Part of South Africa’s strategy to prevent cervical cancer was to adopt a programme that was successful in high-income countries such as the UK and the US. But, 13 years after its implementation, the policy has failed to kick off and its success is limited.
Cancer of the cervix is preventable but remains one of the common cancers among women in South Africa. It is the most prevalent cancer among African women, who account for about 80% of the country’s female population. It is also the most common cancer affecting women between the ages of 15 and 45. Every year, more than 4000 women die from cervical cancer in South Africa.
Screening for cervical cancer involves identifying abnormalities on the cervix, the mouth of the womb, that could develop into cancer in the future. These pre-cancerous abnormalities are then treated to reduce the chances of them developing into cancer.
South Africa adopted a national cervical cancer screening strategy policy in 2002, which uses Pap smear testing. The government aimed to reach 70% of women in ten years. But, by 2014, only 14% had been reached, showing the testing method to be a dismal failure.
The problem is that Pap smears do not lend themselves to an environment where the majority of women are poor and often have to travel great distances to get to a clinic or see a doctor.
Learning from the neighbours
Between 2006 and 2010, three countries neighbouring South Africa introduced very different screening and treatment methods on a wide scale. These involved three affordable and safe procedures – one for screening and two for treatment. Importantly, they can all be done during one visit to a health care worker or clinic.
Zambia, Botswana and Zimbabwe introduced a screening method known as the visual inspection with acetic acid (VIA). Cryotherapy and loop electrosurgical excision procedures are treatment plans to treat pre-cancerous lesions of the cervix.
During visual inspections, vinegar (acetic acid) is applied to the cervix for a few minutes to turn any abnormal areas white. Depending on the size and characteristics of the white area, it can be frozen or cut off. If the lesion is too big to be cut out with an electric current, or is suspected to be cancerous, other procedures are done.
But South Africa has delayed using visual inspections as the mainstream screening strategy for cervical cancer prevention. Visual inspection trials were done in the country but were never implemented nationally.
As early as 2005, local trials showed the visual inspection method was safe and effective. There were less abnormal growths on women who had done the visual inspection screening than on those who went through the delayed evaluation at both six and 12 months.
A landmark study in India two years later also showed the success of the visual inspection screening and treatment, proving the method reduced deaths from cervical cancer and not only the abnormal growths.
South African women are in a particularly vulnerable position. More than three million are living with HIV and as a result are approximately five times more at risk to cervical cancer compared to women who are not infected.
The benefits of another approach
Pap smears present a number of problems in a developing world context. The tests rely on a recall system, where a woman goes for an initial consultation and the sample is sent away for testing. The woman is then called back if an abnormality is found.
Problems that have arisen include results getting lost because they have to be sent to a laboratory, or women failing to make the return visit because of poor transport or lack of money. Because cervical cancer is caused by the Human Papilloma Virus (HPV), another method to screen for the cancer is by using the HPV test. However, the HPV test also needs a visual method if it comes back positive.
In addition, Pap smears and the HPV tests are more expensive than VIA.
Also, the HPV test is generally only recommended for women who are 30 or older. This means that a large cohort of women aren’t covered by the test. Research shows that 20% of all women diagnosed with cervical cancer in South Africa are below 40. Cervical cancer takes about ten years to develop. This means these women had potentially treatable cervical pre-cancerous lesions below 30, which may have been picked up.
The South African government has introduced schoolgirl HPV vaccination as part of its expanded immunisation programme. This will reduce the burden of cervical cancer. But the country still needs to continue screening to prevent cervical cancer.
The advantage of visual inspection screening is that it is driven by nurses, who make up the bulk of the South African health workforce. On top of that screening, a treatment can be done in one sitting and the tests don’t have to be sent to a laboratory. Women are saved the expense and inconvenience of having to return for multiple visits.
Another lost decade
The cervical cancer screening programmes in Zambia, Zimbabwe and Botswana are already starting to pay off. In Zambia, more than 100,000 women have been screened for cervical cancer in seven years. Of the women who were screened, 20% had the early signs of cervical cancer and close to 90% of the women received same day service.
Although South Africa has a larger population than all three countries, had it implemented a national programme at the same time, it too may have seen better screening rates. South Africa also has much better resources. It has just over one doctor for every 2000 citizens while Botswana has one for every 4000 people and Zambia and Zimbabwe one to 8000 people. In addition, South Africa spends close to 9% of its gross domestic product on health care compared with Zambia and Botswana’s 5% on average.
South Africa’s health minister, Aaron Motsoaledi, has referred to the period of South Africa’s inaction on HIV/AIDS as the lost decade. South Africa is at risk of having another lost decade with cervical cancer prevention if it does not change its approach soon.
[hr] Gwinyai Masukume is Medical Doctor, Epidemiologist and Biostatistician, School of Public Health, Faculty of Health Sciences at University of the Witwatersrand.