Non-communicable Diseases as a Global Threat to Public Health: Analysis of Cervical Cancer

Introduction to public health assignment

Background

According to the WORLD HEALTH ORGANISATION (WHO), the world is facing many global threats or challenges which range from the outbreak of diseases, environmental effects like global warming which lead to climate change as well as non-communicable diseases like obesity and cancer.

Our group will focus on one of this threats namely cervical cancer which is a non-communicable disease (NCD). Non-communicable diseases are chronic conditions that progress slowly and share common behavioral risk factors including tobacco use, excessive alcohol consumption, and lack of physical activity or an unhealthy diet. Whilst people tend to think of non-communicable diseases as diseases of the elderly, this phenomenon is not exactly true for countries struggling economically or developing and undeveloped countries. According to the World Health Organization (WHO) studies conclude that countries with fragile health systems, particularly in low to middle-income countries (LMICs), account for 80 percent of NCD-related deaths.

What is cervical cancer?

Cancer is the rapid multiplication of cells which can result in tumors, damage to the immune system, and other fatal impairments. Cervical cancer is a type of cancer that starts in the cervix (opening of the uterus) which can invade or spread to other parts of the body.

According to Michigan Medicine Doctor Diana Harper, most cervical cancer starts with normal cells that develop into pre-cancerous changes. Several terms are used to describe these pre-cancerous changes including:

• Cervical Intraepithelial Neoplastic (CIN)
• Squamous Intraepithelial Lesion(SIL)
• Dysplasia

Doctor Harper also states that these pre-cancerous changes can be detected with a Pap smear. With early detection cervical cancer is easily treatable.

Causes and Risk Factors of cervical cancer include:

Smoking- The chemicals in cigarette smoke interact with the cells of the cervix(these harmful substances are absorbed by the lungs and carried in the bloodstream throughout the body, that is how they reach the cervix), causing precancerous changes that may-overtime- progress to cancer. Women who smoke are about twice as likely as nonsmokers to get cervical cancer. Smoking weakens the immune system, that is, they make the immune system less effective in fighting HPV infections

Prolonged use of contraceptives- contraceptives like a pill and the loop can cause impairments to the cervix if used continuously hence contributing to cancerous or pre-cancerous changes in the cervix.

Human Papilloma Virus (HPV)-HPV have been shown to lead to many of the changes in cervical cells and genetic material that comes from certain forms of HPV has been found in cervical tissues that show cancerous or precancerous changes. This is why HPV is known as a common factor that leads to cancer in the cervix.

Having many sexual partners- increases the risk of being infected or re-infected with HPV which is the main cause of cervical cancer.

Engaging in early sexual activities-girls who engage in early sexual activities are at a high risk of developing cervical cancer because their bodies are still developing and hormonal imbalances can also aggravate the precancerous changes if exposed to HPV.

The disease itself is not contagious but the risk factor, HPV, is the one that is transmitted from one person to another. Both men and women may carry it and is usually transmitted through sexual intercourse. An Article by Mayo Clinic mentions that when exposed to HPV, the body’s immune system typically prevents the virus from doing harm. Furthermore, the virus can survive for years in the body in a small percentage of people, and this contributes to the process that causes some cervical cells to become cancer cells. Another article on cervical cancer and HIV-two diseases, one response by UNAIDS says cervical cancer is highly prevalent in women living with HIV because they are 4-5 times more likely to develop pre-cancerous changes if they have HPV.

In the early stages, one may not bear any signs or symptoms of cervical cancer, but with time one may notice the following:

• Abnormal vaginal bleeding
• Increased vaginal discharge
• Bleeding after going through menopause
• Pain during sex pelvic pain

Cervical cancer is a global public health concern which has left organizations and private institutions fighting enormously to prevent and minimize the number of causalities or victims. Over3 00 000 women die of cervical cancer each year. Nine in 10 women who die from cervical cancer are in poor countries. Over 500 000 cases are registered each year. More than 85 percent of cervical cancer fatalities are from low and middle-income countries. In Sub-Saharan countries, cervical cancer accounts for about 15% of all cancers. Within Botswana cervical cancer is the leading cause of cancer death. More than two-thirds of cases occur in HIV-infected women with a national prevalence of 17-24%

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Practical setting in botswana

In Botswana, about 60% of cancer patients are HIV positive, most present with advanced cervical disease e.g. cervicitis (the inflammation of the cervix) and cervical polyps and cysts (abnormal growths on the cervix). HIV-positive women in Botswana who are symptom-free at initial screening may be lost to essential future screening and follow-up care without greater targeted communication regarding cervical cancer and the importance of regular screening. Challenges remain such as delays in treatment, lack of trained human personnel, limited follow-up care, and little patient education. Between 2003 and 2011, cervical cancer accounted for 14% of all cancers in Botswana and 26% of all the cancers in women. Over 250,000 women in Botswana are in the age group 30-49 years which is about 25% of total female population and they are thus at high risk of developing cervical cancer. Among this subject of women, the HIV prevalence rate approaches 50%. The number of women at risk of cervical cancer will continue to grow until effective primary prevention efforts are established. Botswana is a middle-income country; it does not have advanced technology and skilled health professions for cervical cancer.

The ministry of health and various strategic partnerships strive to treat pre-invasive and invasive cancer, they came up with the see and treat program which is expanding through the country. They also came up with vaccination of school girls and women for the Human Papilloma Virus from 2015 as a way of minimizing the risks of cervical cancer. The ministry continues to educate people about cervical cancer and ways of modifying risk factors and has also availed the services of Pap smear in most of the local clinics and 40% of women tend to keep their follow-up appointments. Findings suggest that women treated at a first visit or referred for additional treatment due to the presence of more advanced diseases had more than doubled the odds of adhering to follow-up appointments compared to women with negative screens. Factors such as age, education, income, and marital status that have been shown elsewhere to be important predictors of adherence tend to be insignificant in Botswana.

Most of cervical cancer risk factors are lifestyle-related which makes it a preventable disease when treated on its early stages. Cervical cancer can be preventable by modification of risk factors and through health promotion and education. Even though cervical cancer can be treated, several deaths still occur due to late diagnosis early and lack of access to the life-saving treatment they need. In May 2018, WHO Director-General, Dr. Tedros made a worldwide call for action toward elimination towards cervical cancer, and to archive this, innovative strategies and technologies are needed and must be used to archive zero woman death due to cervical cancer. There are 2 main interventions that have been put forth to help prevent and treat cervical cancer.

Protective interventions

These are procedures aimed at preventing people from getting cancer. One of this interventions are;

• Vaccination of woman and children against HPV

Vaccines are available to protect young people against HPV infections that are commonly linked to cancer. They only work to prevent the HPV infections. They do not treat an infection that already exists, for the vaccines to be more effective they should be given before a person is exposed to HPV. They also prevent pre-cancers and cancers of the cervix.

• Screening-The check-up of the body for cancer before experiencing the symptoms. This is usually done after every three years. Screening is commonly done in two ways;
• -PAP Smear
• -HPV test pap smear

This is a routine procedure for testing cervical cancer. In this procedure, a health practitioner scrapes and brushes cervical cells which are then examined for abnormal growth. A PAP SMEAR can detect cancerous cells in the cervix or cells that show changes which speed the progression of the cancer. Women who are HIV positive or those that have a weakened immune system from various conditions are advised to have frequent tests.

• HPV test

In this test, cells which have been collected from the cervix are tested for infections with any of the types of HPV which usually leads to cancer. It can also be done with a Pap smear that is called co-testing.

Clinical interventions

These are procedures done to people who have already been diagnosed with cancer to help treat or cure cancer. They include;

• Radiotherapy
• Chemotherapy
• Surgery

CHEMOTHERAPY –This is a type of cancer treatment that uses one or more anticancer drugs as part of a standardized chemotherapy regimen. Chemotherapy may be given with a curative intent or it may aim to prolong life or to reduce symptoms.

SEE AND TREAT PROGRAM-This is a mode of cervical cancer screening which relies on visual test, making it simple, affordable, and sizeable to primary health care facilities in areas where modern laboratory infrastructure is unavailable or inaccessible. Since the results are available immediately, diagnosis and or treatment can be offered at the time of screening, minimizing follow-ups and losses.

SURGERY- this is where an infected part is removed. It is usually done in three ways;

• Cryosurgery- a very cold metal probe is placed directly on the cervix. This kills the abnormal cells by freezing them.
• Laser surgery- A focused laser beam, directed through the vagina, and is used to vaporize (burn off) abnormal cells or to remove a small piece of tissue for study
• Conisation- a cone-shaped piece of tissue is removed from the cervix, this is done using a surgical or laser knife (cold knife cone biopsy) or using a thin wire heated by electricity (the loop electrosurgical, LEEP or LEETZ procedure).

NB: Like any other medicine, most clinical interventions have side effects like; loss of appetite, hair loss, weight loss, and diarrhea above all. These side effects are preventable and most will pass once treatment stops.

Key indicators

Interventions are made to solve the issue of concern which in this case is cervical cancer. To monitor or check if this solutions or interventions are making a good impact on addressing the problem, we look at the following key indicators;

1. Decrease in number of women dying of cervical cancer.
2. Increase in women coming for see and treat and screening of cervical cancer.
3. Increase in number of cervical cancer survivors after being treated with radiotherapy and chemotherapy.
4. Increase in women who are eager about ways in which they can treat or prevent cervical cancer and also students in universities who want to study gynecology.
5. Decrease in new diagnoses of cervical cancer

References

1. www.who.int.news-room/fact-sheets/detail/noncommunicable-diseases
2. https://www.who.int>topics>cancers
3. https://www.ncbi.nlm.nih-gov>pmc
4. www.worldatlas.com
5. Biomedcentral.com/submissions Cancer. Net-Editorial-Board

Cancer research UK

1. Macmillan Cancer Support 2019