Cervical cancer is the leading cause1 of cancer-related deaths in women in South Africa, yet most women feel healthy even as it is developing in the cells on their cervix – the narrow neck where the vagina joins the uterus.
This is because the cervix has few pain-sensing nerve endings and as abnormal cells grow there is no discomfort. The human papillomavirus (HPV) responsible for most cases causes the normal cells on the cervix to mutate slowly into precancerous cells and eventually into cancer.
“In most women it takes 10-15 years for a persistent high-risk HPV infection to progress to cervical cancer if left undetected and untreated,” says Benoni-based gynaecological oncologist Dr Elize Wethmar. “Up to 90% of low-grade abnormalities will clear spontaneously, while up to 30-50% of untreated high-grade abnormalities may progress to invasive cancer over time.” The growth is so gradual, the body adapts and gives no warning signs.
Why it is so dangerous
HPV is the most common sexually transmitted infection globally, and it takes just one encounter to get infected. This can be through skin contact alone, without penetrative sex or the exchange of fluids, although it spreads that way, too.
By the time symptoms are experienced – typically abnormal vaginal bleeding (between periods or after sex) and unusual discharge, says Dr Wethmar – the cancer is sometimes at an advanced and life-threatening stage.
As the tumour grows, it can invade vital neighbouring organs, like the bladder, bowels and kidneys, or metastasise to the liver or lungs. Advanced tumours can also press on the ureters (tubes that carry pee from the kidneys to the bladder), causing kidney damage and severely affecting organ function and fertility.
Early detection can be life-saving
Because early stages present no symptoms, detecting cervical cancer relies entirely on regular screening for the virus. The Cancer Association of South Africa (CANSA) advises having a first pap smear when you become sexually active, then every two years, or more often if you are at risk.
You are at risk if you have HIV, diabetes or other STIs, if you smoke or carry excess weight, and if you become sexually active early (within a year of starting your periods), have multiple sex partners (especially if they too have many partners), and if you don’t use condoms, which offer a degree of protection.
It is estimated that while more than 85% of the population has been exposed to HPV, most women do not develop cervical cancer unless they have a weakened immune system, lowering their body’s ability to fight the virus.
“Most infections clear naturally within 1-2 years, but persistent high-risk HPV can lead to precancer, and over many years, cervical cancer,” says Dr Wethmar. “Cervical cancer risk increases when high-risk HPV persists, especially where immune function is reduced, such as with HIV, immunosuppression, smoking or other host factors. Genetics, the vaginal microbiome, viral type and individual immune response may also influence why some people clear HPV and others do not.”
Some studies suggest a diet high in saturated and trans fats and refined sugar can increase inflammation, making control of HPV infection more difficult.
Prevention options
• Regular screenings are key, and the Department of Health’s Cervical Cancer Prevention and Control Policy provides for women aged 30 and older to have three free Pap smears at public health clinics, usually at ages 30, 40 and 50. CANSA reports that if they experience abnormal symptoms, they can request a Pap smear, and HIV-positive women are eligible for a Pap smear at diagnosis and every three years afterwards if the result is negative for cancer, or yearly if it is positive.
• Vaccination against HPV infection has been a major breakthrough in prevention, and the Department of Health’s HPV School Vaccination Programme2 provides mostly for girls in Grade 5 aged 9 years and older. CANSA advises3 that all young women – especially those aged 9–26 years who are not yet sexually active – should get vaccinated.
“Gardasil 9 is indicated internationally for females and males of 9–45 years, with a 3-dose schedule for ages 15–45,” says Dr Wethmar. “South African patient information confirms use in girls/women and boys/men from age 9 onward, but local funder/public availability may vary.”
Women who have had the vaccination should continue to go for Pap smears, she says. “They still need cervical screening, because vaccines do not treat existing HPV infection and do not cover every oncogenic HPV type.”
Vaccinating boys against HPV can prevent them from acting as carriers who can spread the virus to their sexual partners. It also helps protect women from vaginal, vulvar and anal cancers, and protects the boys themselves from developing penile, anal and throat cancers, and genital warts.
In South Africa, the school HPV programme is currently for girls only, she says. “Boys can receive HPV vaccination through the private healthcare sector; UNICEF South Africa notes boys aged 9 and older are encouraged to access it via a GP.”
• Medical male circumcision has strong evidence for reducing HIV acquisition in men and also reduces penile high-risk HPV acquisition,” says Dr Wethmar.
Treatment options
Treatment for cervical cancer depends on the stage, and may include surgery, radiotherapy (whole pelvic radiation and/or brachytherapy, where a small radioactive source is inserted into your body), chemotherapy or combinations of these, says Dr Wethmar.
Emotional support is important, and CANSA links patients, survivors and caregivers with peers who have walked a similar path.
“Cervical cancer is one of the few cancers that can be effectively addressed through all three levels of prevention: primary prevention with HPV vaccination, secondary prevention through screening and treatment of precancerous disease, and tertiary prevention through timely management of invasive cancer,” says Dr Wethmar. “The tools are available; our challenge is to ensure access and uptake. Vaccinate. Screen. Act early.”
References:
1. https://cansa.org.za/cervical-cancer/
2. https://www.gov.za/news/media-statements/health-human-papilloma-virus-vaccination-campaign-protect-girls-cervical
3. https://cansa.org.za/one-dose-of-hpv-vaccine-one-less-worry-for-cervical-cancer/