Cervical Cancer: What African Women Need to Know

 

By: Adebowale Bello, Freelance Health Writer. With medical review and editorial support by the Datelinehealth Africa Team

 

 

Key Takeaway

 

• The death rate for cervical cancer is high in Africa.

• The human papillomavirus is the primary cause of cervical cancer and is prevalent in Africa.

• Health system and infrastructural constraints as well as socioeconomic factors like poverty, unemployment, early age of marriage and multiple partners pose considerable challenges and  access to screening tests are costly for many women who have to pay out of pocket.

• Public health interventions like improved awareness raising and access points, coupled with health insurance funding to drive access to early screening is needed for the purpose of reducing the burden of the disease within different African countries.

 

 

Introduction

 

A 2020 World Health Organisation report ^{(1, 2)} estimated that 604,000 women had been diagnosed with cervical cancer and 342,000 died.

 

80 - 90% of the estimated mortality rate associated with cervical cancer is linked to low and middle-income African countries and this is because of several public health challenges bedeviling the African health sector.

 

This article provides an overview of cervical cancer in Africa, its prevalence and the risk factors facing African women. Challenges to treatment and prevention is the subject of a different report

 

 

What is Cervical Cancer?

 

Cancer is a group of diseases that cause abnormal cells to grow and divide uncontrollably and these cells accumulate to form a tumor. Cancer can affect any part of the body because the entire body is made up of cells.

 

Cervical cancer is a slowly developing cancer that affects the cervix. The cervix is the lower part of the womb (see figure 1) that connects to the vagina and plays a vital role in pregnancy and overall female reproduction.

Diagram of the female reproductive system. Click on image to enlarge.

 

Early detection of cancerous cells should not be underrated because cervical cancer is entirely treatable when detected on time. On the other hand, the cancerous cells spread to different body organs and tissues if not treated on time. 

 

There are two main types of cervical cancer ⁽⁴⁾ and they are classified based on the cells where the tumor begins to grow.

 

The two types are:

• Adenocarcinoma: 

Adenocarcinoma is a type of cancer that affects the cells that produce glands such as digestive juices and mucus.

Cervical adenocarcinoma is a cancer that affects the gland–producing cells in the cervix.
 

• Squamous cell carcinoma:

Squamous cell carcinoma makes up about 90% of all cervical cancer diagnoses and the cancerous cell growth begins from the cells lining up the cervix's outer part.

These cells are thin, flat-like cells known as squamous cells.

 

 

What Causes Cervical Cancer?

 

Studies over the years have linked the leading cause of cervical cancer to the human papillomavirus (HPV). There are at least 100 different virus strains which can be grouped into low-risk and high-risk. 

 

The high-risk HPV group contains 14 types of HPV strains, with HPV 16 and 18 being responsible for most cervical cancer cases worldwide. ⁽⁵⁾

 

HPV infections are widespread and many sexually active people with this virus can transmit it to their sexual partners. The immune system can resolve most of these infections within a year or two.

 

 

How Widespread is Cervical Cancer in Africa?

 

Cervical cancer is the most commonly diagnosed cancer among women in Africa, with 34 out of every 100,000 women diagnosed and 23 out of these 34 die due to various risk factors ranging from inadequate health services to limiting socioeconomic factors. ⁽³⁾

Eastern Africa is reported to have the highest burden of cervical cancer in Africa. 

 

Some of these socio-economic factors include:
 

1. Lack of awareness: Many women living with cervical cancer reside in rural areas and don't understand what cervical cancer is.

This lack of awareness makes women not to attend or even skip regular medical screening exercises where hidden symptoms can be diagnosed and treatment can begin immediately.
 

2. High prevalence of HPV: Prior studies have shown that at least 24% of all global HPV cases arise from Africa. ⁽⁶⁾

This high level of occurence and transmission rate could be due to early involvement in sexual activities, having multiple sexual partners and inadequate sexual education.
 

3. Inadequate access to healthcare: Quality healthcare in Africa is paid substantially out of pocket and consequently more accessible by the rich. In the absence of government funding support or health insurance, the less financially well off people are unable to afford the exorbitant cost associated with cervical cancer screening exercises, vaccination and proper treatment.

 

 

What Further Risk Factors Increase Cervical Cancer?

 

As an African woman, additional risk factors increase the likelihood of cervical cancer. These include:
 

• Human papillomavirus infection

This virus is the leading cause of cervical cancer and though the immune system can resolve it, the risk of cervical cancer is more significant when the virus persists longer than two years.

It is rampant in Africa and commonly transmitted through unprotected sexual activity or having multiple sexual partners.
 

• Smoking

Multiple studies ⁽⁷⁾ have shown a link between smoking and cervical cancer. The constant weakening of the immune system makes a person more susceptible to HPV infections, preventing the immune system from functioning correctly and clearing off the infection.
 

• Lack of HPV vaccination

Vaccination against human papillomavirus virus is vital in guaranteeing protection against the virus. Many African women either do not have access to this vaccine or are unaware it exists.
 

• Socioeconomic factors

The high rate of poverty and unemployment makes it difficult for African women to access the treatments they need.

In cases where they manage to get a diagnosis, their financial status makes them unable to sustain such treatment, which leads to poorer outcomes, hence the high mortality rate.

 

 

Symptoms of Cervical Cancer 

 

Cervical cancer develops gradually and could take at least 5-10 years before symptoms manifest ⁽²⁾.

 

The cancer may be in its early or advanced stages when symptoms eventually appear. ⁽⁸⁾

 

Some early-stage cervical cancer symptoms include:

• Vaginal discharge 

• Irregular menstrual periods

• Vaginal bleeding after sexual intercourse

• Longer menstrual periods

 

If the cancer has progressed into the advanced stage, the following symptoms might be further noticed:

• Abdominal pain

• Weight loss due to fatigue

• Foul-smelling vaginal discharge

• Painful urination, which may contain blood

• Leg swelling

 

 

Diagnosis of Cervical Cancer in African Women

 

Before a diagnosis of cervical cancer can be made, your doctor will ask you about what brought you to the clinic or hospital. Next, the doctor would ask you to detail the history of your complaints, your past medical history, the medications you are taking, your work, family and sexual history, and whether or not you have had any previous operations or hospital admissions. Following these, your doctor would perform a physical examination on you with focus on your reproductive organs. 

 

At the end of the history and examination process, your doctor would be in a position to make a clinical diagnosis of cervical cancer and may then progress to perform further diagnostic tests to confirm the clinical diagnosis.

 

Some of the diagnostic tests your doctor may perform ⁽¹⁴⁾ include:

• Pap smear test: This is a non-invasive procedure where the doctor carefully takes cell samples from the cervix for testing for abnormalities. This test is very effective at discovering pre-cancerous cells.

 

• HPV test: Human papillomavirus is the primary cause of cervical cancer and it's only logical to test for the virus.

The prevalence of this virus though means that a woman can have the virus but not have cervical cancer and most times, this test is performed alongside a Pap smear test for suggestive evidence of cancer.

If abnormal cells have been detected by the initial tests performed, the following further tests may be carried out to determine if there are more abnormal areas.
 

• Colposcopy: An instrument known as a Colposcope - a special magnifying machine - is placed close to the body and is used to light up and magnify the cervical and vaginal tissues so that the doctor can view the cervix better and locate abnormal areas that can be further analyzed.

 

• Biopsy: This is the principal diagnostic method for many cancers. This test involves the removal of a small piece of cervical tissue and helps to give a definite diagnosis of cervical cancer.

After confirmation of cervical cancer, it's essential to know how far the cancer has spread and imaging tests are carried out.
 

• CT Scans: A computer tomography machine is used to send narrow X-ray beams around a patient's body and it takes digitized images which are combined with a computer to give precise imaging that shows the extent of the cancer.

 

• PET Scans: Positron emission tomography scan is done alongside CT scans most times. It involves using a radioactive sugar known as fluoridated glucose or fluorodeoxyglucose which is consumed majorly by cancerous cells. The scanner in turn, detects the substance and maps out an image of the body.

 

• Magnetic Resonance Imaging: Unlike CT and PET Scans which utilize radiation, an MRI uses magnetic fields to scan the body.

 

Depending on the structure being imaged, a contrast dye may be injected into the veins or taken orally to enable the MRI machine to take more accurate images. 

 

 

Treatment of Cervical Cancer

 

Cervical cancer treatment depends on how advanced the cancer is, whether the cervical cancer is confined to just the cervix or if it has spread to other organs.

 

There are a lot of treatment procedures for cervical cancer and here are three of the major treatment methods.^(12)(13)

1. Chemotherapy: This is the treatment method associated with cancers and it is the use of toxic drugs to kill the cancerous cells repeatedly.

Chemotherapy is usually combined with another treatment method such as surgery or radiotherapy for faster patient recovery.

Some side effects include hair loss, anaemia, fatigue and lack of appetite.
 

2. Radiotherapy: Radiotherapy is the use of radiation to kill cancer cells or damage their DNA eventually leading to death. For radiotherapy to be effective, it is performed repeatedly over several weeks before the cancer cells die off.

Radiotherapy could  be external or internal, depending on many medical factors but internal radiotherapy (also known as brachytherapy) is often used for cervical cancer.

It comes with side effects like bowel pain, discomfort and infertility.
 

3. Surgery: Surgery involves the removal of tissues affected by cancer and this treatment method depends on how extensive the cancer is.

There are different types of surgeries for different stages of cervical cancer such as:

• Hysterectomy

• Cone biopsy (Conization)

• Radical Hysterectomy

• Trachelectomy

• Pelvic Exenteration

 

 

Prevention of Cervical Cancer

 

Research has come a long way regarding cervical cancer and a combination of measures ⁽⁹⁾ at different stages can prevent and manage cervical cancer.

 

• Vaccination

Human papillomavirus is extremely common but vaccination can effectively reduce transmission. Thankfully, there are three highly effective vaccines that give protection against the HPV strains that cause cancer.

 

The Centres for Disease Control and Prevention recommends vaccination to protect young ones within the ages of 9-15 against HPV as they grow. ⁽¹⁰⁾

 

Older females who were not vaccinated would have to consult with a doctor before taking the vaccine as they might have been exposed to the prevalent virus and the vaccine might not be as effective.

 

Note: If you're less than 26 years old, you should get fully vaccinated against HPV.

 

• Early Detection and Screening

Regularly visiting medical centres for screening helps to detect cancerous cells early enough and prevents about 80% of potential cervical cancer cases.

A pap smear is widely used in cervical cancer screening. However, given the challenges in the African health sector, a viable alternative method that involves visible inspection of the cervix, either with Lugol's iodine or acetic acid can be used. ⁽¹¹⁾

These alternative methods are easy to implement by medical personnel, give immediate results and are accurate. In an optimal situation, a pap smear and a visible inspection of the cervix using Lugol's iodine provide the best results.

 

 

Wrap Up

 

Tackling cervical cancer in Africa requires a combination of different approaches such as awareness and education, early detection and screening and prompt treatment. Therefore the healthcare sector needs a revamping and massive investment in personnel, equipment and awareness raising.

 

In collaboration with private investors and international partners, African governments in their respective countries should implement plans and programs to create a sustainable public health framework that improves screening, diagnosis, treatment and prevention of cervical cancer and significantly reduces the mortality rate currently associated with the disease. 

 

 

References
 

1. World Health Organisation. Cervical Cancer. Last updated February 22, 2022. Accessed August 21, 2023.

2. World Health Organisation. Cervical Cancer. Last updated February 22, 2022. Accessed August 21, 2023.

3. World Health Organisation. Cancer. Accessed August 21, 2023.

4. National Cancer Institute. What Is Cervical Cancer? Last updated June 15, 2023. Accessed August 21, 2023.

5. National Cancer Institute. HPV and Cancer. Last updated April 4, 2023. Accessed August 21, 2023.

6. Kutz, JM., Rausche, P., Gheit, T. et al. Barriers and facilitators of HPV vaccination in sub-saharan Africa: a systematic review. BMC Public Health 23, 974 (2023). https://doi.org/10.1186/s12889-023-15842-1

7. Yuan R, Ren F, Xie Y, Li K, Tong Z. The Global, Regional, and National Burdens of Cervical Cancer Attributable to Smoking From 1990 to 2019: Population-Based Study. JMIR Public Health Surveill. 2022 Dec 23;8(12):e40657. doi: 10.2196/40657. PMID: 36563035; PMCID: PMC9823574.

8. National Cancer Institute. Cervical Cancer Symptoms. Last updated October 13, 2022. Accessed August 21, 2023.

9. Finocchario-Kessler S, Wexler C, Maloba M, Mabachi N, Ndikum-Moffor F, Bukusi E. Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective. BMC Womens Health. 2016 Jun 4;16:29. doi: 10.1186/s12905-016-0306-6. PMID: 27259656; PMCID: PMC4893293.

10. Centers for Disease Control and Prevention. Who Should Get HPV Vaccine? Last updated November 16, 2021. Accessed August 21, 2023.

11. Ghosh P, Gandhi G, Kochhar PK, Zutshi V, Batra S. Visual inspection of cervix with Lugol's iodine for early detection of premalignant & malignant lesions of cervix. Indian J Med Res. 2012 Aug;136(2):265-71. PMID: 22960894; PMCID: PMC3461739.

12. National Library of Medicine. Comprehensive Cervical Cancer Control: A Guide to Essential Practice. 2nd edition. Accessed August 21, 2023

13. American Society of Clinical Oncology. Cervical Cancer: Types of Treatment. Accessed August 21, 2023.

14. American Society of Clinical Oncology. Cervical Cancer: Diagnosis. Last updated September 2022. Accessed August 21, 2023.

 

 

Related: Challenges of cervical cancer treatment and care in Africa

 

 

Published: October 6, 2023

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