Prevention and Treatment of Cancer of the Cervix in Africa II
(Editors’ note: this important review is being published in two parts: Part I on epidemiology, screening, prevention and diagnosis of CIN was published in May 2010. Part II this month reviews the treatment of CIN, invasive cervical carcinoma and the challenges in Africa. A pdf of the entire review is available this month.)
Visual inspection using acetic acid or Lugol’s solution and HPV testing has made it possible to effectively provide a screening test for CIN, or precancer, in low-resource settings. However, a screening test by itself does not prevent disease. Safe and effective outpatient procedures to treat CIN, as opposed to treatments requiring hospitalization and an operating room, are viable options for treatment. In many developing countries equipment and trained clinicians have not been available to provide outpatient treatment of CIN. Thus, it is essential that health care policy makers and planners, as well as health care providers, give special consideration to the safety, cost, efficacy, and availability of outpatient methods. (54)(55)
Treatment for CIN can be provided by ablative or excisional methods. With an ablative procedure, abnormal tissue is destroyed, although a biopsy sample can be obtained before the procedure. With an excisional procedure tissue is available to verify the diagnosis through histopathological examination. With the availability of histopathology, treatment effectiveness can be confirmed. (54) Some authors believe that only excisional procedures and subsequent pathologic examination are adequate to diagnose or rule out early invasion. (59)
Ablative methods include cryotherapy, cold coagulation, and laser vaporization. Cold coagulation involves destroying tissue using heat energy. This method is currently available primarily in Europe. Laser vaporization is an effective method but requires expensive equipment not available in developing countries. Cryotherapy involves freezing abnormal areas on the cervix using either CO2 or N20 gas.
Figure 3: Cryotherapy equipment with refrigerant gas (55)
Excisional procedures, which can be done as outpatient procedures, include loop electrosurgical excision procedure (LEEP) and laser conization. Laser conization is rarely used in developing countries because it requires costly equipment. LEEP is usually performed by gynecologists at secondary or tertiary centers with colposcopic guidance. The colposcope is an instrument that allows visualization of the cervix with magnification. (55) A recent Cochrane review concluded that no one excisional technique was superior. LEEP appeared to provide the most reliable specimen for histopathology with the least morbidity. (56) A comparison of treatment methods including LEEP, cryotherapy, laser, and cold knife conization was done in Finland covering 100,285 woman-years and published in 2003. This study showed the clear tendency of cold knife conization being the least effective method of treatment when considering later development of recurrent CIN3+ after treatment. (60)
The procedure of cryotherapy is performed using CO2 or N2O refrigerant gas with the aim of creating an ice ball on the cervix with a depth of freeze marked by a peripheral margin of 4-5 mm of frost. The hypothermia produced by the ice ball results in ice crystal formation within cervical tissue, leading to destruction of the tissue. The cryoprobe is placed on the cervix, covering the entire lesion but not touching the vaginal wall. The coolant gas is allowed to flow through the channels in the metal tip of the cryoprobe. (55)
Figure 4: Ice ball on cervix immediately after cryotherapy (55)
A randomized controlled trial to determine the safety and efficacy of two single-visit approaches for cervical cancer prevention was carried out at ambulatory women’s health clinics in Khayelisha, South Africa between June 2000 and December 2002. 6555 non-pregnant women aged 35 to 65 years were screened using HPV DNA testing and VIA. These women were subsequently randomized to one of three groups: cryotherapy if she had a positive HPV DNA result; cryotherapy if she had a positive VIA test result; or delayed evaluation. The delayed evaluation or control group had colposcopy after six months and after twelve months, as did the other two randomized groups. The results of this study showed a significantly lower prevalence of CIN and cancer in the two intervention groups. The conclusion was that single visit approaches with HPV DNA testing or VIA followed immediately by cryotherapy were safe and resulted in lower prevalence of high-grade CIN compared with delayed evaluation at both 6 and 12 months. (8)
Results of a cluster-randomized trial of the effect of VIA and early treatment with cryotherapy on the incidence and mortality of cervical cancer in Dindigul district, India were published in Lancet in 2007. Screening took place in villages in the district and was done by nurses trained in the technique. Screening clinics were supervised by a doctor. A significant reduction in the incidence and mortality of cervical cancer was documented within seven years of beginning screening. The authors called for the routine teaching of VIA for medical students, nurses, health workers, and doctors to address cervical cancer. (58)
All clients diagnosed with precancerous lesions must be assessed to ensure that lesions are suitable for cryotherapy. The full extent of the lesion as outlined by VIA or VILI should be fully covered by the cryoprobe. Cryotherapy cannot be used to treat lesions that extend into the endocervical canal or onto the vaginal well. (55) For a successful prevention program a referral and management system for cryotherapy-ineligible women must be established. (57)
The most common procedure for cryotherapy-ineligible clients in developing countries would be LEEP. A recent report from Zambia demonstrated that performing LEEP was feasible and safe, with low rates of complications with the implementation of a comprehensive training curriculum for physicians in a university hospital setting. The LEEP training procedure for physicians included observing 10 LEEP procedures performed by experienced gynecologists, performing 25 procedures under close supervision, and then performing 25 additional procedures with an experienced gynecologist in close proximity. Once the trainee appropriately performed a total of 50 LEEPS, s/he was certified to have completed training and eligible to practice independently. (57)
The role of cold knife conization has become increasingly limited in the treatment of CIN due to the widespread acceptance of the use of LEEP. This procedure is typically performed in the operating theatre under either general or regional anesthesia. This procedure is useful where thermal artifact must be avoided and in cases where the cervical anatomy has been altered by previous procedures. A cone-shaped specimen that includes all of the involved area of the cervix is excised circumferentially using a scalpel. Hemostasis is obtained using electro coagulation, application of Monsel’s solution, or by using hemostatic sutures. Monsel’s solution is a chemical styptic agent useful obtaining hemostasis. (61)(62)
While pre-clinical cervical cancer and pre-cancerous lesions are asymptomatic, the clinical presentation of cervical cancer is uniformly predictable. The commonest symptom of early stage disease is contact (postcoital) bleeding, foul smelling vaginal discharge within a year or two (16). In advanced cases, systemic effects are also seen cachexia, micturition symptoms which may include dysuria, increased frequency and urinary incontinence from vesico-vaginal fistula formation, rectal symptoms such as pain and pedal edema.
7.2. Staging
Staging should include an assessment of disease extent and site of spread. Staging of cervical cancer is clinical although early cancers are staged according to the surgical specimen. All women with stage 1B or worse disease should have a chest X ray (CXR) and an intravenous urogram (IVU) to exclude distant metastasis and complete the staging process by looking for obstructive uropathy and therefore disease extending to the pelvic side wall. Staging should include:
Table 3 Staging of cervical cancer International Federation of Gynecology and Obstetrics (FIGO)
Stage |
Features |
O |
Carcinoma in situ, intraepithelial carcinoma. Cases of stage O should not be included in any therapeutic statistics for invasive carcinoma. |
1 |
Carcinoma strictly confined to the cervix (extension to the corpus should be disregarded) |
1A |
Pre-clinical carcinoma of the cervix, i.e. diagnosed by microscopy. |
1A1 |
Minimal microscopically evident stromal invasion <3mm in depth and horizontal spread ≤7mm |
1A2 |
Lesions with a depth of invasion >3mm and no more than 5mm, and horizontal spread ≤7mm |
1B |
Clinical lesion confined to the cervix or preclinical lesions greater than IA2 |
1B1 |
Clinical lesions <4cm in diameter |
1B2 |
Clinical lesions ≥4cm in diameter |
2 |
Carcinoma extends beyond the cervix, but has not extended on to the pelvic wall; the carcinoma invades the vagina, but not as far as the lower third. |
2A |
No obvious parametrial involvement |
2B |
Obvious parametrial involvement |
3 |
Carcinoma has extended to pelvic wall, on rectal examination there is no cancer free space between the tumour and pelvic wall. The tumour involves the lower third of the vagina, all cases with a hydronephrosis or a non-functioning kidney should be included unless they are known to be due to another cause. |
3A |
No extension to the pelvic wall, but involvement of the lower third of the vagina |
3B |
Extension onto the pelvic wall or hydronephrosis or non functioning kidney |
4 |
The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum (bullous edema does not permit the case to be assigned as stage 4) |
4A |
Spread of the growth to adjacent organs – bladder, rectum. |
4B |
Spread to distant organs |
Critics of FIGO staging note that substantial data can be gleaned from CT, MRI, PET or even surgical staging procedures. However, cervical cancer is not just a disease of individualized nations. Staging systems are intended to facilitate data collection and comparative reporting of end results and not only mechanisms to assign treatment. (63)
7.3. Histology
The majority of cervical cancers are squamous (80-85%) and the remainder has an element of adenocarcinoma. The portion containing adenocarcinoma element has been rising. (7, 17, 19)
7.4. Management
The management options to be considered include surgery, radiotherapy, chemotherapy and combinations of these modalities. Age in itself is not a barrier to full assessment and definitive treatment. Treatment could either be curative or palliative. For those with early stage cervical cancer, curative intent with either surgery or radiotherapy needs to be contemplated. In those with more advanced disease, chemotherapy is the preferred method of management but surgery may have a role in a palliative setting (7).
7.4.1. Stage 1A
Stage 1A disease presents a paradox in that cells breach the basement membrane yet are rarely associated with metastasis. Most cases may be managed by simple hysterectomy or even cone biopsy (7). This dilemma is only pertinent in those young women wishing to retain fertility. A suitably planned cone biopsy is both diagnostic and therapeutic. The entire abnormality must be included in the pathological specimen. If the cone biopsy margins are positive for CIN or invasive disease, there is a significant risk factor for residual invasive disease in the re-excision specimen. The risk of distant spread is less than 1% in stage IA1 and less than 5% in stage IA2. (64) Some authorities recommend a more aggressive surgical procedure with pelvic node dissection and a modified radical hysterectomy depending on the volume of the tumour.
7.4.2. Stage IB – 2A
For those with stage IB – 2A disease, the options lie between radical surgery and radical radiotherapy. Radical surgery (Wertheim’s hysterectomy) involves removal of the uterus, upper third of the vagina, parametria, paracolpos and a thorough pelvic lymphadenectomy. In older women a bilateral salpingo-oophorectomy is done.
The optimal therapy is that which provides the highest cure rates with the least associated morbidity. For young women, surgery offers the opportunity to preserve the ovaries, reduce the risk of sexual dysfunction and is not associated with the late sequelae seen with radiotherapy (7). If the ovaries are conserved, they are best transposed (paracaecal on the right and paracolic on the left); thus protecting them should pelvic irradiation be needed subsequently (65). The nodal status impacts long-term survival. The 5-year survival rate is approximately twice as good in node-negative patients (90%) as in node-positive patients (46%).
There is no apparent difference in cure rates between radical surgery and radical radiotherapy (64, 66). For those offered surgical treatment, this should be undertaken by appropriately trained doctors in the context of full support services. Radical radiotherapy is preferred in those centres where surgical expertise is not available or in women who are medically unfit for surgery. Radical radiotherapy aims to control the primary tumour and also prevent any lymphatic spread. Usually a combination of intracavitary (brachytherapy) therapy to treat the primary tumour and external beam therapy (teletherapy) to treat pelvic lymph nodes is used. Planned combination of radiotherapy and surgery are not advocated as this increases morbidity with no attendant gain in cure or survival rates (7). The use of modern after-loading techniques, with high dose regimens (HDR), reduces both the patient morbidity and exposure of staff.
Adjuvant chemotherapy, while not routinely indicated, should be offered to those with pelvic lymph node spread, tumour at the excision margins and other risk factors that make recurrence likely. Neither the overall response rate nor the complete response rate has been reproducibly improved by adding other drugs to cisplatinum. The attendant morbidity is highest when surgery is combined with chemo-radiotherapy (7).
7.4.3. Stage 2B – 4A
For those with stage 2B-4A disease, chemo-radiotherapy is preferred (56). Several studies indicate overall survival advantage for cisplatin based chemotherapy in conjunction with radiotherapy. In earlier stages treatment could be curative; whereas in later stages treatment is only palliative.
7.4.4. Stage 4B
No standard therapeutic protocol applies. Treatment is individualized according to location and extent of the disease. Pelvic irradiation may be used for palliation of bleeding from vagina, bladder or rectum. As distant metastases are present, chemotherapy is often employed, this is only palliative. The 5-year survival rates for radiotherapy are 86.6% for stage I, 69.9% for stage 2, 42.5% for stage 3 and 12.3% for stage 4. (67)
7.5. Complications
7.5.1. Radical Hysterectomy
The complications of radical hysterectomy include bleeding, pyrexia, pulmonary embolism, bladder atony and urinary tract infection, urinary fistula, (vesico-vaginal, uretero-vaginal), bowel problems (atony of the rectum and constipation) and lymphoedema which occurs in about 1% of cases (65). These complications can be minimized with improved surgical technique and appropriate post operative care. Early ambulation and chest physiotherapy are important adjuncts in the prophylaxis against post operative thromboembolism as well as chemoprophylaxis.
7.5.2. Radiotherapy
Complications of radiotherapy can be divided into acute and chronic. Acute complications occur during or immediately after therapy usually due to unregulated dose to the urinary bladder and gut. These can be minimized with adequate packing, bladder catheterization, administration of antispasmodics and anti-diarrhoeal agents. The complications include: perforation of the uterus, sigmoiditis 8%, hemorrhagic cystitis 3%, diarrhoea and abdominal cramps (65). Chronic complications occur as late as 12-18 months after treatment. They are the result of vasculitis or fibrosis. These include vaginal stenosis 70%, rectovaginal fistula 1%, vesico-vaginal fistula 1%, small bowel obstruction 2%, small bowel and urethral strictures. (65)
7.6. Minimal Access Surgery
The presence or absence of lymphatic spread is a critical factor in determining the outcome for women with cervical cancer. This has a significant effect on survival figures, and current imaging modalities are unable to identify accurately those individuals with metastatic disease to the lymph nodes. Several surgical centres now routinely assess the lymph nodes surgically prior to planning treatment. This can either be done using minimal access surgery or using an extraperitoneal approach. Lymph node yield at laparoscopy is equivalent to the open approach. (7, 68, 69) Lymph nodes that are removed are submitted for histological and immuno-histochemical assessment and further management planned. In those with negative nodes, surgical cure is feasible and these individuals proceed with radical or fertility sparing surgery. In those with metastatic disease, cure from surgery is not possible and these women are offered chemo-radiotherapy as their best option to obtain cure.
7.6.1. Laparoscopic Vaginal Radical Hysterectomy (LVRH)
LVRH for treatment of FIGO stage IB1 disease appears to be a safe and effective alternative to conventional abdominal radical hysterectomy (RH). (68-70) Evidence from comparative studies report a non-significant difference in recurrence rate following LVRH compared to RH. (71) Patients with large tumour volume (≥4cm3) undergoing LVRH had a significantly higher recurrence rate (42.9%) than those with small volume disease 2.5%. (71) Descriptive studies show that the mean duration of surgery was longer for LVRH compared to abdominal RH, and more intra-operative complications occurred when surgery was carried out by surgeons in training. (68, 69, 71) Patient hospital stay was shorter after LVRH than after RH.
7.7. Fertility Sparing Surgery
Radical hysterectomy remains the mainstay for stage 1B and early 2A cervical carcinoma. Recently there has been a great interest in performing conservative (fertility sparing surgery) in young women with stage IB1 lesions. Radical trachelectomy is a surgical option. It entails: vaginal resection of the cervix, the upper 1-2cm of vaginal cuff and the medial portions of the cardinal and uterosacral ligaments. Vagino-isthmic anastomosis is carried out with a prophylactic cerclage around the isthmus. The contraindications for the procedure are presence of lymphovascular permeation, positive nodes, tumour >2cm and upper endocervical involvement. Radical trachelectomy does not appear to increase the rate of recurrence provided the tumour diameter is no greater than 2cm and there is no evidence of lymphovascular space involvement LVSI. (72-74)
Radical trachelectomy must be combined with pelvic lymph node dissection for IA2 and IB1 disease. (72, 73, 75) Following radical trachelectomy the majority of women can anticipate conceiving spontaneously and delivery near term. (73, 76) The rate of first and second trimester miscarriage is comparable to that in the general population. (75) Plante et al (75) in their series of obstetrical results following RT reported that 721 of the women progressed into the third trimester of pregnancy. The term (>37 weeks of gestation) was slightly higher at 16% compared to 12% in the general population. Delivery is usually by cesarean section.
Cold knife conization or large loop excision of the transformation zone (LLETZ) is adequate treatment for patients with IA1 disease where fertility conservation is requested. If LVSI is present, pelvic lymph node dissection (PLND) needs to be considered.
7.8. Special Situations
7.8.1. Recurrent Cervical Cancer
Management is multidisciplinary and depends on the mode of primary therapy, type of recurrence and the woman’s fitness. If there is local pelvic recurrence following primary treatment with radiotherapy, the woman may be suitable for exenteration pelvic surgery. With a central recurrence, exenteration surgery in carefully selected women could give a five year survival of 40-60% (77, 78).
If there is recurrence after surgery, the usual treatment is radiotherapy with or without platinum based chemotherapy. Radical hysterectomy and exenterating surgery involving partial resection of the bowel, bladder and/or ureter may be performed in carefully selected women with persistent disease following primary radiotherapy (79). The morbidity from such extensive surgery is high and few women are suitable for this procedure.
7.8.2. Invasive Cervical Carcinoma found incidentally after simple hysterectomy
With minimum invasive disease no further treatment is needed. For more severe lesions there are two options:
a. Immediate post operative radiotherapy
b. Radical excision of the upper vagina and pelvic lymphadenectomy.
For cases with positive surgical margins and when residual disease is left behind at radical hysterectomy, pelvic irradiation is the method of choice.
7.8.3. Cervical Stump Cancer
There are two options:
a. Radical cervicectomy with bilateral lymphadenectomy
b. Radiotherapy
Adhesions and fibrosis from previous surgery make the former option difficult, while the inability to utilize a uterine source of irradiation may compromise the efficacy of the later.
7.8.4. Cervical Cancer in Pregnancy
The incidence of cervical cancer in pregnancy is 1.2 per 10,000 pregnancies (80). The presentation is usually vaginal bleeding though some 20% are asymptomatic. The survival figures are stage for stage the same as those for women who are not pregnant. It is now believed that the route of delivery does not affect the ultimate 5-year survival (7).
If invasive cervical cancer is suspected, a biopsy should be arranged. This should be under general anesthesia because the cervix is highly vascular during pregnancy and there is a risk of severe hemorrhage.
Cervical cancer staging in pregnancy can be challenging because the edematous and softening nature of the cervix and pelvic connective tissue makes clinical assessment of the parametria difficult. Colposcopic examination of the cervix is safe during pregnancy. MRI can also be used to assess the volume of the disease as well as parametrial spread and lymph node metastases (81).
The management is the same stage for stage, as for the non-pregnant woman, although fetal viability is usually an issue. Overall, the prognosis for all stages of the disease is also similar to that for the non-pregnant woman. Management decisions should be made at a multidisciplinary meeting and discussed with the woman and her partner. The risk involved in prolonging the pregnancy once a diagnosis of invasive cervical cancer has been made should be considered.
Prior to 24 weeks, the treatment recommended is the same for women who are not pregnant. If the treatment is radiotherapy, patients in the first trimester usually abort during the external beam therapy. In the second trimester, spontaneous abortion often is not the case, and the fetus must be removed surgically before irradiation.
Radical hysterectomy and pelvic lymphadenectomy can be accomplished at any gestational age. When cancer is detected at the time of fetal viability, radical cesarean hysterectomy can be offered or the fetus can be delivered and therapy instituted thereafter, the route of delivery has traditionally been cesarean section, though this is more related to the possibility of increased bleeding, rather than the older concept of spread of disease if the vaginal route is chosen (7).
Patients diagnosed a few weeks prior to fetal viability or those who refuse abortion on moral or religious grounds present the greater challenge. In such a scenario, appropriate counseling and delivery of the fetus as soon as viability is attained, with institution of appropriate therapy should be the goal.
7.9. Follow-up
All patients will need long term follow-up assessments for reassurance, psychosexual counseling, symptomatic relief and early detection of recurrence.
8.1. Socio-cultural factors
Many factors that increase both HPV acquisition and promotion of the oncogenic effect of the virus are widely prevalent in Africa. These include early marriage, polygamous marriages and high parity. In some societies young girls, usually virgins, are given out to marriage to much older men some with three or more wives (82, 83). This may increase the likelihood of a girl catching HPV infection at first intercourse with her husband. Polygamy has been noted to increase the risk of cervical cancer two fold and the risk increases with increasing number of wives (82). High parity which is common in some cultures in Africa is also a recognized, independent HPV – related co-factor for the development of cervical cancer (82-85).
8.2. Socio-economic Factors
Cervical cancer is often referred to as a disease of poverty (86). Poverty is endemic in Sub-Saharan Africa. Bayo and co-workers in Mali (82) recognized poor social conditions and poor hygienic conditions as major co-factors for cervical cancer. Poverty in its many ramifications is also a very important barrier to prevention and treatment of this disease (14).
8.3. Biological Factors
Poor nutritional status and chronic infections, such as Malaria, HIV and TB, are common in Sub-Saharan Africa and have compromised the immune status of many people. Reproductive tract infections are also endemic. Several studies have linked such sexually transmitted infections (STIs) as Herpes simplex type 2, (87) Chlamydia trachomatis (88) and Neisseria gonorrhea (89) with an increased risk of cervical intraepithelial neoplasia (CIN) and invasive cervical cancer. These infections excite a chronic inflammatory response resulting in the generation of free radicals which are thought to play an important role in the generation and progression of cancers. (90) Unfortunately many women who get these infections receive incomplete treatment, because they are unable to access good health care; thus making chronic and persistent infection very common.
The association between HIV and cervical cancer is well known. The prevalence of CIN has been estimated to be as high as 20-40% in HIV positive women (91). Studies from Ivory Coast (92) and Kenya (93) have confirmed that HIV positive women are more likely to have persistent HPV infections than HIV negative women.
8.4. Awareness and Knowledge of Cervical Cancer
Cervical cancer is yet to be recognized as an important public health problem in Sub-Saharan Africa. Several studies have shown poor knowledge of the disease in Africa which cuts across different literacy levels (94-96). In Lagos, Nigeria only 4.3% of attendees in a maternal and child health clinic were found to be aware of cervical cancer. Similar studies in Kenya (97) and Tanzania (98) have confirmed very poor knowledge of the disease in patients. Poor knowledge is not limited to patients alone. Health care workers who are supposed to be better informed do not have good knowledge either. (98,99) Delay by primary health care providers in referring cases is an important cause of women presenting with late stage disease to secondary and tertiary care centres (100).
8.5. Prevention of Cervical Cancer
HPV prevalence in women with normal cytology is approximately five times higher in Sub-Saharan Africa than in Europe (101). The efficacy of HPV vaccine in preventing the occurrence of cervical cancer is no longer in doubt. However, the present high cost of the vaccine makes it unaffordable and unavailable in many countries in the region.
8.6. Cervical Cancer Screening
Very few women in Sub- Saharan Africa are ever screened for cervical cancer. Less than 1% of women in four West African countries had ever been screened (102). There are very few cervical screening services in Africa and most of them are based in secondary and tertiary health care facilities located in urban areas, thus making it difficult for rural dwellers to access. Screening for cervical cancer is opportunistic and is often limited to women who attend ante-natal and family planning clinics. Women who use these services are generally young and smears are thus being taken from a relatively low risk group. This type of service does not reach women most at risk, ie older women 35-60 years, especially those who live in rural areas (14).
Cytology-based screening, which is used in high income countries, is resource intensive and difficult to realize in many countries in Sub-Saharan Africa because of poor health care infrastructure and lack of resources. There are very few cyto-pathologists, cyto-screeners, and cyto-technicians; some have inadequate training. Quality control is inadequate (14). The default rate among those with cytological abnormalities reaches 60-80% due to absence of effective mechanisms for recall of women with abnormal smears (103)
8.7. Treatment of CIN
More cases of invasive than pre-invasive cancer are treated in most African countries. This is partly due to paucity of screening services. Also equipment for large loop excision of transformation zone (LLETZ) is scarce (104). Cryosurgery machines, though economical, are equally scarce in many centres. The main stay of treatment of pre-invasive lesions is by cone biopsy or hysterectomy.
8.8. Treatment of Invasive Cervical Cancer
Late-stage presentation is a critical factor militating against successful treatment. In Lagos, Nigeria, less than 10% of cases presenting in a tertiary centre are operable (14).Facilities for clinical management of those cases who present at a stage where therapy might be successful are often very inadequate. Most centres for management of invasive cervical cancer are found in urban areas. This makes follow-up very difficult as most of the patients are poor, live in rural areas and cannot afford the cost of going back to urban centres for follow-up after initial treatment (14).
Radiotherapy either for curative or palliative purposes is also not readily available. In 2003, 16 countries in Africa did not have a single radiotherapy machine (105). In 2007, Nigeria, with a population of over 140 million people, had only five radiotherapy centres. This approximates to 0.04 radiotherapy machines per million populations. This is far below the WHO recommendation of 0.4 per million populations. In contrast, in the United States of America, there are 12 radiotherapy machines per million populations (106). The problem of paucity of radiotherapy machines is further compounded by constant breakdown of existing machines because the resources and expertise for proper maintenance is often lacking.
8.9. Mortality
Mortality rate from cervical cancer in Africa is very high. A mortality rate of 35 per 100,000 is reported in Eastern Africa (107). Reported mortality rates in resource rich countries with successful screening programs seldom exceed 5 per 100,000 women. The survival rate for cervical cancer in Sub-Saharan Africa in 2003 was 21% compared to 70% and 66% in the United States of America and Western Europe respectively (108). Some of the causes of high mortality and low survival rates in Sub-Saharan Africa have been mentioned above: poor nutrition, co-morbid conditions e.g. Malaria, anemia, HIV infection and late presentation. Poor quality care provided and high rate of loss to follow-up are also contributory factors.
Mary Sue Makin1 MD, FACOG, ABOG and Chuks I. Kamanu2, MBBCh, FWACS, FICS
1. Professor, Department of Nursing, College of Life Sciences & Nanotechnology, Hannam University, Daejeon, South Korea
2. Honorary Consultant and Head of Dept. of Obstetrics and Gynaecology, Abia State University Teaching Hospital, Aba, Nigeria
