250 000 women die from cervical cancer every year. And yet we have the means to prevent it.
Why does this not always happen?
2.3 million Women have cervical cancer, every year there are 500 000 new cases and 250 000 people will die of the disease.
As frightening as the numbers may sound, we already have the tools to prevent the vast majority of these cases. As with many health interventions though, getting them out there, and getting people to make use of them is a whole different problem.
Professor Lynette Denny, of the Gynaecology Oncology Unit at the University of Cape Town, describes cervical cancer as "a disease of inequity of access to health care."
This is underlined by the fact that 80% of new infections and deaths occur in the developing world - where it is the most common cancer in women. Indeed, in Spain the incidence rate is 3.7 cases per 100 000 women, while the rate in Zimbabwe is 54.3 - more than 14 times higher.
The lifetime risk of developing cervical cancer for black women in South Africa is 1 in 26 compared to 1in 80 for white women, says Denny and the disease claims more than 3 400 South African women every year, according to the Cancer Association of South Africa (Cansa).
The screening short-fall
The good news about cervical cancer is that, if picked up early, it can be treated with a very high success rate. Thus, screening programmes form a key part of keeping the cancer at bay.
"In the developed world mass Pap smear-based screening programmes, both organised and unorganised, have rendered cervical cancer a relatively rare disease," says Denny.
By contrast, virtually no developing countries have managed to either initiate or sustain Pap smear screening programmes, she says.
Amongst other things, Denny says, this lack of efficient screening is a result of:
The fact that financial, human and capital resources are limited,
health care infrastructure is often lacking,
cervical cancer has to compete for resources with diseases like HIV/Aids, malaria, and tuberculosis, and
that some developing countries are plagued by endemic civil strife, war, environmental instability and widespread poverty.
In addition, there are various issues around shame and stigma - relating to things like unusual vaginal discharge - that often keep women from seeking help until it is too late to effectively treat the cancer.
How it works in SA
In South Africa, every woman is entitled to three free pap smears on the public health system - at ages 30, 40, and 50. This screening regime is predicted to reduce cases of cervical cancer by 67%
Once again though, it is very much a matter of balancing the books. If for example, every woman was screened annually for 30 years, it is estimated that rates would drop by 93%. Such a programme would, however, be more expensive and harder to implement.
So far though, the implementation of the screening programme has been "patchy" says Denny, although she is quick to point out that it is now being prioritised in most provinces. She says that an estimated 5 million Pap smears need to be performed to catch up with the current backlog.
According to Cansa, fewer than 20% of women in South Africa have ever had a Pap smear.
The way screening is done may however change quite drastically over the coming years. While current DNA-based screening tests are too expensive for public health systems, new ones are being developed that may be both faster and more affordable.
In addition, visual inspection methods also show promise for areas where no other screening is available.
Expensive but effective
The recent development of vaccines for strains of the human papilloma virus (HPV), t he virus that causes most cases of cervical cancer, have the potential to massively reduce the prevalence of the disease. According to Cansa, "vaccination could eradicate cervical cancer in time."
Vaccination would be an ideal solution for poor countries as the infrastructure required to dispense vaccines is much less complex than that required by other prevention strategies, says Denny.
"It is estimated that the vaccine will prevent at least 70% of all cases of cervical cancer. We see about 6 500 cases per year and 50 - 60% of these women die per year," she says.
Thus, the vaccine is expected to prevent at least 4 550 infections per year in South Africa and save an estimated 2 300 lives annually.
The price to pay
As Cansa points out though, the vaccines are very expensive. And, it is widely felt that the high cost of the vaccines makes it unlikely that they would be provided by public health systems in developing countries any time soon.
Currently, two vaccines are registered in South Africa - Merck's Gardasil and GlaxoSmithKline's Cervarix. The private sector price for Gardasil is R770 (excluding VAT) per unit. Since the vaccine has to be injected three times, the total cost is R2 310. Cervarix costs R700 per unit.
According to Cansa - who have been campaigning for a vaccine in the public health system - it is estimated that about 300 000 South Africans should be vaccinated every year, which works out to about R630 million per year at current costs.
With economies of scale and special prices for emerging economies, Cansa points out, the vaccine price could drop to about R1 000 per person, which would amount to about R300 million per annum.
According to Merck though, there have not been any negotiations with government regarding special prices for the public sector. They did however say that they are "working with a range of partners, including Government and non Government organisations, to bring our new vaccines to as many developing world countries as soon as possib le."
Denny thinks it will take another 10 years before a vaccine is widely available in poor countries. "During this time the commercial companies would have recouped their expenditure and made their profits, and hopefully the price will have come down substantially."
But even though cost is an important factor, Denny points out that creating an adolescent health platform in order to target the most important group for vaccination is also a challenge, and will require resources.
- (Marcus Low, Health24, July 2008)