Public Health Seminar

1. Seminar on
Epidemiology of cervical cancer in Nepal: Current scenario,
public health strategies, and interventions
Under the guidance of
Hari Prasad Kaphle
Associate Professor (Public Health)
By
Sujata Adhikari
At
Faculty of Health Sciences
Pokhara University
2019
1

2. Introduction
• Cervical cancer is widely prevalent among women mostly of low and
middle income countries.
• It is the 4th most frequent cancer in the world after breast, colorectal,
and lung cancer.
• Cervical cancer occurs in the cells of cervix, the lower part of uterus
that connects to the vagina.
2

3. Contd..
• Human Papilloma Virus infection, 1st intercourse at early ages,
multiple sex partner, smoking, decreased immune system, past history
of carcinoma and so on are the risk factors of cervical cancer.
• It has been evidenced that HPV infection is the principal factor for the
causation of the cervical cancer.
• The major elements for cervical cancer control are screening program,
primary prevention, early diagnosis and treatment.
3

4. Contd..
• Cervical cancer screening program have reduced the incidence and
mortality rate in developed countries by 80%.
• However in developing countries like Nepal, lack of information,
unaffordability, lack of skilled human resources hinders the screening
program.
4

5. Global scenario
• About 528,000 new cases of cervical cancer are diagnosed each year.
• 85% of the cases are seen in developing countries.
• In 2012, 266,000 women died due to the cervical cancer.
Out of them 231,000 women lived in the low and middle income
countries.
And 35,000 women lived in the high income countries.
• According to GLOBOCAN 2018, cervical cancer is ranked in 4th in
most frequent cancer in the world after breast, Colorectum and lung
cancer
5

6. Regional scenario
• GLOBOCAN 2018 reported that,
• The highest regional incidence and mortality rates of cervical cancer
are seen in African region.
• The rates are 7 to 10 times lower in North America, Australia/ New
Zealand, and Western Asia
• Similarly, In South East Asian region, the incidence rate of cervical
cancer is 17.2 per hundred thousand
• The mortality rate of cervical cancer is 10.0 per hundred thousand
6

7. 48.1
40.1
29.5
27.7
26.8
17.2
16
15.5
15.2
14.2
13
13
10.9
9.5
7.8
7.2
6.8
6.4
6
4.1
20
30
23
18
21.1
10
6.1
8.5
7.1
6.3
7
8.2
4.1
2.1
2.2
5.1
2.1
1.9
1.7
2.5
0 10 20 30 40 50 60
Southern africa
Eastern Africa
Western Africa
Melanesia
Middle Africa
South Eastern Asia
Eastern Europe
Caribbean
South America
Micronysia/Polynesia
Central America
South central Asia
Eastern Asia
Northern Europe
Southern Europe
Northern Africa
Western Europe
Northern America
Australia/Newzealand
Western Asia
Mortality Incidence
Age standardized rate per 100,000
Fig: Region specific incidence and mortality Age-Standarized Rates for cancer of cervix in 2018
Source: GLOBOCAN 2018
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8. WHO regional comparison of cervical cancer
WHO Regions Cases (in thousand) Death (in thousand)
African 92 57
American 83 36
Eastern Mediterranean 15 8
European 67 28
South East Asia 175 94
Western Pacific 94 43
World 528 266
*International agency for Research on Cancer, WHO, 2015 (GLOBOCON 2012)
8

9. Annual age incidence rate of cervical cancer in
SEAR
2.8
7.9
8.8
11
12.8
13.1
19
19.2
22
0 5 10 15 20 25
Iran
Pakistan
Afghanistan
Maldives
Bhutan
Sri lanka
Nepal
Bangladesh
India
Cervical cancer: Age standardized Incidence rate per
100,000 women per year
www.hpvcentre.net,Feb7,2014
9

10. Nepalese context
• In Nepal, 2332 women are diagnosed with cervical cancer and 1367
die each year
• The age standardized annual incidence of cervical cancer in Nepal is
19 per 100,000 (WHO information center on HPV and cervical
cancer)
• 80.9% of cervical cancer cases are diagnosed in late stages in Nepal
• Women living in the rural areas and mountainous areas are at greater
risk of developing cervical cancer.
10

11. Age wise distribution of cases (1998-2008)
Age Group Total cases (%)
<30 110 (3%)
30-39 472(14%)
40-49 1112(33%)
50-59 944(28%)
60-69 505(15%)
>70 227(9%)
Jha et al. A scenario of cervical cancer in a cancer Hospital
11

12. Risk factors of the cervical cancer
1. Infection with Human Papilloma Virus
• Human Papilloma Virus is the group of viruses.
• There are greater than 100 types of Human Papilloma Virus and 14 of
them are cancer causing.
• The virus is transmitted during the sexual activity
• The human papilloma virus type 16 and 18 are responsible to cause
70-80% of cervical cancer.
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13. Contd..
2. Weakened immune system
3. Use of oral contraceptives
Many research have shown that if the women uses the oral contraceptive pills
for more than 5 years, it increases the risk of developing the cervical cancer
4. Tobacco smoking
• The cells of the cervix is damaged by the chemicals of tobacco
5. Multiple sex partner
6. Low socio economic status
7. 1st intercourse at early age
13

14. Symptoms
1. At early stages:
There is often no symptoms at early stages. But if present, shows the
following symptoms:
• Discharge from vagina
• Abnormal bleeding after sexual intercourse
• Bleeding after menopause
• Heavy menstrual period
14

15. Contd..
2. At late stages
• Loss of weight
• Fatigue
• Back pain
• Bone fracture
• Leaking of urine from vagina
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16. Public health strategy
WHO recommended the following strategies for the National cervical
cancer control and prevention
• Development of national policies and guidelines
• Provision of health information
• Vaccinating the girls of age group 9-13 years before they become
sexually active.
• Cervical cancer screening to identify the precancerous lesion
• Treatment of the cancer before it spread to other organs
• Cancer registry system to monitor the incidence and mortality rate of
cervical cancer.
16

17. Contd..
1. Development of national policies and guidelines
- Government of Nepal has developed the National policies and
guidelines for cervical cancer screening and prevention in Nepal in
2010.
- It aims to provides pre and post screening counselling to the women
and their family
- It focuses on providing accessible and affordable services to the
women residing in rural areas
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18. Contd..
2. Provision of health information
• Health education, counselling, awareness raising are the prime
elements of cervical cancer prevention and control.
• It helps to increase the vaccination coverage, screening coverage and
treatment.
• Health education messages aware the women, families, communities,
about cervical cancer, its risk factors, and prevention methods.
18

19. Contd..
• Health care providers should be appropriately trained to discuss
sexuality in a non judgmental way.
• They should respect the confidentiality of patient.
• If possible, health care facilities should provide the private room to
individual women for counselling and education. So that they can
make a better decision.
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20. Contd.
3. Vaccinating the girls of age group 9-13 years
• The human papilloma virus type 16 and 18 are responsible to cause
70-80% of cervical cancer.
• Human Papilloma Virus Vaccine prevents the infection from HPV 16
and 18
• In Nepal, this vaccine is recommended for girls as well as boys aged
11-12 years as a 2 doses
• Vaccinating the girls before they become sexually active is
recommended.
20

21. Contd..
4. Cervical cancer screening
Cervical cancer screening should be carried out by target women (30-49
years) at least once to prevent from the cervical cancer.
5. Treatment of cancer before it spread to other organ. The treatment
option are surgery, radiation therapy, Chemo therapy
6. Cancer registry system to monitor the incidence and mortality rate of
cervical cancer
• Cancer registry will provide the opportunity to the national cancer
control program to comprehensively address the different types of
cancer
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22. Public health intervention
1. Cervical cancer screening:
• According to WHO, screening is one of the major public health
intervention.
• Screening test is performed in an asymptomatic women (30-49 years)
who are at risk of developing disease
• Pap smear test tends to be more effective in reducing the incidence and
mortality of cervical cancer.
22

23. Contd..
• Various screening program have been implemented in developed and
developing countries which helps to identify the cervical cancer at an
early stages.
• Early treatment can reduces the cancer up to 80%.
• However, very few screening program (only 5%) have been
implemented in developing countries and about 40-50% screening
program in developed countries.(4,5)
• In Nepal, 2.4% women are involved in cervical cancer screening
program. (Human Papillomavirus and Related Cancers Fact Sheet
2013, 2014)
23

24. Contd..
• The reason for few screening program in developing countries are
inadequate skilled and competent human resource, lack of information
about the etiology, diagnosis and treatment of cervical cancer, cultural
belief, lack of awareness about the screening test and its benefit and so
on.
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25. Contd..
• For cervical cancer to be beneficial, the women with positive
screening result should receive the treatment.
• The “screen and treat” approach or “screen, diagnose and treat”
approach is necessary.
• In the “screen and treat” approach, the decision to take treatment
depends on the screening result.
• Positive screening result is followed by the immediate treatment
without diagnostic test.
25

26. Contd..
• In the “screen, diagnose and treat” approach, the positive screening
result is followed by the diagnostic test such as colposcopy, Biopsy to
histologically confirm the pre cancer diagnosis.
• Treatment depends upon the result of histological confirmation.
26

27. Contd..
2. HPV vaccination
• WHO recommends the girls of age group 9-13 years to be immunized
with HPV vaccine.
• Education and the messages regarding the HPV vaccines, HPV
infection, cervical cancer are needed to be delivered to the community,
parents, teachers, and other stakeholders.
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28. Contd..
3. Treatment of the cervical cancer and palliative care
• When the cancer has not spread to other organ, surgery is
recommended.
• However for invasive cancer, (has spread to other organ) it requires
either radiation therapy or combination of radiation therapy and
chemotherapy
28

29. Contd..
• Palliative treatment helps the patient to get relief from the pain and
suffering
• It provides support to the patient, families so that they can live their
life as much as they can, when the patient and their families faces
difficulty in coping
• It helps to get relief from pain and other types physical, psycho-social
and spiritual suffering
29

30. Bibliographies
1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer
statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36
cancers in 185 countries. CA: a cancer journal for clinicians. 2018;68(6):394-424.
2. Kashyap N, Krishnan N, Kaur S, Ghai S. Risk Factors of Cervical Cancer: A Case-
Control Study. Asia-Pacific Journal of Oncology Nursing. 2019;6(3):308.
3. Pandey RA, Karmacharya E. Cervical cancer screening behavior and
associated factors among women of Ugrachandi Nala, Kavre, Nepal. European
journal of medical research. 2017;22(1):32.
4. Shakya S, Syversen U, Åsvold BO, Bofin AM, Aune G, Nordbø SA, et al.
Prevalence of human papillomavirus infection among women in rural Nepal. Acta
obstetricia et gynecologica Scandinavica. 2017;96(1):29-38.
5. Sherpa AT, Karki BS, Sundby J, Nygard M, Franceschii S, Clifford G.
Population based study of cervical cancer screening in Bharatpur, Nepal. Journal of
Manmohan Memorial Institute of Health Sciences. 2015;1(4):3-8.
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31. Contd..
6. Shrestha J, Saha R, Tripathi N. Knowledge, attitude and practice regarding cervical cancer screening
amongst women visiting tertiary centre in Kathmandu, Nepal. Nepal Journal of Medical Sciences. 2013;2(2):85-
90.
7. Johnson DC, Bhatta MP, Gurung S, Aryal S, Lhaki P, Shrestha S. Knowledge and awareness of human
papillomavirus (HPV), cervical cancer and HPV vaccine among women in two distinct Nepali communities.
Asian Pac J Cancer Prev. 2014;15(19):8287-93.
8. Thapa N, Shrestha G, Maharjan M, Lindell D, Maskey N, Shah R, et al. Burden of cervical neoplasia
in mid-western rural Nepal: a population-based study. Journal of gynecologic oncology. 2018;29(5).
9. Ranabhat S, Tiwari M, Dhungana G, Shrestha R. Association of knowledge, attitude and demographic
variables with cervical Pap smear practice in Nepal. Asian Pac J Cancer Prev. 2014;15(20):8905-10.
10. World health Organization. Comprehensive Cervical cancer prevention and control: a healthier future
for girls and women 2013.
11. World Heath Organization. Comprehensive cervical cancer control: A guide to essential practice 2014.
12. Jha AK, Jha J, Bista R, Basnet B, Kandel P, Lama G, et al. A scenario of cervical carcinoma in a
cancer hospital. JNMA; journal of the Nepal Medical Association. 2009;48(175):199-202.
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