Cervical Cancer Control in Developing Countries: Memorandum from a WHO Meeting
Size of the problem
Cervical cancer is the commonest form of cancer that affects women in virtually all developing countries and the second commonest form of cancer that affects women in the world. Globally, there are an estimated 450000 new cases each year, with 300000 deaths. If the undiagnosed, early cases are taken into account, the number of new cases each year would be 900 000 worldwide. This is approximately the same as the total number of new cases of acquired immunodeficiency syndrome (AIDS) among males and females each year, but in contrast to AIDS, large numbers of women with cervical cancer are usually ignored.
State of the art
Cervical cancer is both preventable and curable, provided it is detected at an early stage. In developed countries 80% of cervical cancer cases detected are cured because of early detection. However, in developing countries 80% of cervical cancer cases are incurable at the time of detection, if they are detected at all. Five out of six women with cervical cancer live in developing countries, which possess only 5% of the global resources for cancer control. There are few, if any, cytology screening programmes with a coverage sufficient to have an impact in developing countries; standard radiotherapy is often not available.
A realistic, pragmatic approach to cervical cancer control has to be sought for developing countries, coupled with the provision of curative therapy and palliative care and pain relief.(a) Over the years WHO has advocated "downstaging" (visual inspection of the cervix) as a more realistic approach to active coverage in developing countries(b,c) than, e.g., cytology screening; however, its sensitivity and specificity remain to be evaluated in controlled studies. One of the purposes of the consultation was to initiate and coordinate such studies. Another approach that is highly relevant in developing countries is to educate women about the early warning signals of cervical cancer and to inform them that the disease is curable if diagnosed early enough.(d) It is an open question as to what will come first -- effective cytology screening coverage, as is the case in developed countries, or a vaccine for primary prevention. For a cost-effective, basic prevention programme it would seem rational to combine activities against sexually transmitted diseases (STDs), AIDS, and cervical cancer.
In developing countries the major problems associated with cervical cancer are the following: lack of knowledge among women about its symptoms; a fatalistic attitude towards cancer, in general, and lack of awareness about the possibility of a cure; shortage of health care facilities in rural areas, with often total lack of standard therapies; and male dominance and ignorance, combined with a low priority for women's health issues.
Early detection and screening have been successful in reducing morbidity and mortality from cervical cancer in some developed countries, but not in others. Lack of effect is most often due to poor management and implementation of inappropriate policies with mainly young women being screened and insufficient coverage of older women.(e)
In most developing countries a purposeful coverage of all women at risk through cytological screening will not be possible for decades to come, because of the paucity of economic and technically competent manpower resources and inadequate quality assurance for smear tests.
Empowering women with knowledge about cervical cancer -- its early warning signals, such as intermenstrual, postcoital or postmenopausal bleeding, foul discharge, its curability if diagnosed early -- combined with the availability of adequate therapies could have a major impact. In developing countries the incidence of cervical cancer is often equal to mortality. Experience in Nordic countries shows that before the introduction of any formal cytology screening programme the proportion of advanced disease among invasive cancers decreased significantly when therapy became available and women had been made aware about the condition. …