Dr Olive Sentumbwe-Mugisa Family Health and Population Advisor:WHO

Uterus
Ovary

Vagina
Cervix

This is the uncontrolled growth of some cells on the cervix [the mouth of the womb]. Cells on the cervix begin to grow slowly and abnormally over several years.
These early (pre-cancerous) changes can grow into cancer if they are not identified [screening] and treated early.

Symptom free- Women are usually healthy looking and the condition is usually painless in early stages Irregular / intermenstrual or contact vaginal bleeding Foul vaginal discharge that never improves with treatment Pain (deep pelvic or back pain) In advanced cases; severe anaemia, renal failure, fistulae (rectal/vesico-vaginal), lymphoedema

Magnitude of Cervical Cancer in Uganda:

Actual magnitude is unknown-no national data Cacx data not captured by HMIS National cancer registry-covers Kyaddondo county
Among female cancers Cervical cancer accounts for 40% of cancers Breast cancer accounts for 23% Others account for 37% Cacx accounts for over 80% of female cancers

Clinical Reports
Cervical cancer patients occupy 30% - 50% of Gyne beds at Mulago & RRH . Over 80% of women with cacx are diagnosed with advanced disease. Stage III.

Over 40% of radiotherapy patients have cacx. From admission to diagnosis is 2 to 4 weeks.

Leading cause of Gynaecological deaths Almost all cases advanced. Facilities to screen and treat are limited. Skills to diagnose & treat are limited as most cases are missed as STIs. The symptoms are mistaken with those of other gyne conditions Women suffer silently and do not report Only about 5% of women ever get access to screening.

Human papillomavirus (HPV) types 16 & 18. 99.7% of cervical cancer cases are associated with HPV

Progression from HPV infection to cancer usually takes about 15 years

Early age at first sexual intercourse

Multiple sexual partners Wives in polygamous unions All risky sexual behavior smoking Any women who have ever had sex All those above 25 years up to 60.

Prevalence of high-risk HPV infection No organized screening programs, despite many efforts Competing health problems Limited awareness of cost effective approaches to prevention Until recently, no vaccine was available to prevent infection Symptom free and goes unnoticed till late

Education & awareness Main stay is regular screening;

Screening options
Pap smear - annually HPV testing used inconjunction with Pap or alone Visual inspection of cervix with 5% acetic acid/lugols iodine every 3 years

Treatment of pre-cancer (cryotherapy, LEEP), For early invasive cacx (surgery, radiotherapy), For inoperable disease (Radiotherapy, Palliative care)

Colposcopy/biopsy used with above 3

Commitment:

Inability to scale up & sustain pilot screening projects inspite of available evidence. Lack of commitment from policy makers to prioritize cancer control.

Lack of prioritization of women's sexual & Reproductive Health Failure to allocate resources to Cervical & other Cancers control programs. Lack of enabling policies & evidence based guidelines Competing priorities- ? HIV, TB, Malaria?

Lack of awareness that Cervical Cancer and other RH cancers are a major health problem among the population, health care providers' leaders & policy makers. Poor attitudes, misconceptions & beliefs that cancer is untreatable & therefore a death sentence. [stigma surrounding diseases of genital tract]. Failure to openly discuss issues related to sex & diseases of the genital tract presents major barriers to RH & cervical cancer control. Lack of symptoms at stages where treatment is effective.

Weaknesses in health systems,

Equipment maybe locked up Lack of facilitative supervision HMIS not capturing cancer data-burden unknown! Failure of H/W to recognize cacx as a big problem

lack of appropriate equipment, and Lack of skills among providers limits access to prevention activities, screening, diagnosis treatment, follow up and palliative care.

RH policy & Service standards Policy goal is to enhance integration of services for; Screening cervical & breast cancers Treatment of RH cancers in both men & women

The WHO/MoH are on Masaka pilot [VIA] project (12 months)

UCL-Uganda Womens Health Initiative in peri -urban Kampala.
University college-London Project is for 3 years Ongoing for 20 months & screened 3500 women [VIA/VILI]. Working with PATH & MoH on National Scale up plans for cervical cancer prevention.

PATH on the Cervical Cancer Vaccine project & already supporting Secondary prevention and National scale up plan IEC & Advocacy

Others are

University based researchers Association of Obstetricians & Gynaecologists of Uganda

Visual Inspection Acetic acid Cervical Screening Protocol

Visual Inspection Lugols Iodine

Cervical Cytology (Pap Smear)

ABNORMAL

Colposco py

ABNORMAL

Cryothera py

Two vaccines proven effective: [cervarix &

gardasil]

5 Year project 2006 to 2011 6 - main activities

Funding from Bill & Melinda Gates Foundation (BMGF)

Formative Research Demonstration project Financial analysis Secondary prevention National scale-up Advocacy and communication Financial analysis

Objective: To strengthen the capacity of developing countries to prevent cervical cancer through generating and providing necessary evidence about publicsector introduction of cervical cancer vaccines.
PATH picture

1. Formative Research ongoing

(Gulu, Soroti, Kampala, Masaka, Mbarara)
Social cultural Knowledge, Attitudes Delivery options and systems Policy analysis Advocacy strategy Communication design

Objective: To assess feasibility of schoolbased strategy for reaching girls in school aged 10-12 years, plus additional strategy for reaching girls out of school, possibly synchronized with semi-annual Child Health Days

Primary outcome: 3-dose vaccination coverage in each group

Secondary outcomes: 1- and 2-dose vaccination coverage Vaccination drop-out rate Cost of each strategy Acceptability (KAP) among recipients, families

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DISCUSSION & WAYFORWARD