Thousands of South African women die of cervical cancer, caused by the human papillomavirus, every year. (Envato Elements)
If private hospitals are willing to rent out open theatre space to government hospitals at an affordable price, thousands of South African women who die of cervical cancer each year, can be saved, says Langanani Mbodi, the head of the gynaecologic oncology units at the University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital.
Most cases of cervical cancer are caused by a sexually transmitted germ called the human papillomavirus (HPV). Although almost everyone who’s had sex gets the virus, most people clear it naturally and therefore don’t develop cancer.
Cancer of the cervix is the most common type of tumour among black South African women.
“If the private sector can open up and forget about this business idea that they have about cancer, and say we want to help by charging a minimum [theatre] fee, [government] doctors will flock in there and we’ll kill that waiting period,” Mbodi told Bhekisisa’s television show, Health Beat.
Women diagnosed with cervical cancer in the public health sector — a cancer that can be prevented almost entirely by a vaccine and regular screening — often have to wait for surgery for so long they either become untreatable or die, says Mbodi.
“By the time that the [women] we diagnose now return for surgery in three or four months [when a space on the waiting list has opened up], they’ve [often] progressed to a [next] cancer stage [which may require different treatment, for instance chemotherapy or radiation] and for which they then have to join another queue.”
Women who have HIV are six times more likely to develop cervical cancer than those who are HIV negative. Almost a quarter of South African women between the ages of 15 and 49 are HIV positive.
Meanwhile, countries such as the United Kingdom and Australia have virtually wiped out cervical cancer after introducing HPV jabs for school girls (before they become sexually active). South Africa started with this in 2014 — but the Covid pandemic made us fall far behind.
So what makes black women in South Africa more likely to get cancer of the cervix than other races? Mbodi explained it to Mia Malan in our eleventh Health Beat episode.
Mia Malan (MM): What is the link between HPV and cervical cancer?
Langanani Mbodi (LM): The cervix (also called the mouth of the womb) consists of three layers. We know that [almost] 99% of cancers of the cervix are [caused by] HPV. [The virus] infects the deepest layer and sits there. The longer the infection stays there, the more it infects and [eventually] changes the DNA of the cervix, and the cells now become abnormal. If they’re allowed to progress without treatment, then they can become cancerous.
MM: Why does HPV affect black women in South Africa more?
LM: You need a healthy immune system to fight HPV. [In] 90% [of cases] people with a healthy immune system can get rid of HPV at the early stage [of infection]. The problem is the 10% that can’t — and this is the majority we see in our country. In South Africa, the issue is poverty. You can’t have a healthy immune system when you don’t have enough good, nutritious food. [There’s also] the prevalence of HIV. HIV and HPV almost go together. But HIV also affects the immune system. [Because] we have a high prevalence of HIV in the country, it means that those women who are infected with HPV are likely going to have HPV stay there [in the cervix]. The other part is [linked to] the healthcare system’s failures. The system makes [access] difficult. For example, people have to go and consult or sometimes book [an appointment], consult, go get the results [and] go for follow-up [appointments]. So, they might go once and not have money to go back, and hence they’re being affected. The other reason is that it’s difficult [for especially Black women] to have access to prevention, screening or treatment when cancer is identified.
MM: One of the things women can do to pick up signs [of cervix cancer] early is to have a Pap smear. Does the access to Pap smears in the government system have something to do with black women not being able to get screened fast enough?
LM: Women will go in and have a Pap smear done, but time and again when they go [back], the results are not ready or they are not found. At some point they will be told: go and repeat another Pap smear and then they wait and wait and wait again. Or when they go [back] again, they get told that the person who deals with that part of the healthcare system is not available. So the truth is that the healthcare system is also letting women down when it comes to screening and follow-up.
MM: How often can you get a Pap smear in the government system? And how is it different from what happens in the private sector?
LM: We do it every 10 years (and ideally you shouldn’t start screening if you’re younger than 25). [If you start screening at age] 30, you do it again at 40, and again at 50, provided the tests are normal. If they’re not normal, then your frequency will change. Currently we are on a 10-10-10 [year screening plan], which means three times in a lifetime. [The World Health Organisation recommends self-testing for HPV, which involves a woman taking a swab sample from her vagina herself. This can be done every five years. The health department hasn’t yet introduced self-testing. In the private sector, people are doing it every year. But doing it every five years, compared to doing it every [year] does not put you at a disadvantage at all.
MM: Why is it important to get vaccinated then and when can you do it?
LM: A vaccine prepares your body to fight against the enemy before it comes. So, the vaccine will prepare the immune system on the cervix itself, so that by the time you get [exposed to] HPV the immune cells are prepared and you eliminate it [the virus]. If you eliminate [the virus], it means we’re increasing the pool [who are HPV free]. People who have a competent immune system naturally get rid of [the virus]. So, with a vaccine we can increase that pool [of people who] can get rid of it. In New Zealand and Australia, for example, they’ve almost eliminated cervical cancer because of the vaccine.
MM: What type of cancer can boys or men get from HPV?
LM: Men or boys are mostly the carriers. We have not seen many incidences of penile cancer from HPV as yet. But boys who have sex with boys, [could get] rectal cancer or colon cancer from HPV. Those who [have] oral sex, might get throat cancer. But on its own, it’s rare to see penile cancer compared with cervical cancer. It makes sense that we must not [only] treat the victim, we must also treat the “perpetrator” [the carrier]. If you’re giving a vaccine to the girls so that they don’t die from the cancer, why don’t you vaccinate the boys who bring the HPV to the girls as well?
MM: Is cost an issue for not vaccinating boys?
LM: My personal belief is that it’s not cost. I think this disease is political. If cervical cancer was affecting men, we would have long got the vaccine to every single living human being in the country. I think it’s more [about] political will. We don’t have political will in the country to protect our women or to stop [them] from dying of cervical cancer.
MM: If a woman gets cervical cancer, what can the government hospitals do for her?
LM: Cervical cancer [at] an early stage, for example stage 1A or 1B, can be operated. [The surgeon] removes the womb and then you are cured. For anything above that, you must get [chemo]therapy or radiation. If it’s advanced, then we have to give you treatment, to control the pain, the bleeding and [dis]comfort, so that your quality of life can improve. Currently in government, you can get all the management strategies. If you have cancer and it’s early, there are services for operating. If it needs chemo, you can get chemo. If it needs radiation, you can get radiation. However, access is limited because of the number [of patients]. There’s a lot of women who are waiting for surgery, a lot of women awaiting radiation, [and] a lot of women are waiting for chemo[therapy]. Ideally, [a doctor will] want to operate on [a] patient within two weeks of diagnosis. [But] what are we doing? [We] diagnose and operate in three or four months, which is not ideal at all.
MM: Given late access to services, what’s the survival rate in the government sector for cervical cancer?
LM: Ideally, we want the average [survival rate] to be about 80 tp 90%, which means [you want] 80 to 90% of patients that you diagnose to still be alive in five years. We are at 60%, sometimes less than 60% [in state hospitals]. It’s because of the same thing [late access]: if today we tell [a patient] ‘You are at stage 1B, which needs to be operated’ and when [they] come for the operation [three or four months later], the doctors have to reassess. In most cases, we find that because we waited long, by the time they come [to hospital] they’re no longer operable. So, we need to book them for radiation and chemotherapy. And when they go there, they [have] to join another queue — and their waiting period is also the same: three to six months.
MM: What do we do to make it work?
LM: In the private sector theatres are underutilised. If we can [out]source those services, theatre staff and doctors are there. If the private sector can open up and forget about this business idea that they have about cancer, and say ‘We want to help. We’ll charge you a minimum fee to access the theatre’, then we’ll kill that waiting period. We [will be able to] see a person today [and] in seven days we’re operating. And we’re convinced it will improve the outcome for women with cervical cancer in the country.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.