Cervical Cancer in Sudan By Dr. Aida Ahmed Fadlala Dr. Dina Sami KhalifaGeneva Foundation for Medical Education and Research GFMER Sudan 2012 Forum No: ( 2 )
Name of presenterName Position InstitutionAida Ahmed Fadlala Obs/Gyn Nursing Head UMST Department Name of contributorsName Position InstitutionDina Sami Khalifa Epidemiologist Ahfad University for Women (AUW)Nuha Ahmed Kamal Research Fellow- RCRU UMSTAmjaad Farah Research Fellow- RCRU UMST
Content of the presentation• Background on Ca Cervix• Ca Cervix in Sudan• Solutions for Ca Cervix• National Initiatives• Gap in Research• Recommendations
Background on Ca CervixThe cervix is the lower, narrow end of the uterus that leads to the vagina.
Stages of Ca cervix:• Precancerous changes, known as dysplasia (months or years) aim of screening Early detection treated by cryosurgery, cauterization, or laser surgery Highly curable at that stage.• Invasive cervical cancer:1. Stage I: cancer cells only in cervix.2. Stage II: tumor grown through cervix and invaded upper part of the vagina but not pelvic wall or lower part of the vagina.3. Stage III: tumor invaded pelvic wall or lower part of vagina.4. Stage VI: tumor invaded bladder or rectum or spread to other parts of the body (e.g. lungs)
Signs & SymptomsS&S very common to other female infections and health problems• Early cancer is usually symptomless• Larger tumours causes: V. Bleeding:• Between regular menstrual periods.• After sexual intercourse or a pelvic exam• Longer or heavier periods• Bleeding after menopause• Increased vaginal discharge Pain: Pelvic Pain or pain during intercourse
In Sudan: (Data from two National Oncology Centres/ Khartoum*)• 8 –10 000 New Cancer Cases are treated in the two oncology centers.• Expected cancer cases 39 –40 000 new Cases every year Cases seen far less than expected cases• Ca cervix : 2nd most common cancers in females in Sudan. Breast Cancer 29 –34.5% Cervical Cancer 12 –15.5%* Radiation and Isotope Center in Khartoum (RICK), and the National Cancer Institute of the University of Gezira(NCI-UG) in Wad Medani, Gezira State (formerly “Institute of Nuclear Medicine Molecular Biology & Oncology”,INMO) .
• 70 % of women with Ca Cervix present with Vaginal bleeding and discharge for more than 3 months i.e. present late with symptoms.• 80 –85 % of cases Present with stages 3 and 4.• 5 % Present with Renal Failure, 4 % with Fistulas.• Mostly Postmenopausal Females with more than 3 months history, too shy to complain about Vaginal bleeding and discharge.
Why Advanced cancer in Sudan:• Lack of a awareness of Cervical smear and vaccination.• Lack of Effective Health Education and Early Detection.• Poverty, Illiteracy, the large size of the Country, Local healers ,the poor distribution of the limited Medical resources and lack of policies and commitment.• Lack of Knowledge about Cancer among some Medicals and Para medicals.• The limited number of Cancer Hospitals (two) and Oncologists.
Treatment options:SurgeryRadiation therapyChemotherapyA combination of these methodsThe choice of treatment depends on :• Size of the tumor.• Metastasis.• Future preference for pregnancy.
Causes and Risk Factors of Ca Cervix • Early Age at first sexual intercourse Young women 15-19 currently married/in union 23.4 % ¹ • Multiple sexual partners or a partner who has had multiple sexual partners • OCPs OCP use is Sudan is 6.3 % ¹ • Social economic status 36 % of women fall in the two lowest wealth quintile¹¹SHHS 2010
• ParityTFR in Sudan 5.6 ¹ .Theory: Increase in TFR will decrease Ca cervix (no evidence of that from poor countries)• SmokingLocal evidence: Ca Cervix is associated with smoking among Sudanese women *• STDsPrevalence rate 4.7 case/1000 population (1999/ under reported) (Sudan National Strategy for RH)• HPVNo local evidence on HPV burden¹ SHHS 2010* A Idris, H Mustafa, A ismail et al. Impact of tobacco use as a risk factor of cervical cancer among Sudanesewomen. 2011. SMJPH, (6);3
Estimated Incidence of cervical cancer in Sudan, Northern Africa and the World (per 100,000 population per year)* Indicator Sudan North World Africa Crude Incident Rate¹ 4.5 5.2 15.8 Age standardized Incident 7.0 6.6 15.3 rate Annual number of new 923 5278 529828 case Note: Incidence of cervical cancer in Sudan by cancer registry NOT available*WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers inSudan. Summary Report 2010. [Date accessed]. Available at www. who. int/ hpvcentre¹ IARC, Globocan 2008. (Specific methodology for Sudan: ’All sites but skin’ incidence rates from Egypt, Aswan (1999-2002) were partitioned by cancer site, sex and age using proportions obtained from the recorded new cancer casesin Gezira (2006) and Khartoum (2007) cancer registries. The incidence rates were applied to the 2008 population.
“Solutions for Ca cervix”Prevention :• HPV testing & vaccination No national HPV vaccination protocol in SudanLocal Evidence :No local estimate of HPV burden.One study (2010): The high risk HPV genotypes (16-58) were not associated with cancer in Sudan.¹¹ Salih et al. Genotypes of human papilloma virus in Sudanese women with cervical pathology. Infectious Agentsand Cancer 2010, 5:26. http://www.infectagentscancer.com/content/5/1/26.
• Health professionals key role in cervical cancer control :1. Identifying women for whom cervical screening is recommended (age, SES, sexual history..etc)2. Educating women about the importance of regular Pap tests.3. Informing women of the need to seek medical attention for abnormal vaginal bleeding and other clinical symptoms, regardless of a normal Pap test result.
Screening for Ca cervix:Goal:• “Application of a relatively simple, inexpensive test to a large number of persons in order to classify them as likely, or unlikely, to have the cancer so as to decrease incidence , morbidity and mortality from Ca cervix.” (ref BC) Success of screening depends on four related factors: Women’s participation (High coverage, effective, acceptable) High Sample quality (quality assurance training) Laboratory performance. Adequate management and treatment of detected abnormalities
Types of screening and confirmatory tests• Asymptomatic women with clinically clear cervix The Papanicolaou (Pap) smear for cervical dysplasia and early invasive carcinoma of the cervix.Local evidence: no available data on coverage or effectiveness of pap smears.• Symptomatic women high false negatives with Pap smear biopsy. “A woman with a visibly abnormal cervix or abnormal bleeding should be referred appropriately, regardless of the Pap test findings”
• VIA: “Visual Inspection using Acetic acid” Local Evidence ¹: VIA has higher sensitivity and lower specificity compared to Pap smear. VIA is useful for screening of cervical cancer in the primary health care setting in Sudan. “No cost effectiveness studies on VIA available to date”¹ Cervical cancer screening in primary health care setting in Sudan: a comparative study of visual inspection withacetic acid and Pap smear International Journal of Women’s Health 2012:4 67–73
National initiatives :At Policy level :• Screening for Ca cervix is one of the prioritized components in National RH policy strategies.Targets: (2006-2010)• Establish a screening program for breast cancer and cancer of the cervix• Strategies: Pre-service and in-service training of RH service providers on Ca breast & cervix screening.
Developing of national protocols and guidelines on screening for breast cancer and cancer of the cervix for all levels of the health care system. Providing of needed equipment in the PHC centers for pap smear and proper referral to cytology centers. Establishing of two specialized centers for management of cases of breast cancers and cancer of the cervix, with provision of needed trained staff, equipment and supplies
Sources of funding to implement strategies 40% from public funding & 60% from external funding Where are we now ?
At Program level :NCCP in 1982 to:1. To update the Radiation & Isotope Centre of Khartoum (RICK) to provide adequate therapeutic and diagnostic facilities for cancer patients,2. To develop sufficient trained healthcare personnel to meet cancer patients needs,3. To develop a programe for early detection of cancer.• Evaluation data on effectiveness, efficiency, competence appropriateness and accessibility of program not yet available
At Facility level :1. lack of facilities to perform the screening2. Two cancer hospitals in Sudan: Radiation and Isotope Center in Khartoum (RICK) National Cancer Institute of the University of Gezira (NCI-UG) in Wad Medani, Gezira State (formerly “Institute of Nuclear Medicine Molecular Biology & Oncology”, INMO)1. lack of personnel to perform the proper quality sample collection for screening2. Lack of qualified oncologists
Gap in research:• Population data on incidence and prevalence of ca cervix and its risk factors.• Cost effectiveness studies of the different screening protocols.• Health equity studies to highlight social determinates of Ca cervix in Sudan so as to target prevention with evidence.
Recommendations1.Avail screening programs in all hospitals with trained health workers and nurses in this program.2.Incorporate Health Education about Cancer and Early Detection Activities, in the Primary Health Care System, this is the most effective strategy.• Develop Curriculums for Cancer Control.• Governments long Term Strategies and Plans are needed.