Cervical cancer – the largely preventable cancer

A doctor gives an HPV vaccination to a 13-year-old girl in her office on September 21, 2011 in Miami, Florida. ­— Getty/AFP/File photo

WHEN talking about cancer, we mostly understand that cancer can be an inevitable disease for some as the risk of developing it increases with age and with some certain genetic factors.

But in the case of cervical cancer which develops in the lower part of a woman’s womb, the disease has been found to be largely preventable through regular screening tests and the administration of the Human Papillomavirus (HPV) vaccine.

Coming in as the fourth most common cancer in the world for women, the disease is mostly seen as a developing world disease as 85 per cent of all new cases globally occur in developing nations — accounting for up to 12 per cent of all female cancers.

In Sarawak, it is the second most common cancer with 117 new cases seen at Sarawak General Hospital (SGH) in 2016.

In Malaysia as a whole, the incidence rate of cervical cancer is 20 per 100,000 population — more than double compared to developed nations such as Australia, the UK, the US and even neighbouring Singapore.

Just from this information alone, it would be logical to conclude that Malaysia and Sarawak are experiencing higher rates of cervical cancer due to a lack of access to screening tests and HPV vaccines.

However, this is not true as screening tests for cervical cancer are widely available at nearly all government clinics and the HPV vaccine has already been included in our school immunisation programmes.

If this is true, why is it that our cervical cancer rates are still much higher compared to other countries that have similar preventative measures in place?

According to Dr Junie Khoo, an oncologist at SGH and local committee member of the Annual Scientific Conference of the Malaysian Oncological Society (Ascomos) 2017, the main reason is a lack of awareness of the disease itself and the importance of cervical cancer screening and the HPV vaccine.

“Due to these preventative measures, there has been a 75 per cent decrease in the incidence and mortality of cervical cancer over the past 50 years in developed countries. So it’s very important to raise awareness on this.

“Besides that, rates of cervical cancer are also high locally due to resource limitations. Available funding is usually shunted to areas of disease treatment rather than screening, awareness programmes and other preventative measures,” she shared.

Estimated cervical cancer incidence worldwide in 2012. Source: Globocan

HPV-cervical cancer link

Dr Khoo emphasised that awareness of the disease should first start with understanding the link between cervical cancer and HPV.

Explaining the link, she said: “Ninety-nine per cent of the cancer is concurrently seen with the HPV infection, indicating a strong link between the two.

“HPV infection is basically a sexually transmitted disease and can spread when infected people engage in any type of unprotected sexual acts.

“There are more than 40 different types of the HPV virus and about 15 are associated with cervical cancer and other related cancers such as anal and oropharyngeal (throat and mouth) in both males and females.

“The most dangerous types are types 16 and 18 which are associated with 70 per cent of all cervical cancer cases and 90 per cent of all anal cancers.”

Symptoms of HPV are mostly silent but as HPV infections are usually found concurrent with other types of sexually transmitted diseases (STDs) like gonorrhoea and syphilis, infected people may see symptoms of vaginal discharge, genital warts, bleeding and abdominal discomfort.

And repeated infection can cause pelvic inflammatory disease and even fertility issues for some.

In men, the situation is the same. Concurrent with other STDs, they may see symptoms of penile discharge, painful urination and swollen lymph nodes around the groin area.

As mentioned by Dr Khoo earlier, HPV infections are spread through unprotected sexual acts but research has also found that infections, and subsequently cervical cancer, are also associated with other riskier sexual activities like sex at a young age, bearing children at a young age, having multiple partners and having promiscuous male partners.

Dr Khoo added that HPV infection is not the sole risk factor in developing cervical cancer as research has also shown that patients who smoke or are immune-deficient from being on immuno suppressants due to transplants, are also at a higher risk of developing the cancer as there has been association between these factors and the cancer found.

The solution is vaccinations

Knowing that a large majority of cervical cancer cases are caused by HPV infections, the solution to addressing our high incidence of the disease is simple: undergoing HPV vaccinations.

“As most of cervical cancer is associated with HPV, vaccination will play a very strong role in reducing incidence rates.

“There are three vaccines available — Gardasil, Gardasil 9 and Cervarix. All these have inactivated HPV viruses, providing us immunity to prevent infections of HPV such as the high risk types 16 and 18, and other types of HPV that cause sexually related cancers.

“The difference between the three vaccines is the number of HPV types that it protects against,” Dr Khoo said.

For Cervarix, the vaccine protects against types 16 and 18 while Gardasil against 16, 18, 6, and 11.

Gardasil 9 is the most comprehensive vaccine as it protects against the four from Gardasil and 5 more — 31, 33, 45, 52, and 58.

In Malaysia, the HPV vaccine used in our school immunisation programme is Cervarix and the vaccination schedule for it is for 13-year- old girls.

“It’s done a young age because the best time to protect them against HPV infections is prior to sexual activity.

“The vaccine is given in three doses, one to two months after the first dose, and six months after the first.

“This provides life-long protection against HPV and will dramatically reduce the risk of vaccinated young girls from developing the disease,” Dr Khoo explained.

For older women or girls who have missed the vaccination programme and not been exposed to the HPV virus yet, Dr Khoo advised they could still undergo vaccinations or catch-up vaccinations as it is not too late and the effectiveness is the same.

“Even if they have already contracted the HPV infection, the vaccine may still be a good idea because it depends on what type of HPV they have contracted — it can still give protect against other types of HPV.”

While males are not at risk of developing cervical cancer due to their obvious lack of a cervix, vaccinating males can be beneficial as well as it can help prevent further spread of HPV in our population.

“Having the majority of the population vaccinated against a disease lends protection to the unvaccinated in what is called herd immunity,” she added.

Besides, she said there are other benefits that vaccinated males could reap in the long-term from just being protected against HPV.

These benefits include a reduced risk of developing HPV-related anal and oropharyngeal (throat and mouth) cancers in both males and females.

Diagram of female reproductive system.

Screening for cervical cancer and symptoms

While being vaccinated can help to dramatically reduce the risk of getting a HPV infection and subsequently develop cervical cancer, it is important to understand vaccinated women can still get cervical cancer because the vaccines available on the market right now protects against most but not all HPV types that can cause cervical cancer.

And women who have gotten the vaccine only after becoming sexually active, potentially exposing themselves to HPV, may not get the full benefit of the vaccine as well.

Besides, as mentioned, there are also other risk factors associated with a heightened risk of developing cervical cancer.

To address this in protecting against cervical cancer, Dr Khoo recommended that all women between the ages of 21 and 65 or once they are sexually active, should begin screening for the disease every three to five years.

The screening method of choice for the cancer is called a pap-smear, a process where a doctor will examine the cervical area to check for any abnormalities and swab the area to obtain cells (cytology) which will then be examined to see if there are any signs of abnormal cells.

“Usually, once you start, it is recommended that you do it every year, and if three consecutive years are normal, the screening will be carried out every three to five years.

“If you have not begun screening yet, please start because another critical time to adopt this habit is between the ages of 30 to 39 because we know about 50 per cent of cervical cancer patients are between the ages of 40 to 60.

“So if we are able to pick up the patients early at ages 30 to 39, we will be able to spot any potential developing cervical cancers at an early stage when the cancer is still highly treatable,” she said.

The importance of screening is further emphasised when we look at the symptoms of the cancer.

According to Dr Khoo, the disease develops slowly over a period of several years and in some women, it may not cause any symptoms at all while in others, it can cause abnormal vaginal bleeding or discharge.

“And a lot of times, people think it is nothing — that it will go away itself, so a lot of times, they will delay their medical treatment until very late.

“For example, patients can have bleeding after sex, bleeding between their periods or post-menopausal bleeding but they think it’s normal and ignore it until the cancer progresses further.

“If detected early, cervical cancer is highly treatable. There is   a 93 per cent rate of survival if diagnosed and treated in Stage 1, while the disease is still confined in the uterus,” she said.

Unfortunately, this rate of survival goes down dramatically at later stages, so early detection is very important in successfully treating the cancer.

Treatment

On treatment of the cancer, Dr Khoo pointed out that it would largely depend on what stage the cancer has progressed to.

For earlier stages, where the disease is confined to the uterus, surgery will primarily be used as treatment, and for more advanced cases, surgery will usually be performed in conjunction with radiation therapy, chemo therapy and brachytherapy — a treatment where a device emitting radiation is inserted near the affected area to kill off cancer cells.

“Very early cervical cancers can even have surgical removal of the tumour whilst preserving fertility,” she added.

Unfortunately, it is well known that radiation therapy does include some side effects and in the case of cervical cancer, some of the side effects involve feeling tired, frequent and uncomfortable urination and diarrhoea while late complications include discomfort or dryness during intercourse, weakened pelvic bones and menopause.

“Understandably, these side effects can seem very daunting. But most of the acute effects can resolve when treatment is completed.

“And there are always new changes, new drugs, and new treatments and therapies available to us, so I would advise patients to seek medical help with us,” she said.

In the larger picture however, Dr Khoo staunchly believes the key to tackling cervical cancer is raising awareness of the disease.

“The fact is cervical cancer is very common locally and can cause morbidity and mortality issues to our child bearing women, limiting their ability to function and contribute to society because the disease and treatment side effects may render them unable to work or give birth.

“Because of this, it’s very important to raise awareness of its link to HPV first and foremost so people can see the importance of being vaccinated for HPV and of regular screening to catch the disease early. Earlier detection and treatment offer best the chance of cure.”

Currently in Malaysia, HPV vaccinations are widely available in both private and public clinics and hospitals for women who have missed the vaccination programme currently running for girls still in schools.

Pap-smear exams are available to all Malaysians and Sarawakians for a nominal fee; they need only go to any government clinic.

Dr Junie Khoo

About Dr Junie Khoo

Graduating from IMU, Dr Khoo has spent most of her medical career serving in East Malaysia before deciding to pursue her masters in Clinical Oncology at University Malaya.

And since graduating, she has returned to east Malaysia to serve as a clinical oncologist at SGH.

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