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Cervical Cancer: One Disease Worlds Apart

Issue: Vol.2, No.2 - January 2003

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Article Type: Editorial

Neville F Hacker. MD
Gynaecological Cancer Centre, Royal Hospital for Women, University of New South Wales, Sydney Australia.

No Cancer epitomizers the stark contrast between the developing world as well as cancer of the cervix.

Cervical cancer is the second most common cancer in women world wide, and represents 12% of all female malignancies. It is estimated that there are 500,000 new cases diagnosed each year, of which 79% occur in developing countries?. It is the leading cause of cancer related death among women in developing countries, whereas in the developed world, its incidence and mortality have progressively decreased. In the United States, it no longer ranks in the top 10 cancers in women2.

Invasive cervical cancer develops from cervical intrepithelial neoplasia (CIN), and the progression normally takes may years. Pre-invasive disease is asymptomatic, but can be diagnosed by use of the Papanicolaou smear, and readily treated in an outpatient setting. Hence, most cases of invasive cervical cancer are preventable through regular screening.

The major reason for the great disparity in incidence of the disease world-wide relates to screening practices in different countries. It has been estimated that only 5% of women in developing countries have been screened in the past 5 years, compared with 40% to 50% of women in developed countries3.

Pap smear screening is costly and labour intensive, and requires a well educated population of women to attend regularly. In the developed world, National Cervical Screening programs exist in many countries, including Australia, and more sophisticated, automated Pap smear screening instruments are available. In developing countries, mass screening by cytology is an unternable proposition, so alternative, less costly strategies have had to be developed4. Direct visualization, of the cervix after the application of 5% acetic acid (DVI) appears to be a feasible alternative in such countries5. This technique is aimed at diagnosing pre-invasive disease, and ?down staging? invasive cancer.

In the developed world, vast sums of money are spent investigating very minor cytological abnormalities. For example, it is estimated there are 3 million women in the United States each year with pap smears showing low grade squamous intraepithelial lesions (LSIL?s) or atypical squamous cells of undetermined significance (ASCUS). Management options include immediate colposcopy and biopsy, follow-up with repeat smears every 4-6 months and colposcopy if the abnormality persists, or triage using DNA testing for cancer associated HPV types6. In developing countries, a 'see and treat' policy with relatively cheap modalities such as cryotherapy or LEEP (Loop Electrodiathermy Excision Procedure) for presumed pre-invasive lesions may be reasonable.

Once invasive cancer develops, treatment is much more expensive and expertise unevenly distributed. Early cervical cancer may be treated by radical developing countries, which have yet to benefit significantly from the sub-specialization in Obstetrics and Gynaecology which has occurred in most western countries in the last 10-20 years. The developed world is now treating advanced cervical cancer with sophisticated techniques of chemoradiation7, but radiation equipment is scare in developing countries, and so is expertise in the management of advanced cervical cancer. In addition, compliance with treatment is a problem, many women failing to complete therapy once symptoms such as bleeding have been controlled.

The great hopw for cervical cancer is for some method of primary prevention. It is now believed that cervical cancer is caused by infection with high risk types of the sexually transmitted human papilloma virus (HPV), particularly types 16,18,31 and 45.

Primary prevention should be possible through preventing HPV infection, and programs promoting delayed child bearing and sexual monogamy may be appropriate interventions for the developing world8. Several centers in the developed world are working on the development of prophylactic HPV vaccines and these should be a cost effective approach 9. We can only hope their introduction into the developing world is not delayed by low immunization rates in these countries and a shortage of health care workers4.


REFERENCE

1. Shanta V, Krishnamurthi S, Gajalakshmi CK, Swaminathan R, Ravichandran K. Epidermilogy of Cancer of the Cervix: global and national perspective. J Indian Med Asso 2000;98 (2): 49-52
2. Jemal A, Thomas A, Murray T, Thun M. Cancer Statistic 2002. CA Cancer J Alin 2002;52:23-47.
3. Sherris J, Herdman C, Eliz C. Cervical Cancer in the developing world. West J Med 2001;175:231-233.
4. Soler ME, Gaffikin L, Blumenthal PD. Cervical cancer screening in developing countries. Prim Care Update Ob Gyn 2000;7:118-123.
5. Denny L, Kuhn L, Pollack A, Wright TC, Direct Visual Inspection for cervical cancer screening. Cancer 2002; 94:1699-1707.
6. Soloman D, Schiffman M, Tarone R. for the ALTS Group. Comparison of three management strategies for patients with atypical squamous cell of undetermined significance. Baseline results from a randomized trial. J Nat Cancer Inst 2001; 93:293-299
7. Rose PG, Bundy B, Watkins EB, Thigpen T, Deppe G, Maiman MA et al. Concurrent cisplatin based radiotherapy and chemotherapy for locally advanced cervical cancer.N. Engl J Med 1999;340: 1144-1153
8. Drain PK, Holmes KK, Hughes JP, Koustsky LA. Determinant of cervical cancer rates in developing countries. Int J Cancer;2002:100(2):199-205.
9. Harro CD, Pang Y-YS, Roden RBS,Hildesheim A, Wang Z, Reynolds MJ et al. Safety and immunogenicity trial in adult volunteers of a human papilloma virus 16 L1 virus like particle vaccine. J Nat Cancer Inst 2001,93:284-292


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