A practical approach to an old problemBMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39293.614954.59 (Published 02 August 2007) Cite this as: BMJ 2007;335:260
- Ben Moore, retired NHS gynaecologist
A spell of gynaecological work in central Africa provided a reminder of major problems still existing in many parts of the world, including the morbidity and mortality from neglected cervical cancer. By chance the African experience was followed almost immediately by a medical attachment in southern India that gave insight into how this problem might be tackled.
The first move was to a general hospital in eastern Zambia, a job involving three surgical and two outpatient sessions per week. At the clinics some complaints were ever present, including infertility (always the largest group) and pelvic and abdominal masses, plus two smaller groups: young women with urinary incontinence (mostly from obstructed labour) and older women with pelvic pain and foul vaginal discharge—a combination almost invariably heralding a cervical neoplasm. Of the last two groups the latter was more to be pitied. Fistula surgery was available but for advanced cervical cancer there was nothing. Over a two-month study period there were 18 such cases, a high incidence similar to that noted a year previously when working at a district hospital in Tanzania. (Tanzania, unlike Zambia, did have a radiotherapy unit providing free treatment for those able to get to the capital, Dar-es-Salaam.)
The second journey was to Andhra Pradesh in India, where the Institute for Rural Health Studies (IRHS) a charity with links in the United Kingdom, ran projects south of Hyderabad. One was a primary care clinic staffed by two paramedics and five ancillary workers (supported occasionally by a volunteer doctor). This, despite its small size, attracted patients from a wide surrounding area, partly due to its modest charges and partly due to its reputation for giving impartial advice. Among gynaecological complaints, infertility problems were rare, there were few pelvic masses and—during a study period comparable to that in Zambia—no urinary fistulas and only one obvious cervical cancer.
Another IRHS project was the Cervical Cancer Screening and Treatment Programme, a small group providing a peripatetic service based at the local district hospital. The group, supervised by a gynaecologist, was engaged in a survey comprising visual inspection, colposcopy, cervical biopsy, and cryotherapy. It was staffed by four or five locally trained, female health workers who travelled with their equipment (including a small petrol generator), the usual venue being a vacated classroom at the village school. Before screening (which was free) women were registered, counselled, and consented, and afterwards medication prescribed and follow-up arranged as required. The itinerary involved approximately 25 villages over a three month period.
Observing the group in action provided a possible explanation for the lower number of cervical cancer cases noted at the Indian location. It also demonstrated the positive impact made by a health team visiting a rural community: the buzz of excitement surrounding the team's arrival, the banner draped across the narrow street proclaiming its health protection work, the surge of interest when wives of village dignitaries attended for examination, the pretty young health workers in flowing white saris—all were factors bringing cervical cancer firmly to the public's attention and encouraging participation.
Cervical cancer is the commonest form of cancer among women in virtually all developing countries and is globally responsible for approximately 300 000 deaths per annum. In recent years it has received sporadic attention, principally through screening—the aim being to identify pathology at an early stage when available treatment can still be effective. Ideally screening is accurate, simple, cheap, reproducible, safe, and acceptable to the target population. Such perfection is rarely attainable and the procedure represents a compromise between accuracy and affordability; that is, if too simple it is not sufficiently accurate to achieve its purpose and if too complex accuracy may improve but it becomes too expensive. The service given by IRHS—good diagnostic accuracy, “screen and treat” for minor problems, and an efficient referral system for more complicated cases—seemed to provide a satisfactory balance between these extremes. Unfortunately, many areas lack such advantages. Nevertheless, if mortality from cervical cancer in developing countries is to be reduced some form of mass screening—appropriate to local circumstances—must be involved. In time, pre-pubertal vaccination may be the answer to cervical cancer, but such a method will require years to prove its worth. In the interim screening represents the best approach.
In time, pre-pubertal vaccination may be the answer to cervical cancer, but such a method will require years to prove its worth
The British Consultancy Charitable Trust (BCCT) gave financial support for the author's work with IRHS.