Cervical cancer is a serious health problem, with nearly 500000 women developing the disease each year worldwide. It is a significant public health problem in developing countries like Nepal, India. It is the second most common cancer and a leading killer among women worldwide and is the principal cancer of women in most developing countries, where 80 percent of cases occur.1 The primary cause of carcinoma cervix is Human Papilloma Virus (HPV) infection, the most common sexually transmitted infection worldwide.
Cervical cancer causes and risk factors include:
- Human papillomavirus (HPV) infection.
- Having many sexual partners.
- Smoking.
- Birth control pills (oral contraceptives) used over the long term.
- Engaging in early sexual contact.
Symptoms of cervical cancer include:
- Vaginal bleeding after coitus.
- Vaginal discharge.
- Pain or Bleeding after coitus
- Painful Urination
- Abnormal vaginal bleeding
- Abnormal menstrual cycles
Five million new cervical cancers are detected each year causing 266,000 deaths worldwide of which 80% occurs in developing countries.1 Cervical cancer is a major public health problem, especially in developing countries. It has a long precancerous phase (10 years or more) before it develops into invasive cancer. It can be prevented through the implementation of a routine screening program. Routine screening program has reduced its mortality by more than 70% in developed countries.2 Visual inspection of cervix with the application of 5% acetic acid (VIA) and with Lugol’s iodine (VILI), Papanicolaou’s smear test (PAP smear), liquid-based cytology (LBC), human papillomavirus deoxyribonucleic acid test (HPV DNA) and colposcopy are different methods for its screening. VIA is a simple and cost-effective test which can be performed by all level of health workers. Colposcopy and biopsy are the gold standard but are expensive and need skilled manpower. It is also a major cause of morbidity and mortality in Nepal, as in other countries within South Asia and developing countries worldwide, where some suggest it causing as high as 34% of all cancers in women.2 A Pap test is the best way to detect cell changes that may be an early sign of the pre-cancer of the cervix. There are now other screening tools available e.g. visual inspection of cervix with acetic acid (VIA) for resource-poor settings, and HPV DNA test for those who can afford.
The use of HPV prophylactic vaccines among young adolescents (ages of 9-13), who have not been previously exposed to the infection, as primary prevention holds most promise for the prevention of cervical cancer.3 But, the unfortunate reality of this disease is that in spite of its being completely preventable, we in developing countries, unlike in the west, have not yet been able to prevent it.4
Vaccinations are one of the most successful public health approaches to preventing and controlling many infectious diseases. New vaccines (Gardasil and Cervirax), a great breakthrough of the 21st century, are available which protect against the major types of HPV that cause the most cases of cervical cancer. They are highly effective in preventing the HPV infection and are already available in the developed world. It costs the US $360 for a set of three doses. The second and third doses should be given at two and six months after the first dose. As the vaccine does not protect against all types of HPV and will not prevent all cases of cervical cancer or genital warts, women who are vaccinated should still have regular Pap tests. The vaccine which is very safe to use is a preventive tool and is not a substitute for cancer screening.
Though the vaccine will be most effective if received before the onset of sexual activity (9-13 years of age), vaccination can be offered to those who are already sexually active as well, regardless of a previous history of HPV infection or an abnormal Pap test.
An effective HPV vaccine, and one that is accepted, could have enormous public health benefits for both men and women by decreasing the morbidity and mortality associated with HPV related cancer. The mass administration of an HPV vaccine provides great potential for improving the health of millions of women, as well as men and it has the potential to reduce cervical cancer deaths around the world by as much as two-thirds, if all women were to take the vaccine and if protection turns out to be long term. The approval of the vaccine against cancer-causing HPV strains is significant in the public health world, but more so in developing countries that lack the health care resources for routine cervical cancer screening, therefore saving millions of lives.
Society generally perceives that cervical cancer is the problem of women, and believes there is minimum or no role of men in transmitting the virus to women. However, the contrary is true, and to prevent infection from HPV to females, males should be vaccinated as well. Moreover, there are disputes over whom to vaccinate and whether it should become a national program run by the government or paid by adolescent’s parents.
Even though the vaccine provides protection from developing HPV-associated cervical cancer, many adolescents are reluctant and their parents are not endorsing the vaccination due to the barriers such as parental acceptability, fear of promiscuity in the teenagers, myths, and high cost. There is still uncertainty about whether the vaccine can last its immunogenicity for long or just a few years. The protective effects of the vaccine are proven to last a minimum of 8 years after the initial vaccination. Other unresolved issues include long-term protection, cross-protection against HPV types not included in the vaccine, and whether booster doses will be needed. Another issue of concern is the high cost associated with the vaccination; with the present cost, it is practically impossible to implement mass vaccination in countries like Nepal. Another concern is about the
of concern is the high cost associated with the vaccination; with the present cost, it is practically impossible to implement mass vaccination in countries like Nepal. Another concern is the argument that vaccination could “promote promiscuity” but there is no evidence suggesting a connection between a decrease in HPV and an increase in sexual activity. Lack of awareness, public demand, and political will, lack of coordination between cancer control, sexual and reproductive health, and vaccine delivery services are additional challenges.
The single-most barrier to the introduction of the vaccine for adolescents is the unaffordable high price. From a public health perspective, the first priority in resource-poor settings would be to vaccinate young adolescent girls by school-based or community-based vaccination programs.5
And there are rays of hope, the noble work of vaccinating our school girls have been initiated in developing countries too and GAVI’s announcement of providing the vaccines to developing countries at highly subsidized price (the US $ 5 per dose) is also a positive step.
This is now high time that a serious consideration for widespread use of the HPV vaccine in this country needs the topmost priority. This will only be possible through public awareness, cultural acceptability, political will, policy formulation, and public support.