Taking Control of Women's Health: Why Cervical Cancer Screening Matters
Author: Nr. Chika Jones RN, RM, RPHN, BNSC
Reviewed by Dr Azuka Chinweokwu Ezeike, MBBS, FWACS, FMCOG, MSc (PH)
Highlights
- Cervical cancer is the fourth most common cancer affecting women globally
- Cervical cancer is primarily caused by Human Papillomavirus (HPV)
- Various screening methods are available such as pap smear, HPV DNA testing, and visual Inspection methods.
- Women in low-resource settings face more challenges in accessing cervical cancer screening.
Introduction
In 2022 alone, cervical cancer claimed over 350,000 women's lives globally. It is the fourth most common cancer affecting women globally. Cervical cancer develops in the cells of the cervix (the lower part of the uterus that connects to the vagina)
The disease develops gradually from a precancerous stage until it becomes a malignant (cancerous) tumour. Malignant tumours multiply and can spread to surrounding and even distant organs through the blood and lymph vessels.
Cervical cancer can be cured by early identification, prompt diagnosis, and early treatment. For example, in developing countries, cervical cancer is the leading cause of death among women [1]. Moreover, if cervical cancer screening had been done earlier, it could have detected and treated precancerous cells, preventing the development of cervical cancer.
The occurrence and death rate of cervical cancer is significantly higher in low-resource settings compared to higher-resource settings [2]. Approximately 87% of the death rate due to cervical cancer occurs in low-resource settings [3]. The high occurrence and death rate of cervical cancer in low-resource settings is due to a lack of knowledge and poor access to cervical cancer screening services [4].
This article sheds light on cervical cancer screening, the various types, and their importance. We would look into the barriers women in low-resource settings face to access cervical cancer screening and how it can be resolved. This would be an enlightening journey. Stay tuned!
Cervical Cancer Overview
Cervical cancer is a malignant tumour that develops in the cervix. Human papillomavirus (HPV) is responsible for 99% of cervical cancer cases. [5]. It is contracted through sexual intercourse. It is particularly caused by high-risk types of HPV.
Types of Human Papillomavirus (HPV)
HPV can be spread through oral, anal, or vaginal sex [6]. HPV can resolve without treatment. In 90% of people, HPV resolves within two years without treatment.
Persistent HPV infection does not clear on its own. Instead, it causes changes in the cervix that can lead to precancer and, if left untreated, eventually develop into cervical cancer. [7]. It takes 15-20 years for cervical cancer to develop after HPV infection.
HPV is of two types:
- High-Risk: There are about 13 subtypes of high-risk HPV that cause cervical cancer. High-risk HPV causes over 99% of all cervical cancers. Of the high-risk HPV, serotypes 16 and 18 play a major role in the causation of cervical cancer. They cause 70% of cervical cancer cases worldwide.
They also play a role in the causation of other cancers such as;
- Cancer of the penis
- Cancer of the Vulvar
- Cancer of the vagina
- Cancer of the anus
- Oropharyngeal (throat) cancer
A high-risk HPV infection usually does not cause symptoms. [6].
- Low-Risk: They do not cause cancer. Though, they cause warts around the mouth, anus, or throat. Respiratory papillomatosis can occur if warts develop on the throat.
What are the Risk Factors for Cervical Cancer?
The risk factors that could lead to cervical cancer include:
- Multiple sexual partners
- The onset of sexual activity at a young age.
- Having a high-risk sexual partner
- Weakened immune system: Women with HIV or AIDS may develop cervical cancer within 5-10 years. This is faster than the normal process of 15-20 years due to weakened immune systems.
- Multiple childbirths.
- Smoking
- Taking oral contraceptives for an extended period. However, the association is not clearly understood.
We now understand what cervical cancer is and the aim of screening. But what tests are carried out to detect precancerous (abnormal) cells?
Types of Cervical Cancer Screening Tests
Pap Smear (Pap test)
It was considered the gold standard used for cervical cancer screening. It detects precancerous (abnormal) cells in the cervix that could lead to cervical cancer. There are two types of Pap smears done:
- Traditional/Conventional: Cervical cells are collected using a brush and spatula. The cells are placed in a slide with a preservative. This is only used to test for cervical cancer.
- Liquid-based/ Cytology: Cervical cells are collected using a brush and placed in a liquid preservative. This method screens for cervical cancer, gonorrhoea, and chlamydia in a single collection. The sample can also be used for HPV DNA tests. The results are easier to interpret, and the method filters out debris and blood.
To perform a traditional pap smear, a healthcare professional inserts a special instrument (speculum) into the vagina to view the cervix. A small brush or spatula is used to gently scrape the cervix. The sample is smeared on a slide and later examined under a microscope.
High-risk HPV Test
Human Papillomavirus (HPV) Test is a specific test used to detect the presence of HPV. It is recommended as the first-choice cervical screening test. Cervical cancer is caused by numerous high-risk HPV subtypes. Among all of them, HPV 16 and 18 cause most cervical cancer. It is a swab test. A healthcare professional collects a sample from the cervix or vagina. The test result would indicate the presence of HPV and the type found.
HPV and Pap Smear Test.
This test employs both methods (HPV and Pap smear). It detects high-risk HPV types and abnormal cell changes in the cervix.
Visual Inspection with Acetic Acid (VIA)
Visual Inspection with acetic acid test is carried out in a low-resource setting. Due to less laboratory equipment required for the test. It gives immediate results.
It can be used as an alternative to a Pap smear or High-Risk HPV test. Diluted acetic acid is rubbed on the cervix. It is visually examined with bright light to check for white areas. This denotes precancerous cells.
Visual Inspection with Lugol's Iodine (VILI).
This test is quite similar to visual Inspection with acetic acid. It is also used in low-resource settings. There are some peculiarities such as
- Lugol's iodine is used in place of acetic acid.
- Visual Inspection with acetic acid is first conducted. If positive (cervix appears white after one-minute application of acetic acid). Visual Inspection with Lugol's Iodine is conducted.
- Normal cervical tissue absorbs iodine. It becomes brown.
- Precancerous cells on the cervix can easily be identified by a yellow or mustard colour.
Colposcopy
It is a test done to examine the cervix. A colposcopy is performed if the above-mentioned cervical screening test found abnormal cells resulting from HPV.
It is a diagnostic procedure that examines the cervix, vagina, and vulva. A colposcope, a lighted instrument with a microscope, is used. It is used to detect abnormalities that may not be seen with the naked eye. If abnormalities are detected, cervical tissue may be taken for a test (biopsy).
Colposcopy plays an important role in determining the course of treatment. However, it is scarce in low-resource settings due to the need for specialized equipment and trained healthcare professionals.
Advantages and Disadvantages of Visual Inspection Methods
Advantages
- Visual tests could be used in low-resource settings.
- It is cheaper, provides immediate results, and can be performed by other trained healthcare professionals.
- It can be performed in outdoor settings
- It operates without the need for electricity
Disadvantages
- It can give false positive results. A false positive means a screening test indicates precancerous cells when none are present. This subjugates the women to go for unnecessary treatments.
- Visual Inspection results depend on the skills of the healthcare professionals. If the healthcare professionals are not properly trained on how to identify cervix changes resulting from a visual Inspection test. The result may not be credible.
- It is not an appropriate screening for postmenopausal women. This is because the area where cervical cancer develops is inside the cervical canal. This makes it hard to see precancerous cells during visual Inspection.
- It does not provide tissue samples for further tests.
Benefits of Cervical Cancer Screening
- Cervical cancer screening can reduce occurrence rates of 70-80% of cervical cancer cases.
- Cervical cancer screening detects HPV infections early even without symptoms. The earlier it is detected; the easier it is treated.
How Often Should Cervical Cancer Screening Be Done?
There are various cervical screening guidelines but our focus is women In low-resource settings. The World Health Organization (WHO) has made recommendations for cervical cancer screening. We will discuss more about it.
- Cervical cancer screening should start for women aged 30 - 49 years. The recommended screening is HPV DNA testing conducted every 5 to 10 years.
- When HPV DNA is not available, the WHO recommends visual inspection test or pap smear be conducted every 3 years.
Furthermore, women with some health history may require frequent screening. Such health conditions include:
- Weakened immune system like HIV
- Women living with HIV must start cervical cancer screening at 25 years of age. An HPV DNA test is conducted every 3 to 5 years.
- Exposed before birth to diethylstilbestrol (a hormone given to prevent pregnancy complications). produced from the 1940s to the 1970s).
Women need to understand and practice cervical cancer screening.However, some barriers would prevent them from accessing it. Women in low-resource settings are most at risk due to a lack of access to screening.
Barriers to Cervical Cancer Screening
Understanding specific barriers to screening is important. This would help to develop a tailored intervention and policies to improve cervical cancer screening outcomes in the settings [9].
The barriers to cervical cancer screening are multifaceted and interdependent [9]. They include:
- Poor Education and Health Literacy: Some women have low access to both formal and health education. They are not aware of cervical cancer and the various screening programs available [10].
- Access to Healthcare: Screening services may not be readily available everywhere. For example, Nigeria has 37 states and is located in Africa. Screening services are readily available in some government-owned and big private hospitals. However, there are only a few in some states in the country [10]. The cost of transportation from rural areas might be expensive. Cervical cancer screenings may not be readily available in the primary health care facility. Instead, some private hospitals can offer screening services. However, cost constraints may reduce accessibility.
- Inadequate Skilled Healthcare Providers and Equipment: Cervical cancer tests are carried out by a skilled healthcare provider. A shortage of skilled healthcare providers may hinder screening uptake. The lack of equipment is another factor. There could be skilled healthcare providers but the equipment may not be available.
- Lack of Spousal Support:
In some settings, husbands play a significant role in a woman's decision to undergo cervical cancer screening. Not only may they need to grant permission, but women may also rely on them to cover the costs. Unfortunately, societal stigma surrounding cervical cancer can be a major obstacle. Since cervical cancer is transmitted through sexual intercourse, some men may accuse their wives of being promiscuous, leading them to refuse consent. This highlights the need for education and awareness to combat misconceptions and promote support for cervical cancer screening.
- Socio-cultural and Religious Beliefs: In African and Asian cultures, women are very conservative about their bodies. In Africa, it is viewed that exposure of your private parts is only for your husband, unless for compelling reasons.
- Male healthcare providers handle the screening in some cases. Some women may not be encouraged to participate due to male involvement. This could lead to a decline in participation.
Steps to Curb Low Uptake of Cervical Cancer Screening
- Awareness Campaigns: Outreaches should be organized by the Government and non-governmental organizations to educate women about all aspects of cervical cancer, not just screening methods.
- Affordability: Cervical tests should be affordable or even free. This will encourage women to go for cervical cancer screening.
- Increased Accessibility: Screening services should be carried out in primary health care or community hospitals. It will increase uptake and reduce the cost of travelling to tertiary hospitals.
- Trained Healthcare Professionals: They should be trained on cervical cancer and available screening methods. This will enable them to share correct and accurate information with the patients. More healthcare professionals can be employed to curb the human resource shortage. Female healthcare workers should receive comprehensive training on proper screening procedures. Ensuring their availability for testing can help alleviate women's anxieties. Moreover, healthcare providers must demonstrate cultural competence to deliver care that respects diverse values, beliefs, and backgrounds.
- Access to Proper Equipment: Colposcopy and HPV tests require standardized equipment. Healthcare professionals must be trained on how to use this equipment and maintain it.
- Male involvement: Lack of male support can be a hindrance to a woman's compliance with screening, Therefore, men must be educated on cervical cancer screening. Awareness campaigns about cervical cancer must be inclusive of men.
Conclusion
Cervical cancer can be prevented through early detection and treatment, making it essential to understand the disease and the importance of screening. However, barriers to screening are complex and require a multifaceted approach to overcome them effectively.Do you now have a better understanding of cervical cancer and the available screening programs?
If you’ve had a screening, which one did you take? And if you haven’t, what’s holding you back?
References
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- World Health Organization. Human papillomavirus and cancer [Internet]. WHO. 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/human-papilloma-virus-and-cancer
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