Dechen Tshomo
About five in 100,000 women die of cervical cancer every year in Bhutan.
The population based cancer registry, 2014 to 2018 report, which is yet to be published shows that the country has an age-standardised incidence rate of 19.9 and age-standardised mortality rate of 4.7 per 100,000 women.
A gynecologic oncologist with the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Dr Ugyen Tshomo, during the national workshop towards cervical cancer elimination held in Thimphu last week, said these are true figures, not estimates.
“It means about 20 women out of 100,000 gets cervical cancer every year and about five die,” she said. Bhutan’s incidence rate per 100,000 exceeds the world rate, which is 14 per 100,000.
Cervical cancer is the fourth most common cancer in females worldwide, representing 12 percent of cancers in women. The number has come down in developed countries because of the screening, she said, In America, it is now the 14thmost common cancer.
About 85 percent occurs in the developing countries, and it remains fourth in the developing countries, as there were no screening programmes in most of the developing countries. South and South-East Asia carry 50 percent of the world’s burden.
In Bhutan, Dr Ugyen Tshomo said that cervical cancer continues to be the most common cancer in women. It is also the most common cause of cancer deaths.
“Although our incidence is high, the number of deaths is less. This could be because our screening programmes are picking up women with cancers at an early stage,” she said. “In the past, death was also very high.”
Cervical cancer is also the most common cancer referred for treatment. Surgery could be done at an early stage of cervical cancer, but radiation therapy is the main treatment for the cancer at an advanced stage.
While JDWNRH has started providing radiation therapy since January 2018, Dr Ugyen Tshomo said complete treatment for cervical cancer is not yet available.
Causes and risks
Early marriage, early age at first childbirth, multiple sexual partners of a woman or her partner, human papillomavirus (HPV) and other STIs infection, Immunosuppression (the partial or complete suppression of the immune response of an individual), cigarette smoking, prolonged oral contraceptive pill use, are the risk factors for cervical cancer.
If a woman gives birth to her child before she is 17, she is seven times more likely to get cervical cancer.
Dr Ugyen Tshomo said Bhutan has all these risk factors. The biggest risk, she said is not having enhanced screening programme. “When women come to us with abnormal bleeding, we always ask if she has done pap smear. If she has not, then she is more likely to suffer from cervical cancer.”
In terms of age, a majority of the women diagnosed with cervical cancer are between 40 and 60 years.
In the past, cervical cancer was most common in women who are in 40s and the deaths were also more common in woman in this age. But, deaths from cervical cancer now has shifted to women aged in 50s and 70s.
“Deaths are more in older women because they do not participate in screening. By the time the cancer is diagnosed in them, it is at an advanced stage,” she said.
It was found that cervical cancer incidence is more common in women from the eastern dzongkhags. Trashigang has the highest incidence, followed by Mongar and Wangdue.
“In cancer, we always see the ethnicity because different ethnic groups have different cultures and customs,” she said.
High incidence, she said could be because of high or poor screening coverage, poor access to treatment of pre-cancers, or poorer socio-economy. It could also be because there is only one treatment centre.
If there are no treatment centres, she said dzongkhag health officers and the public should demand.
She said that just having a pap smear test is not be enough. The test must pick up abnormal pap smears and these women with abnormal test result must undergo treatment. “This is the most important part of the screening.”
If a woman with an abnormal pap smear report is not treated then the test has not done her any good, she said.
Prevention
Primary prevention of cervical cancer can be done by providing sexuality education including educating the women on the risk factors and vaccination against HPV.
In secondary prevention, the focus is on the screening and early detection. Women who are infected with HPV should be treated.
Dr Ugyen Tshomo said that HPV is the necessary cause of cervical cancer which is a sexually transmitted infection. “According to our studies, nearly 40 percent of the young women were infected with HPV.”
In 80 to 90 percent, the HPV infection disappears meaning it gets rid of by the host immunity. In 10 to 20 percent, the HPV will persist and develop into cervical intraepithelial neoplasia (CIN) and it is these women who are a higher risk of getting the cancer if not treated.
Tertiary prevention is provided when a patient suffers from the cancer. The patient is treated with radiation and surgery to prevent death and providing palliative care.
Information is one of the three important things in prevention of cervical cancer.
Dr Ugyen Tshomo said that informing women of cervical cancer and its prevention would attract as many women as possible to use the services. “Aim at women in their 30s and 40s to make your programme cost-effective.”
Screening younger women will lead to exhaustion of resources without bringing down cancer incidence since most of the HPV infection and CIN will disappear in this age group.
Screening as many women as possible is also important so that coverage of more than 70 percent is maintained.
She said that there should be a linkage between screening and treatment centres to decrease loss of follow up. “The health assistants in the dzongkhags have to make appointments with the colposcopy centre and send the women on a fixed date so that she gets the service.”
Currently, the country has 14 cytology centres and six colposcopy or LEEP (loop electrosurgical excision procedure) centres.
“If any of these is not working then the pap smear programme will fail,” she said.