What causes Cervical Cancer?
It has been found that >95% of cervical cancer are associated with the Human Papilloma Virus (HPV). This virus is known to infect the mucosal lining of the cervix. Over a long period of time, the virus interferes with mechanisms that control cell division and growth. This eventually leads the cervical epithelial(lining) cells to multiply and grow in an uninhibited, uncontrolled manner (i.e. transforming them to cancerous cells).
How many women get cervical Cancer in Kenya?
Cancer of the cervix is the second most common cancer among women in Kenya (No. 1 is breast cancer). However, it is the leading cause of cancer deaths in women in Kenya (Globocan, 2020). Based on this data, more than five thousand women were diagnosed with cervical cancer in 2020. It’s therefore, an extremely common disease that causes profound suffering and eventually death. It’s notable that Western countries have dramatically reduced their rates of cervical cancer, primarily through screening programs.
What is Cervical Cancer screening?
The term screening means the detection of disease before the appearance of any symptoms. In cervical cancer, once a woman has symptoms, the disease is usually too advanced to achieve a complete cure. Among all cancers, cervical cancer is unique in having an effective, safe, and relatively cheap screening protocol. We’ve had more than 70 years of highly successful cervical cancer screening in Western countries, particularly the USA with PAP smears.
What are cervical cancer modalities in Kenya?
There are 3 main ways to screen for the presence of premalignant lesions of the cervix.
- Visual examination of the cervix under acetic acid and/or Lugol’s iodine (VIA/VILI)
- Cytology /PAP smears
- HPV testing.
Let’s briefly look into each method.
Visual inspection with Acetic acid/ Lugol’s iodine)
In this method, the cervix is checked visually after applying some dilute acetic acid on it. The colour on the cervix changes when premalignant cells are present. The same procedure is used when Lugol’s iodine is used instead.
This method has several advantages:-
- It’s fast
- Results are obtained instantly and communicated to the client. This is very helpful as some women never go back for their results (Loss to follow up)
- Cost-effective both in terms of materials and clients
- Does not require highly-trained specialists – Any Nurse, clinical officer or medical officer can perform the procedure after some basic practical training
Pap Smears ( Papanicolaou Test)
A Pap smear involves collecting(scoping or brushing) some cells covering the cervix. This material is applied on a slide, stained appropriately then examined under a microscope for abnormal cells. This method is accredited with > 80% decline in cervical cancer screening in the USA and other developed countries.
Advantages of PAP Smears:
- Highly accurate.
- Can diagnose other conditions e.g. infections
Disadvantages of Pap Smear
- Require a trained pathologist/cytologist to interpret
- Not widely available.
- Takes longer to get results,
- More expensive
- Some patients never go back for their results (lost to follow-up)
Infection with the HPV virus leads to cervical cancer over time. There are variants (or types) of the virus that are most likely to cause cancer. These so-called high risks are types 16 and 18. Moderate risk variants are 30,33 and so on. The low risk has very little association with cervical cancer. In terms of testing, cervical secretions are sampled the same way as the Pap smear above, tested in the laboratory for the presence of high-risk HPV variants. It can be performed as the only test or in combination with a pap smear
- Including equivalent or higher sensitivity than Pap smears
- Ability to predict women at high risk for future disease
- lower technician skill level than cytology
- potential for self-collection
- On their own, they may not detect actual cancerous changes in the cervix
Next, Let’s look at the possible outcomes of testing
Who should go for Cervical Cancer Screening in Kenya?
The Kenya National Cervical Cancer Prevention Strategy advocates for women the aged 29-59 years to have cervical cancer screening. How often depends on several factors and each woman should have an individualized plan based on her specific risk factors and circumstances. Generally, there is no preference for one testing modality over the other. In general terms, the screen should be done every 3-5 years if the previous screening is normal.
How is cervical screening done?
It’s a fairly straightforward procedure. These are the steps.
Where is screening for cervical cancer done?
- Most government/public hospitals (Level 4-6) E.g. Kenyatta National Hospital, County referral hospitals etc
- Mission Hospitals
- Private hospitals
- Private Laboratories
How much does cervical cancer screening cost in Kenya?
A surprisingly hard question to answer! Some government hospitals like KNH charge about Kes1,100 (USD 10 approx). In private laboratories, medical centers and hospitals the cost ranges from 3500 to as high as 7,000.00. The opaqueness of pricing makes it extremely difficult to discover costs. The NHIF covers the cost ( according to its Benefits Package 2015, I will update if this has changed). 2 of the examined private insurance companies did not have cervical cancer screening as an exclusion in their publicly available documents on their websites.
How is the Experience, How painful is it?
Time to address the elephant in the room. The screening procedure requires sensitivity on the part of the provider. It’s not painful but most women describe some “discomfort”. Sometimes a bit of bleeding or spotting may be experienced shortly afterwards.
How to prepare for a Pap Smear
Cervical cancer screening does not require specific preparations, However, here are a few key issues to keep in mind:-
- Menstrual cycle – It’s best to wait at least 3-5 days after the last day of menses before a screening procedure, especially a Pap smear
- Abstinence – Recommended about 2 days of abstinence before the procedure
- Avoiding douching, vaginal gels, cleansers etc. These may wash off abnormal cells or obscure them making interpretation difficult.
Possible results of Cervical Cancer Screening
The overwhelming majority of women who go for routine screening( meaning it was a scheduled visit, no symptoms) have normal results. This means no evidence of abnormal cells could be found.
Abnormal results could mean changed cells are found that haven’t transformed into cancer( but potentially could) This is the most important reason to screen-catch these cells before transforming into full-blown cancer. In very few women, the cells could be concerning for malignancy.
(Note: A more detailed article on pap smear can be found here)
What happens if your results are abnormal
In case your results are abnormal, your provider will recommend more tests or refer you. If the changes are very early, a follow-up review in 6 months may be warranted. If more advanced findings or worrisome for cancer, then colposcopy with biopsy is warranted to further evaluation. Whatever the situation, your provider will be at hand to guide you.
It’s critically important to increase the uptake of cervical cancer screening in Kenya. I hope this article has addressed most of the basics of cervical screening in Kenya. I’m sure there are many aspects that we could not cover in one article. In that case, you are welcome to interact with us in the comment section or directly through our contacts here. We’ll be updating this post with any cervical screening camps in the future, so be sure to subscribe to our newsletter.