Article on Cervical Cancer - Silent Killer in Uganda - and news about vaccines arriving there..

Silent killer
By BAMUTURAKI MUSINGUZI

IT’S A PAINLESS DISEASE — SO you can’t easily tell that you are infected with cervical cancer,” says Peace Amanyire. “Many women have it, but they don’t know.”

In her case, Ms Amanyire only discovered that she had the disease when she noticed a discharge, which she mistook for urine three years ago.

But even a gynaecologist in Kampala reached the wrong conclusion, telling her that she was going through her menstruation period.

“In 2002 I visited a gynaecologist for a biopsy test and his conclusion was that I was in my menstruation periods. I told him that I had not had menstruation for two years, but he insisted he knew these things better because he was a doctor,” says Ms Amanyire.

“I later developed a constant flow of discharge which made my life uncomfortable,” she says, adding that, “I thought my gall bladder had a problem. It is only after I visited another doctor in August 2005 and another biopsy test was done that I learnt that I had cervical cancer. I then underwent a major operation to remove the tumour the following month.”

Cervical cancer is caused by the human papilloma virus (HPV), which is sexually transmitted. Persistent infection with HPV is responsible for 99 per cent of all cervical cancers.

The disease primarily strikes women aged 35-50. This has catastrophic consequences on families and communities, especially in developing countries where women are the backbone of society.

It exacerbates the already damaging effects that HIV/Aids has on communities where women are often burdened with the responsibilities of catering for extended families, the sick or orphaned children.

HPV is the most common sexually transmitted infection in the world. There are more than 100 strains of the virus, but only a handful cause cancer. Women are usually infected in their 20s or early 30s, but they don’t show symptoms until much later, so they are not aware. Without screening, there are no warning signs until the cancer has become life-threatening.

After her operation, Amanyire, 50, went public about her condition and on formed the Women’s Awareness Against Cervical Cancer (WAACC).

She is the country director of WAACC, which has 26 members in Uganda. Its major objective is to create awareness among women about the disease and to sensitise them about the need to go for regular check-ups.

WAACC wants the government to develop a policy that will compel women who seek other services at health units to test for cervical cancer as well. Men should also be sensitised to stand by their wives when they are found to be suffering from the disease.

According to Ms Amanyire, lack of knowledge by health providers about the disease has meant that women only learn that they are victims late in life. “Health providers lack information on cervical cancer to sensitise women on its symptoms and dangers. If, for example, I had known about my status much earlier I wouldn’t have reached the point of being operated on,” she said.

Ms Amanyire says there are no facilities in Uganda to detect the disease, especially in upcountry hospitals where patients are always referred to Mulago National Referral Hospital in Kampala and some can’t afford the costs.

“It is saddening that cervical cancer is one of the leading killer diseases in Uganda and nothing is being done to save the lives of women,” she says. “We shouldn’t be dying of cervical, breast and prostrate cancer, which are preventable in this modern age.”

Ms Amanyire, married and a mother of six, notes that the disease is stigmatising at its fourth and fifth stages (fully blown) when both urine and faeces flow out easily and uncontrollably, attracting flies around the victim. “If you don’t have somebody to attend to you, no one will want to be around you. Even your husband will abandon you and most men have done this,” she says.

T HE DISEASE FFECTS MORE than 500,000 women worldwide each year, killing more than 250,000. Eighty per cent of the fatalities occur in developing countries where prevention and treatment are not available, making it the most common cause of cancer-related deaths for women in these countries.

Health experts warn that if the current trends continue, by the year 2050 there will be over one million new cases annually.

In Uganda, statistics show that the median age of a person diagnosed with breast cancer is 45, while for a cervical cancer, it is at 43. And the prognosis for most Ugandans with cancer is poor: Only 45 per cent of breast cancer patients and 18 per cent of cervical cancer patients survive five years after diagnosis, in part, researchers believe, because the cancers is diagnosed at a late stage.

Cervical cancer is the most common cancer affecting women in Uganda. Over 80 per cent of women diagnosed or referred to Mulago Hospital with cervical cancer are at an advanced stage.

However, plans are underway for systematic screening programmes based on visual inspection, as pap smear screening is not not easily available. Effectiveness of population screening programmes requires high uptake and for cervical cancer, minimal loss to follow up.

Uganda has a poor reproductive health services uptake; 10 per cent postnatal care attendance, 23 per cent contraceptive prevalence and 38 per cent skilled attendance at delivery.

Barriers identified after analysis by the Department of Obstetrics and Gynaecology at Makerere University Medical School include ignorance about cervical cancer, cultural beliefs, economic factors, domestic gender power relations, alternative sources of reproductive health knowledge, and unfriendly healthcare services.

The findings of the study released in June show that knowledge about cervical cancer among Ugandan women is low. “For an effective cervical cancer-screening programme, awareness about cervical cancer needs to be increased,” it says, and adds, “Health planners need to note the power of the various authoritative sources of reproductive health knowledge and involve them in the awareness campaign.”

Cultural and economic issues explain the perceived reluctance by men to participate in women’s reproductive health issues. Men are potentially willing partners if appropriately informed.

Health planners need to address the apparent loss of confidence in the healthcare delivery system, as well as consider use of other cervical cancer screening such as mobile clinics or camps, the researchers say.

In January and February 2006, WAACC interviewed women and healthcare providers in Uganda and discovered various factors. Women in polygamous unions attributed the cause of the disease to witchcraft by their co-wives; some health providers claimed that it was due to unfavourable changes in body cells; while others said it was sexually transmitted.

Yet others claimed that when you have more than five children, you are likely to get the disease.

Besides, new vaccines which protect against the most dangerous strains of HPV are largely unavailable in developing countries.

Vaccines and innovations in HPV screening and treatment for women have the potential to end the threat of cervical cancer worldwide.

Effective screening programmes in rich countries catch the disease early and have cut death rates by more than 80 per cent.

New, simple and cost effective screening techniques exist, but are scarcely used in the developing world.

At the beginning of 2008, young women in Uganda, India, Peru and Vietnam will become the first in the developing world to live without fear of cervical cancer as PATH International and its partners begin the pilot introduction of new vaccines for the disease. These four countries are laying the groundwork for vaccination throughout the developing world.

PATH is an international, NGO that creates sustainable, culturally relevant solutions, enabling communities worldwide to break long standing cycles of poor health. By collaborating with diverse public and private-sector partners, it helps provide health technologies and vital strategies that change the way people think and act.

WORKING CLOSELY WI- with its government partners, PATH is supporting HPV vaccine demonstration projects in the four countries. All the countries have shown a commitment to preventing cervical cancer, have strong existing vaccination programmes, and are likely to expand successful demonstration projects.

Results from pilot tests in the four country projects will be synthesised and widely disseminated to inform HPV vaccine policy, programming and funding decisions made by other countries and by regional and global agencies.

This advocacy and dissemination role will build on existing advocacy mechanisms developed by PATH and will be implemented in close collaboration with the World Health Organisation and other global partners.

PATH says that since it is usually babies who receive routine vaccinations, new delivery strategies will be needed to reach the young people.

The NGO has signed a memorandum of understanding with the government of Uganda to allow decision making in introduction of cervical cancer vaccine.

Already, there are two vaccines on the global market — Cervarix by Glaxo Smith Klein, and Gardasil by Merck Company. Both have been proven effective and are licensed in over 50 countries, including Kenya.

“We expect Uganda to license these vaccines before the end of this year,” said PATH Uganda Cervical Cancer Vaccine Project country manager, Emmanuel Mugisha.