Women in this country face a one in 42 lifetime risk of developing cervical cancer and with the lack of up-to-date figures, these numbers might be the tip of the iceberg.
As the world observes World Cancer Day on 4 February, our focus zeroes in on a persistent and deadly adversary — cervical cancer. In South Africa, this disease claims the title of the second most common cancer among women and the leading cause of cancer-related deaths. Women in this country face a one in 42 lifetime risk of developing cervical cancer and with the lack of up-to-date figures, these numbers might be the tip of the iceberg.
The intersection of cervical cancer with high HIV prevalence in our country adds another layer of complexity. Women living with HIV, often dealing with immunosuppression, face a heightened risk of developing cervical cancer and are more likely to be diagnosed at advanced stages. Compounding this is the socio-economic reality many women face: no regular screening, limited access to healthcare services and cultural barriers that delay preventive care.
In 2020, the World Health Organisation (WHO) introduced a cervical cancer elimination strategy: vaccination of 90% of girls against human papillomavirus — the causative agent of cervical cancer, screening of 70% of women for pre-cancer, and treatment of 90% with cervical pre-cancer or cancer by 2030. To achieve these ambitious targets, our mission is clear, we need to “Close the Care Gap”.
The Pap smear, a screening tool in our arsenal
In the battle against cervical cancer, early detection is our best defence. Prevention is only possible when there is a high coverage of screening for pre-cancer. According to the National Indicator Data Set, national coverage of Pap smear screening was 47% in 2019-20, varying from as low as 32% in the Northern Cape to 58% in Mpumalanga. While achieving high Pap smear screening coverage is crucial, it’s equally important to be aware of the test’s sensitivity to detect pre-cancer — which varies from 90% to as low as 30%. This variability underscores the need for a unified, high-quality screening tool that can reliably identify women at risk.
The effectiveness of cervical cancer screening programmes, including the quality of Pap smear tests and follow-up protocols for abnormal results, plays a critical role in early detection. Inadequacies in screening programmes can result in missed opportunities for early intervention.
Another factor to consider is the adequacy (defined as having endocervical cancer cells) of the smear itself. An inadequate sample can compromise the test’s sensitivity, leading to missed diagnoses. The adequacy of all Pap smears conducted by the National Health Laboratory Service was 54% in 2010 and increased to 67% by 2022.
Detecting abnormalities is only half the battle
Ensuring that women with abnormal Pap smears receive timely colposcopy services is where our healthcare system fails. While national data is not available, only about half of the women referred for colposcopy services in the Western Cape use them. This situation is probably more dire in other regions; for instance, the linkage to care in Johannesburg hospitals is as low as 16%. These statistics paint a concerning picture — we are falling far below the WHO target of linking 90% of women with precancer or cancer to care. Without intervention, the strides made in screening are rendered futile.
“Although we’ve made strides in cervical cancer screening over the last 20 years, the true measure of our system’s efficacy lies in the continuum of care post-diagnosis,” said Dr Cari van Schalkwyk, a cervical cancer epidemiologist. “Our data exposes a critical gap in the cancer care cascade — the linkage to care. Screening efforts are commendable but offer little hope without the necessary strategies ensuring that women with positive screens are navigated through to timely and appropriate treatment. This gap is not merely a healthcare oversight; it is a systemic failure that disproportionately affects the most vulnerable in our society.”
The challenges are manifold: in regions with lower rates of regular screening and linkage to treatment, women are often diagnosed at later, more advanced stages of cervical cancer.
The stage at diagnosis has life-or-death implications. Between 50% to 70% of women get diagnosed at stage III and IV. Survival rates five years after diagnosis drop drastically from nearly 75% for stage I to a grim 25% for stage III and nearly zero survival for stage V. These numbers are a call for reform in the national approach to cervical cancer, to prioritise early detection and improve linkage to treatment.
Inadequate awareness about the disease and socio-cultural obstacles also impedes women from seeking timely care. This is where targeted educational initiatives focusing on symptom awareness, destigmatising cancer and encouraging earlier healthcare-seeking behaviour can play a significant role in promoting early detection.
The stage at which cervical cancer is predominantly diagnosed also serves as a telling barometer of the effectiveness and reach of our healthcare system. The availability and quality of healthcare infrastructure significantly influences the stage at which cervical cancer is diagnosed. In areas with limited healthcare resources, there may be delays in screening, diagnosis and referral for treatment, leading to more advanced disease at the time of diagnosis. This disparity is not just clinical; it’s a stark illustration of inequality.
As we approach 10 years since the roll-out of the public-school human papillomavirus vaccine programme, vaccine coverage among the target girls has remained at about 80%. While vaccination is available in private pharmacies for women up to the age of 26, this option is not accessible to all, leaving a vast majority of adult women vulnerable to cervical cancer.
The WHO’s ambitious goal to eliminate cervical cancer necessitates a concerted, evidence-based approach to prevention, screening, and treatment. This goal is not just a vision, it’s a clarion call to action, especially for policymakers, who hold the key to overcoming the systemic barriers that hinder our progress. This World Cancer Day, we urge policymakers to recognise and address the barriers to cervical cancer elimination head-on.
It’s time to unite healthcare providers, communities and policy architects to overhaul the cervical cancer care landscape in South Africa. By investing in healthcare infrastructure, enhancing public awareness and education, improving screening programme quality, and ensuring equitable access to healthcare services, we can “Close the Care Gap”. This concerted effort will not only change the course of cervical cancer in our country, but also safeguard the health of future generations of South African women.
Dr Yuri Munsamy is the science officer at the DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis at Stellenbosch University.