The cervical cancer: a perspective in Bangladesh
The Cervical Cancer is a deadly Cancer that clutches lives of the women in most of the cases due to lack of consciousness in the developing countries.
Unfortunately the cervical cancer is the second leading cause of deaths in Cancer in Bangladeshi women having the lack of preventive care. More than 50 percent of those diagnosed with the disease will die from it. There are thirteen thousand woman die every year in Cervical Cancer Bangladesh (according to a research report under Professor (Dr.) Parvin Shahida Akhter of National Institute of Cancer Research and Hospital
Carcinoma of Cervix accounts for 11% of all cancers and for 50 to 60% of all malignant tumors of female reproductive tract and is second to carcinoma of the breast in frequency among all cancers in women. According to the statistics about 95% of women in developing countries suffering from cancer cervix die due to failure of receiving treatment in time. Cervical cancer occur mostly in women aged more than 40 years but recent studies have shown the incidence even in women aged 25-35 years
The risk factors for Ca Cervix are mainly multiparty, multiple partners, early first pregnancy, postpartum lacerations, untreated chronic cervicitis, sexually transmitted diseases, low socio economic status ,HIV AIDs , infection with human papillomavirus. The disease is progressive Initiation occurs when carcinogens (cancer causing factors) changes the structure and function of the cells.
Promotion occurs with additional assaults to the cells resulting in further genetic damage. At some point these genetic events result in a malignant conversion. With progression the cells are increasingly malignant in appearance and behavior and develop into an invasive cancer with metastases to distant body parts.
Staging of Ca Cervix as recommended by International Federation of gynecology and Obstetrics
Stage I-Carcinoma strictly confined to cervix
Stage II- Carcinoma extends beyond cervix to upper part of vagina. Invasion is limited to depth of less than 5mm and no wider than 7mm
Stage III-Carcinoma extended to pelvic wall.
Stage IV-Carcinoma extends to bladder, rectum and spreads to distant organs.
Physical signs include induration of cervix, it is fixed and lost its mobility and bleeds on touch.
The clinical manifestations include blood stained foul smelling discharge, pain and cachexia.
Women are anemic with signs of uremia and weight loss.
Diagnostic evaluation is done by physical examination especially by PV. Clinical staging estimates the extend of disease so that treatment can be planned more specifically.
Biopsies are best tools of grading.
Cervical Exfoliative Cytology by Papanicolaou test or popularly known as Pap Smear test or surface biopsy can detect 98% of cancer of cervix and 90% of endometrial cancers.
Colposcopy and Cervicography are other tests of significance after pap smear test.
The Prevention:
HPV vaccines are developed from the capsid coat of the virus.
Bivalent Vaccines ( Cervarix) against HPV types 16,18 and Quadrivalent ( Gardasil) against HPV types 16,18,6,11 are effective in prevention of about 90% cervical cancer. Both the vaccines have some cross protection against HPV types 31,33and 45. Vaccines are given to girls aged 12-18 years, in 3 doses IM over the deltoid muscle. Vaccines are safe and well tolerated by the
female who have not already got infected.
Vaccine induced neutralizing antibodies (IgG, IgA) work locally (cervix) by preventing the attachment of the virus to the cervical epithelium. Vaccines are effective for at least 7.5 years.
Other measures of prevention are use of safe sex practices and maintaining hygiene.
Definitive treatment modalities are
Observation with Colposcopy every 4-6months.
Local ablative methods by Cryotherapy , cold coagulation, Electrodiathermy and laser vaporization.
Excisional methods are Large loop (electro surgical)excision of transformation zone (LLETZ) and laproscopic Assisted Vaginal Radical Trachelectomy with pelvic and Aortic Lyphadectomy (LARVT) Cone excision using a knife or laser These methods are for women who desirous of reproduction.
Pregnancy incidence of invasive carcinoma of cervix is about 1 in 2500 pregnancies. Most of the cases matured fetus is delivered by cesarean section.
Other treatment modalities include Radiotherapy, brachy therapy , chemotherapy combination
therapy.
Advance staged Ca Cervix needs-
Modified Radical Hysterectomy.
Palliative treatment is to provide comprehensive care for relief of symptoms along with treatment of cancer in the advanced stage
Prognosis depend upon the clinical staging of the disease.
Results of the therapy is expressed in terms of 5 year survival rate. 2nd stage patients survival rate is 76% , 3rd rd stage 50.5 and 4th stage 29.6%
Recurrence in majority of the cases happens in the first 2 years .
A patient is declared cured if she remains well even after 10 years following initial therapy...
The A K Khan Healthcare Trust has undertaken a program on Cervical Cancer Awareness and Screening deliberately to help the vulnerable women in their treatment.
The renowned physicians from US and Bangladesh extend their hands to screen the women at Korail Slum at Gulshan.
Since 2008, Prof. Dr. A K Goodman, MD, (Massachusetts General Hospital -MGH) has been working in favor of reducing these disparities in cervical cancer prevention and treatment as part of Mass Generals efforts to extend medical advances to people around the globe. Prof. Dr. Goodman, Prof. Dr. Sultana Razia and Prof. Dr. Syed Akram Hussain have been instrumental in establishing a Cervical Cancer Screening program in Korail, the largest slum in Dhaka, (Bangladeshs densely populated capital of more than 14 million) under an amazing support of A K Khan Healthcare Trust.
Dr. Goodman and the Bangladeshi colleagues recruited local women to serve as community health workers in the Korail clinic.
People dont necessarily understand what a cervical cancer screening is, Dr. Goodman says. Theres actually no word for vagina in Bangla (the Bengali language). You talk about the place where the baby comes through. It makes you understand that its not intuitive to do a vaginal examination. (MGH Takes on Cervical Cancer in Bangladesh by S.M. Nichols in Cancer Center, Global Health)
An Alternative to the Pap Test
To overcome these linguistic and cultural barriers, Dr. Goodman and the Bangladeshi colleagues recruited local women to serve as community health workers in the Korail clinic under the financial supports of A K Khan Healthcare Trust. During a three-month training, the women learned to perform pelvic examinations using a low-cost, highly accurate method requiring just the naked eye and a swab of diluted vinegar applied to the cervix.
Back in her office at Mass General, Dr. Goodman sees women with gynecological issues and screens women for cervical cancer.
Areas of the cervix that turn white after the solutions application indicate precancerous cells. Clinic patients with these results receive treatment on the spot, either by freezing the affected tissue or by cutting it out using a heated surgical instrument. This see-and-treat approach relieves the patients of repeat visits, for which many might not return.
These nonprofessional workers are people that the community trusts and will go to see, says Dr. Goodman. Although they dont have a formal education, they are smart and theyre very skilled. Its been really fun to train them. Dr. Goodman reports on her work in an article published in the Open Journal of Obstetrics and Gynecology.
The Social Barriers that the women are meeting in Bangladesh.
The awareness of Cervical Cancer is very extensive and inspiring. Women, being enveloped in a conventional and conservative social system interrupt a smooth screening at a large scale due to shyness and uncomfortable feelings since there is a lack of female healthcare.
The rural women are reluctant to unfold their diseases in front of male physicians or a health worker. Screening for cervical cancer in these communities is comfortable if done by a female healthcare provider under conditions with sufficient privacy.
B. Ganga Bhavani
Principal, Vrundavan institute of nursing education,
Goa, India.
Nurse scientist And Former Nursing Director
A K Khan Healthcare Trust
Dhaka , Bangladesh
Shabnam Sultana Nina
Project Manager
A K Khan Healthcare Trust
Dhaka, Bangladesh
