a stigma that it is a sexually transmitted disease and a consequence of “promiscuity”. As a result, there is reluctance to present for screening at hospitals and clinics. Though young women as well as older women who are sexually active are at risk from contracting the virus, scientists say older women, particularly those in their 30s and older, are at a higher risk.
The cancer is thought to be associated with genital tract infection by a strain of the human papilloma virus (HPV), which is commonly associated with genital warts. Unless treated in a pre-cancer stage, the virus can lead to fully blown cancer of the cervix, which rapidly spreads to all the soft tissue surrounding it. Women in the late stages of the cancer suffer excruciating pain, as the disease eats away at the bladder and the rectum. One of the more horrific consequences is that the dying woman starts to “leak” faecal matter through the vagina.
There are several research projects under way to determine the feasibility of developing a vaccine against the HPV, by isolating the particular strand that infects the genital tract.
According to Cansa’s statistics, at least 80% of women who pre- sent at clinics are at an advanced stage, when it is too late to do anything. Those who can be “saved” have to go for costly radiotherapy, which the state can ill afford. At about R40 a smear, women’s health workers say the government is doing itself a long-term favour by managing the disease in its infancy.
The WHP has been involved in setting up several pilot sites in Gauteng and other provinces, such as the Northern Province, which will develop the systems needed for the initial stages of the programme to be tested.
The decentralisation of health services has meant that health services and government clinics at district and local level see more patients than hospitals in the urban centres. With more women attending such clinics, they play a pivotal role in the screening and treatment of the disease. This is why, say experts, the programme needs to introduce infrastructure to help the district health services manage cervical cancer, such as the provision of equipment and training of staff.
Regardless of location, pap smears in South Africa have taken place on what Cansa describes as “an opportunistic basis”. Smears have only been taken at irregular inter- vals when women presented themselves, and at the discretion of doctors. In some cases, follow-up treatment of positive smears have not been forthcoming, mainly due to lack of laboratory facilities. Those women living in urban areas have had access to screening, but this has not been uniform. A gynaecologist at a large academic hospital in Gauteng complains that even at the bigger hospitals women face obstacles.
“Sometimes they are asked to pay, which they can’t, and in some cases, nurses simply lie and say there is no such facility,” she says.
At one clinic, in the Eastern Cape, there have been reports that staff refused to do the smears, saying it was “not their job”.
The situation in rural clinics is exacerbated when there is no equipment to do the smears, such as speculums, swabs and laboratory facilities to process the results.
Fonn says the need to take the programme forward should be done within a realistic framework, because of the limited and already stretched resources of the state.
“We do not have the infrastructure of First World Western countries, where the aim is to screen every sexually active women every two to three years,” she says.
Experts also say it is necessary to be sensitive to staff constraints and limitations, emphasising that often huge public health policies, like the provision of free antenatal care to pregnant mothers in state facilities, are issued from the top and their impact on those who are doing the actual work is not taken into account.
Women will no longer be randomly tested only those in high-risk categories will be tested. Coordination between various health services will mean that a woman’s smear results will be processed and she will be treated speedily and effectively and, if necessary, referred elsewhere for specialised treatment.
“As always, there will be significant challenges in moving from poli-cy to implementation,” says Fonn.