PRB

(December 2000) Cancer of the uterine cervix is a major public health problem in Latin America and the Caribbean. Based on 1990 data from the International Agency for Research on Cancer (IARC), it represents the most common cause of cancer for women in the region (52,000 new cases per year) and the fourth leading cause of death among women ages 15 to 64 (25,000 deaths per year).

Haiti has the region’s highest incidence of cervical cancer (91 cases per 100,000 women) and Nicaragua has the highest mortality from the disease (33 deaths per 100,000 women).

Cervical cancer is caused primarily by certain strains of the human papillomavirus (HPV), a common sexually transmitted infection. According to the Pan American Health Organization (PAHO), 60 percent of this type of cancer occurs in women between 35 and 60.

Cervical cancer is preventable and can be treated effectively provided women know about the disease and the means to detect and prevent it; many women in Latin America and the Caribbean do not know about cervical cancer or about available screening and treatment programs. Prevention efforts have focused on using the Papanicolaou (Pap) smear to screen at-risk women and then treating the precancerous lesions by removing the diseased tissue. Most countries in the region offer Pap screening but they lack prevention programs and do not offer follow-up or treatment in cervical cancer cases detected by the smear.

Overall, 63 percent of women in the region have had a Pap smear at least once, but there are great differences across countries. While 70 percent of women in Brazil and Costa Rica have had at least one Pap smear, only 35 percent of women in Nicaragua have had at least one test. The vast majority of these women have been screened during their reproductive life, at young ages when the risk of precancerous lesions is lower. It is important to note that one Pap test alone is essentially useless; women need to obtain regular Pap tests.¹

Women from lower socioeconomic status and those with less education are less likely to know of the Pap test. Furthermore, women with the least education are more likely to be diagnosed with later stages of cervical cancer. In most instances, they do not have the financial resources to obtain treatment.

Whatever the screening test used, a fundamental problem in the region is the follow-up of screened women and the provision of diagnosis and treatment for cancer cases detected during the screening. A recent study in Peru showed that only 20 percent of women who had a Pap smear that identified a precancerous lesion received a diagnosis and follow-up treatment.²

There are effective alternatives to Pap tests and efforts to use HPV testing to identify women at high risk for cervical cancer. Researchers are also working to produce a viable vaccine against one or two types of HPV. There are also simple and inexpensive techniques to treat precancerous lesions, like cryotherapy, that can be applied in primary care clinics throughout Latin America and the Caribbean, thus reducing much potential suffering for affected women.

A Woman’s Perspective

Women’s feelings are often not considered and made an integral part of care, even in difficult situations when a woman needs to be told that cancer has been diagnosed.

“When they tell you that you have cancer, you get all nervous; and even though they explain it quickly, you somehow don’t hear. They said ‘Do you have any questions?’ and I said ‘No, its okay I understand everything clearly,’ but I did not understand, and I was so nervous that all I wanted was to leave. They told me what I had, and I started crying, for blocks and blocks, as if someone had died within me. People were looking at me and my little girl; I was looking at the trees, as though I had never seen them in my entire life. I thought that tomorrow I was going to be dead, and who would care for my children.” I wanted to question the physician, who didn’t even look at me; instead, he said ‘Go outside’.”³

In the Region, Central America Has the Highest Incidence and Mortality Rates

Cervical cancer is a significant reproductive health problem in the countries of Latin America and the Caribbean, which have one of the world’s highest incidence and mortality rates for the disease, according to IARC.⁴ Generally, incidence is high across many of the countries in the region, regardless of their development status. Countries with low and medium low economic status, however, exhibit higher mortality levels. Among the sub-regions, Central America has the highest incidence and mortality rates.

According to PAHO, trends in the region suggest that mortality due to cervical cancer did not decline between 1960 and 1993 but remained fairly constant (five to six deaths per 100,000 women).⁵ This scenario applies to countries as varied as Brazil, Colombia, Cuba, Ecuador, Guatemala, Trinidad and Tobago, Uruguay, and Venezuela. Three countries — Chile, Costa Rica, and Mexico — have recorded changes over time, but not always for the better. For instance, in Costa Rica, there was a reduction in mortality from 1965 to 1973; however, this may be due to improved coverage and accuracy in the certification of deaths rather than due to real reductions. Chile realized a decline in mortality from cervical cancer among women under 35, but not among older women, who represent the majority of cases. In Mexico, on the other hand, there appears to have been an increase in deaths from cervical cancer, but this may be due to better certification of deaths.⁶

Women Typically Become Infected During Their Teens, 20s, or 30s

Cervical cancer is a disease that largely affects middle-aged and elderly women. Sixty percent of this type of cancer occurs in women between 35 and 60 who are in the prime of life and important supporters of their families. Unlike many cancers, cervical cancer can be prevented. The first step is to educate women about how to protect themselves against HPV, a common sexually transmitted infection (STI) that can cause cervical cancer. According to the World Health Organization’s Programme on Cancer Control, over 99 percent of cervical cancers are due to certain types of HPV. Other important factors associated with the disease include tobacco use, number of sexual partners (for either the woman or her partner), early age at first intercourse, and early age at first birth.

Women typically become infected with HPV during their teen years and in their twenties or thirties. However, it may take 20 or more years for cervical cancer to develop after the initial infection. Cervical cancer develops slowly from precancerous lesions (dysplasia). There are typically three stages: low-grade cervical dysplasia, high-grade dysplasia, and invasive cancer. Seventy percent of low-grade dysplasia disappears over time and does not require treatment. High-grade dysplasia, which will progress to cancer within 10 years if left untreated, requires both treatment and regular monitoring. Invasive cancer, if not treated with surgery and radiation therapy, is always fatal.⁸

Primary prevention, which includes a focus on using condoms or other barrier methods and engaging in mutually monogamous sexual relationships, help prevent cervical cancer, but it is unclear how these strategies affect the overall incidence of the disease. Preventing HPV transmission may pose greater challenges than most STIs. It is easily transmitted, asymptomatic, and the virus can remain in the body for years. Furthermore, HPV can occur in the genital and anal parts of the body, including areas not covered by male condoms.

Proper Screening Can Be an Effective Intervention

Secondary prevention strategies such as inexpensive screening, treatment, and follow-up have been highly effective in reducing the incidence of cervical cancer. To date, prevention efforts have focused on using the Pap smear to screen at-risk women and then treating the pre-cancerous lesions by removing the diseased tissue. In situations where screening quality and coverage is high, this procedure has significantly reduced the incidence of cervical cancer. In Latin America and the Caribbean, an estimated 63 percent of women have had a Pap smear. There is, however, great variability in coverage across countries. For example, PAHO survey data suggest that only 35 percent of women in Nicaragua have had a Pap smear at least once, compared with 70 percent in both Brazil and Costa Rica. In Haiti, there is no national screening policy for cervical cancer, and there are only a small number of cytologists throughout the country.⁹

Other factors such as age, education, income, and residence contribute to large differences in Pap smear coverage across the region. For instance, according to PAHO, in Brazil, Chile, and Mexico, women from lower socioeconomic status are less likely than their better-off counterparts to know of the Pap test or to have undergone a test. In addition, in some countries such as Ecuador, the incidence of cervical cancer is almost twice as high among women with no education or only primary education when compared to those with secondary or higher education. And women with the least education are more likely to be diagnosed with later stages of cervical cancer (stages III or IV) whereas women with higher education have their cancers detected earlier.⁹

When implemented properly, screening can be an effective intervention for cervical cancer. According to the IARC, screening once every three years can produce a 91 percent reduction in lifetime incidence of the disease, while an interval of five years confers an 84 percent benefit.¹⁰ Furthermore, treating the precancerous tissue protects women from developing cervical cancer in the future.

In addition to being easy and effective, screening and treatment of precancerous lesions is cost-effective when compared with expensive hospital-based treatment of invasive cancer. According to the World Bank, it costs about US$100 per disability-adjusted life year (DALY) gained to conduct cervical cancer screening (defined as screening women every five years, with follow-up for identified cases). This compares with about US$2,600 per DALY for treatment of invasive cancer and palliative care.¹¹

While screening and treatment programs have been highly successful in reducing deaths from cervical cancer in more developed countries, they have not been applied successfully in Latin America and the Caribbean. Researchers at PAHO have cited several specific weaknesses to implementing and sustaining screening and treatment programs. These include:

• Low levels of coverage for high risk women (those ages 35 to 64 who have no access to screening programs) and inappropriate repetitive screening of younger lower risk women (under 30) through family planning and prenatal care programs. This does not mean that younger women should not obtain Pap smears. Most screening programs miss older women who do not seek family planning and prenatal care programs and only come to medical attention at late stages of their disease.
• Lack of timely consultation due to a lack of understanding about cervical cancer or sociocultural barriers, or both, among women at risk; limited access to health services; and poor communication between women and their health care providers.
• Poor quality of cytology tests; lack of knowledge about other screening options; and insufficient monitoring, treatment, and follow-up for women with abnormal cytology results
• Little knowledge by policymakers about the total societal costs of various screening and treatment options.¹²

In order to surmount these weaknesses, some countries have restructured their cervical cancer screening programs. Strategies have been adopted to limit screening to women at highest risk of high-grade dysplasia, to reduce the frequency of screening among women who have had at least one normal smear, and to recommend regular follow-up rather than treatment for young women with mildly abnormal smears.

Screening Methods Other Than Pap Smears Can Also Detect Cervical Cancer

Visual inspection involves simply looking at the cervix for any signs of early cancer. Though this procedure has not been effective in identifying precancerous conditions, it has yielded positive results. Visual inspection with acetic acid (VIA) involves wiping the cervix with a solution of acetic acid (vinegar), illuminating the cervix, and then having a trained health care worker inspect the area with the naked eye. The vinegar causes precancerous tissue on the cervix to appear as white blotches. Results of several studies in developing countries have shown that VIA can be as effective as Pap smears in detecting high-grade lesions. According to researchers with JHPIEGO, a reproductive health agency affiliated with Johns Hopkins University, more than 75 percent of pre-cancerous lesions in cervical tissue can be revealed using this screening method.¹³ This procedure may become a first line of defense against cervical cancer in developing nations. It is less expensive and complex than Pap smear screening and may allow for screening and treatment to occur in the same visit. Using VIA will still require training a broad range of primary care providers to make determinations about proper treatment for precancerous lesions.

In addition to visual inspection procedures, other researchers have focused on using HPV testing to identify women at high risk for cervical cancer. These scenarios may prove promising for developing countries in the future; however, barriers such as cost and technical requirements prevent their use in low-resource settings.

Finally, there are also efforts underway to produce a vaccine for HPV. According to PATH, nearly 30 HPV vaccines are being tested in clinical trials. If effective, a vaccine would reduce the risk of cervical cancer significantly in the treated population. A viable vaccine against one or two types of HPV may be available in as little as five years.¹⁴

Two Relatively Simple Treatment Options

In addition to screening, adequate treatment services need to be provided. In the past, many countries have provided inadequate monitoring of women with abnormal cytology smears and have delayed confirming the diagnosis and treating the high-grade lesions. There has also been “overtreatment” of preinvasive cervical lesions with aggressive and costly approaches such as cone biopsy or hysterectomy, as opposed to more appropriate, outpatient approaches.

Two relatively simple treatment options exist for destroying or removing pre-cancerous tissue. One common method, cryotherapy, which involves freezing abnormal tissue, has an overall effectiveness rate of 80 percent to 90 percent. Cryotherapy has particular advantages in low-resource settings:

• The equipment can be relatively cheap and easy to operate.
• Specialist surgical skills are not required, although trained physicians must perform the procedure (often they are not available at the primary health care level).
• Complications are rare, although the procedure can have negative health effects such as bleeding, discharge, and cervical scarring.
• It reduces the number of visits a woman must make to receive proper care.

Another procedure, the loop electrosurgical excision procedure (LEEP), which uses a thin electrified wire to excise cervical lesions, also has high efficacy (90 percent to 95 percent). A PAHO survey of health professionals in the region indicated that many preferred and used LEEP.¹⁵

Education Is Key to Prevention and Treatment

Despite the availability of screening and treatment options for cervical cancer, many women in Latin America and the Caribbean do not know about the disease nor are they aware that detection and treatment can prevent the health problem. For instance, in one study carried out by researchers at Mexico’s National Institute of Public Health and the National Autonomous University of Mexico, nearly 42 percent of the women were not familiar with the purpose of the Pap test. Of this group, only about 3 percent had ever had the test.¹⁶ Another study conducted by a University of Chile researcher determined that Chilean women avoided taking the Pap test as they were afraid of being reproached by health-care workers for having failed to have the test at the recommended interval (60 percent), feared experiencing pain from the test (39 percent), feared bleeding (20 percent), and feared losing part of their uterus (14 percent). In addition, of the women with intrauterine devices, over 25 percent feared removal of the device.¹⁷

Efforts to improve women’s awareness and health providers’ knowledge of prevention options are critical to achieving a successful cervical cancer prevention program. Most importantly, information needs to reach all women but particularly those who are at the highest risk for treatable, pre-cancerous lesions (those between the ages of 35–60). PATH has recommended several approaches including using established communication channels like the mass media; local community and women’s groups, their children, and their husbands; and linking screening to an important event in a woman’s life such as becoming a grandmother. In addition, health providers need to be educated about the public health rationale for limiting the frequency of screening, focusing on older women, and emphasizing treatment of pre-cancerous conditions.¹⁸

Liz Creel is a population specialist at the Population Reference Bureau.

References

1. Jacqueline Sherris, Program for Appropriate Technology in Health (PATH), personal communication with author, November 2000.
2. Cristina Ferreccio, Pan American Health Organization (PAHO), personal communication with author, November 2000.
3. M. Matamala et al., “Calidad de la atencion desde un enfoque de genero,” Mujer, Salud y Desarrollo (Washington, DC: PAHO, 1995.)
4. Jacques Ferlay, D. Maxwell Parkin, and Paolo Pisani, “GLOBOCAN: Cancer Incidence and Mortality Worldwide” (Lyon, France: International Agency for Research on Cancer, 1998).
5. PAHO, Cervical Cancer Screening in Latin America and the Caribbean, November 1996.
6. Sylvia Robles, Franklin White, and Armando Peruga, “Trends in Cervical Cancer Mortality in the Americas,” Bulletin of the Pan American Health Organization 30, no. 4 (1996): 290-301.
7. PAHO, Health in the Americas, Vol. 1 (1998): 171-73.
8. K. Nasiell et al., “Behavior of Mild Cervical Dysplasia During Long-Term Follow-Up,” Obstetrics and Gynecology, 67, no. 5 (May 1986): 665-69; and P. Holowaty et al., “Natural History of Dysplasia of the Uterine Cervix,” Journal of the NCI 91, no. 3 (Feb. 1999): 252–58 as cited in Jacqueline Sherris and Cristina Herdman, “Preventing Cervical Cancer in Low-Resource Settings,” Outlook 18, no. 1, September 2000.
9. Anthony Miller and Sylvia Robles, “Workshop on Screening for Cancer of the Uterine Cervix in Central America,” Bulletin of the Pan American Health Organization 30, no. 4 (1996): 397-408.
10. Fabián Corral et al., “Limited Education as a Risk Factor in Cervical Cancer,” Bulletin of the Pan American Health Organization 30, no. 4 (1996): 322-29.
11. Miller and Robles, “Workshop on Screening for Cancer of the Uterine Cervix in Central America.”
12. D.T. Jamison et al., Disease Control Priorities in Developing Countries (New York: Oxford University Press, 1993).
13. PAHO, PAHO Backgrounder Sheet, accessed online at www.paho.org/
    
    English/Dpi/releases1999/rl990921.htm on Sept. 22, 1999.
14. The Lancet, March 13, 1999 as cited in Environmental Health Perspectives 107, no. 10 (Oct. 1999), accessed online at http://ehpnet1.niehs.nih/gov/docs/1999/107-10/forum.html.
15. Adrienne Kols and Jacqueline Sherris, “Vaccines: Promise and Challenges,” (Washington, DC: PATH, July 2000).
16. Amie Bishop, Jacqueline Sherris, Vivien Davis Tsu, and Maggie Kilbourne-Brook, “Cervical Dysplasia Treatment: Key Issues for Developing Countries,” Bulletin of the Pan American Health Organization 30, no. 4 (1996): 378-86.
17. Patricia Nájera Aquilar et al., “Factors Associated with Mexican Women’s Familiarity with the Purpose of the Pap Test,” Bulletin of the Pan American Health Organization 30, no. 4 (1996): 348-53.
18. Silvia Álvarez, “Knowledge and Fears Among Chilean Women With Regard to the Papanicolaou Test, Bulletin of the Pan American Health Organization 30, no. 4 (1996): 354-61.
19. Jacqueline Sherris, Planning Appropriate Cervical Cancer Control Programs (Washington, DC: PATH, 1997).

What Do These Terms Mean?

Cervix: the narrow passage at the lower end of the uterus, which connects with the vagina.

Cytologist: a person trained in the study of the structure and function of cells. The examination of cells under a microscope is used in the diagnosis of various diseases such as cervical cancer, where cells are obtained by scraping the cervix.

Palliative care: the World Health Organization defines this as the active, total care of patients whose disease is not responsive to curative treatment (or for whom curative treatment is not available). It aims to provide the best possible quality of life for patients and their families. Palliative care includes control of pain, of other symptoms, and of psychological, social, and spiritual problems.

For More Information

The Alliance for Cervical Cancer Prevention was formed in 1999 with the support of the Bill and Melinda Gates Foundation to clarify, promote, and implement strategies to prevent cervical cancer in developing countries. It is composed of five international agencies:

• EngenderHealth, a family planning and reproductive health agency,
• the International Agency for Research on Cancer (IARC), WHO,
• JHPIEGO Corporation, a reproductive health agency affiliated with Johns Hopkins University,
• the Pan American Health Organization (PAHO), WHO, and
• PATH (Program for Appropriate Technology).

For more information about the Alliance, visit their website at www.alliance-cxca.org