SPECIAL REPORT: Ignorance, other factors threaten cervical cancer elimination in Nigeria

As it has become a global custom in the last 22 years, Nigerians joined the rest of the world to mark the 2022 edition of the World Cancer Day on Friday.

Apart from the rising number of deaths, the www.worldcancerday.org, a website dedicated to activities around cancer care, puts the annual estimated global economic cost of cancer at $1.16 trillion.

Themed “Close the Care Gap,” this year’s activities are geared towards raising awareness of the equity gap noticed in cancer management, which is said to affect people in high as well as low- and middle-income countries, and which is costing lives.

This year thus marks the first of a new three-year campaign which centres on the issue of equity.

In joining the cancer awareness campaign, PREMIUM TIMES will, in the coming days and weeks, dedicate special attention to the coverage of cancer care in Nigeria, spotlighting various types, causes, signs and symptoms, and the general preventive and management measures as offered by experts and narratives of patients and survivors.

In this piece, our reporter focusses on one of the commonest types of cancer – cervical cancer – detailing relevant statistics, awareness level and, particularly, Nigerians’ knowledge level of an ongoing vaccination campaign against the disease.

What is cancer?

Cancer is a disease that occurs when changes happen in a group of normal cells within the body leading to uncontrolled, abnormal growth and forming a lump called a tumour. This definition, according to www.worldcancerday.org, is true of all cancers except the cancer of the blood, otherwise referred to as leukaemia.

According to the website, “if left untreated, tumours can grow and spread into the surrounding normal tissue, or to other parts of the body via the bloodstream and lymphatic systems, and can affect the digestive, nervous and circulatory systems or release hormones that may affect body function.”

Types of cancers

Depending on where the tumour is discovered, cancers are generally classified into five major groups including Carcinoma, which affects the lining of cells that helps to protect organs such as breast, lung, colon or prostate; Lymphoma and Myeloma, which affect the immune system, and Sarcoma, which affects bones or soft tissues.

There is also Leukaemia, which affects the blood, and those tumours that affect the central nervous system, which could either be brain or spinal cord cancers.

Generally, it is estimated that 10 million people die of cancer annually worldwide, and that 70 per cent of these deaths occur in low-to-middle income countries including Nigeria.

What is cervical cancer?

Cervical cancer, a type of cancer that develops in a woman’s cervix, is the fourth most common cancer among women globally. Experts said in 2018 alone, it caused an estimated 311,000 deaths worldwide.

Expectedly, the majority of these cases were reported in low- and middle-income countries (LMIC), where approximately 84 per cent of global cases and nearly 90 per cent of deaths from the disease occur.

A research by The Lancet reveals that more than 44 million women globally, stand to develop cervical cancer between 2020 and 2069.

It also warned that deaths from cervical cancer will increase a further 50 per cent by 2040, and that many women, their families and communities will be impacted.

Although the causes of cancer are unknown, 14 out of the 100 types of Human Papillomavirus (HPV) strains have been identified to cause at least 99 per cent of cervical cancer cases.

HPV versus cervical cancer

According to WHO, HPV types 16 and 18 cause at least 70 per cent of cervical cancers and pre-cancerous cervical lesions.

There is also evidence linking HPV with cancers of the anus, vulva, vagina, penis, and oropharynx.

“What HPV does is that it invades the cells of the cervix when infected through either anal, oral or vaginal sex. So once that happens, it goes to the cells and causes what we call continuous DNA replications,” Amina Isah, an expert in obstetrics and gynaecology, told PREMIUM TIMES.

Ms Isah explained that although HPV is a causative agent in cervical cancer, not everyone infected with HPV eventually ends up with cancer of the cervix.

WHO estimates that cervical cancer could be the first cancer to be eliminated if 90 per cent of girls are vaccinated against HPV, 70 per cent of women are screened and 90 per cent of women with the disease receive treatment.

However, poor access to the HPV vaccines, low awareness and negative perceptions of vaccines generally are amongst other factors hindering the elimination of cervical cancer.

How much do Nigerians know of HPV?

In late 2020, Gloria Lawal lost her long time friend to cervical cancer after three years of intensively battling the disease.

Although an unfortunate incident, it was also an eye opener for Ms Lawal as she never heard of cervical cancer, its causes or even the dreadfulness of the disease prior to this.

“I have heard about cancer generally but I never knew something like cervical cancer existed until my friend died from it,” Ms Lawal told this reporter.

Similarly, Mariam Baba, a final year student at the University of Abuja, said although she knows about cancer, she had never heard of cervical cancer or its causes.

“I believe everyone must have heard about cancer, especially breast cancer but I am unaware of cervical cancer. This is the first time I am hearing about it,” she said.

Just like Ms Lawal and Ms Baba, many Nigerians have very little knowledge of cancer and for the few that have heard about it, they do not know about cervical cancer.

At least 45 persons interviewed by PREMIUM TIMES did not know about cervical cancer, its causes, and how it can be prevented.

1. Do you know that Human Papilloma Virus (HPV) is the main cause of Cervical cancer?

— Premium Times (@PremiumTimesng) January 26, 2022

 

A Twitter survey carried out by this newspaper on January 26 to ascertain people’s knowledge of the disease shows that less than 40 per cent of the respondents know the main causes of cervical cancer.

The survey carried also shows that 62.2 per cent of the respondents were unaware of vaccines for the HPV, the virus that causes cervical cancer.

It also shows that almost 92 per cent of the female respondents were unvaccinated against the virus.

Health experts, however, say more women need to be fully vaccinated to avert a looming disaster.

About HPV vaccine

With the introduction of vaccines for HPV, many health professionals predicted a global drop in incidence of cervical cancer.

However, many years after, over 570,000 women are diagnosed with cervical cancer every year, according to the World Health Organisation (WHO).

Various researches, including a recent analysis, have established that the HPV vaccines could lead to the outright eradication of cervical cancer.

A meta-analysis of over 600 prior studies of HPV vaccination funded by WHO and published in the peer-reviewed journal, Lancet, found a decline in cases of HPV and in growths that could lead to cervical cancer.

Covering 600 million people in 14 high-income countries, cases of HPV from the vaccine’s introduction up till 2019 fell 83 per cent in girls 15 to 19; and 66 per cent in women 20 to 24 years.

Meanwhile, pre-cancerous growths also saw a 51 per cent decrease in girls 15 to 19; and 31 per cent in women 20 to 24.

“These results provide strong evidence of HPV vaccination working to prevent cervical cancer in real-world settings, as HPV infections — which are the cause of cervical cancer — and precancerous cervical lesions are significantly declining,” said Marc Brisson of Université Laval in Quebec, who led the review, in a statement to USA TODAY.

But despite the preventive benefit and documented efficacy in its protection against cervical cancer, a low percentage of women globally are vaccinated against the virus.

Although there is no available data on HPV vaccination in Nigeria, health experts said less than three per cent of women in the country are vaccinated against HPV.

The low percentage is partly due to low awareness, unavailability of vaccines and the relatively high-cost, findings by PREMIUM TIMES show.

Nigeria in retrospect

Africa’s most populous nation is one of the countries where high cases of cervical cancer are reported. It is the second most common cancer among women in Nigeria.

There were 31,955 new cervical cancer cases in West Africa in 2018, out of which Nigeria accounted for almost half (14,943). There were also 10,403 deaths from cervical cancer in the country the same year.

In 2020 alone, 12,075 new cases of cervical cancer were recorded in the country, according to Globocan statistics.

Wale Akinboboye, an expert in obstetrics and gynaecology at the Federal Medical Centre (FMC), Jabi, Abuja, said deaths from and increased cases of cervical cancer can be prevented if everyone gets vaccinated against HPV.

Mr Akinboboye said no woman should die of cervical cancer because it is highly preventable, insisting that vaccination should be done early for both boys and girls between the ages of 9-15.

“This is necessary because the HPV can cause other diseases in both genders, not just cervical cancer,” he said.

The gyneacologist explained that women who are not vaccinated at an early age can still get vaccinated during their reproductive years.

He lamented that shortage of resources and the high cost of HPV vaccines pose a major obstacle in tackling cervical cancer in the country.

“HPVs vaccines are available in some health facilities unlike before when it was very difficult to access. Fortunately, in Abuja, Lagos and other major cities in the country, HPV vaccines are available but at a high cost,” he said.

Costly but effective

Although HPVs are preventable through vaccination, the high cost and unavailability of these vaccines frustrate those willing to get vaccinated.

Rachael Moses, a woman in her early 20s, said she had attempted to get vaccinated against HPV twice but failed.

Ms Moses said; “I was advised to do an HPV test earlier in 2022 and it was negative. After this, I decided to get vaccinated at the Wuse General Hospital but the attendant said the vaccines were not available in the hospital. She advised that I should visit a private health facility to get the vaccines.

“On getting to the private facility, I was told a dose of the vaccine costs about N15,300 and that I would need three doses to be fully protected. That’s over N50,000. As a student, there is no way I can afford that.”

To corroborate Ms Moses’ account, PREMIUM TIMES visited some health facilities in Abuja and confirmed the trouble patients encounter to get vaccinated against HPV.

The first stop was Medicaid, a private health facility that specialises in cancer related issues. At this facility, a dose of the HPV vaccines costs N13,500, which amounts to N40,500 for the three doses needed.

These three doses are taken in the space of 0 month to one month, and then to six months.

At FMC Jabi, a public hospital, a dose of the vaccine costs N15,000, meaning that N45,000 would be required for the complete dosages of the vaccines to gain full protection.

Similarly, at the Wuse district hospital, a public facility, a dose of the vaccines goes for N15,500. Although the vaccines were unavailable at the time this reporter visited the facility, the nurse on duty promised to get the vaccine once payment is confirmed.

Inquiries made at the National Hospital also show that the vaccines are not available.

A nurse who spoke to PREMIUM TIMES anonymously said “I can’t remember the last time we had HPV vaccines in this hospital. You know it is not included in the immunisation programme so it is too costly for the hospital to have in store.”

Quest for inclusion in Nigeria’s vaccine programme

Ms Isah, the gyneacologist, said most women still suffer from cervical cancer because “HPV vaccines are not readily available, it is not accessible and it is not affordable.”

She called on the Nigerian government to include the vaccines in the country’s vaccine programme.

“Most of the institutions that have this vaccine in Nigeria are private institutions. It is not in our National Immunisation Programme and that is why we are pleading with the government to consider this,” she said.

“That is, it should be incorporated into the country’s immunisation programme so it can be free for both females and males, especially in the rural communities where we have the most populated and the less-educated ones.”

George Ikaraoha, the Cervical Cancer Prevention Programme advisor for the Reaching Impact, Saturation and Epidemic Control (RISE), said the best way to handle cervical cancer is through primary prevention.

“From age nine, girls are supposed to have access to the HPV vaccines but the problem we have is access to these vaccines. It is not included in the national immunisation schedule, so persons have to pay out of pocket,” he said.

Mr Ikaraoha said more advocacy is needed for the government to include the HPV vaccines in the national programme.

Late case presentation

Ms Isah, the gyneacologist, said Nigerians, especially those in the rural communities, and to some extent, those in the urban centres, have poor health-seeking behaviour such that when they have some symptoms, they do not go to the hospital early.

She said this boils down to lack of awareness of cervical cancer and other killer diseases.

She explained that many women diagnosed with cervical cancer die because the disease is identified too late to prevent further progression.

“The symptoms include abnormal vaginal discharge, which a lot of women experience at a time and they think it is a toilet infection.

“What I am advocating now is for every woman that has abnormal virginal discharge to visit the health facility to get a pap smear done or even evaluate the discharge.

“If it is other infections, it will be treated and if pre-cancerous legion is detected, it will be treated. Other symptoms are bleeding after sex, postmenopausal bleeding, lower abdominal pain, etc.”

Matilda Kerry, the founder of George Kerry Life Foundation, a non governmental organisation, said there is an urgent need to enlighten at least 10 million Nigerians about cervical cancer.

Ms Kerry said women of childbearing age and those sexually active are more vulnerable to the disease.

She said cervical cancer is one of the few cancers with a pre-cancer stage, hence it can be stopped before it starts.

“It is instructive for these vulnerable groups of women to undergo screening once in two to three years,” she said.

Risk behaviour, Screening

Mr Akinboboye explained that the increased risk for cervical cancer is having multiple sexual partners or those that have partners with multiple sexual partners.

He said those that engage in sexual activities at an early age are also at risk of HPV.

“Cigarettes smoking also perpetuates the virus and increases the risk of having cervical cancer. Also people living with HIV/AIDS are at higher risk of cervical cancer, diabetes patients and generally those with immunosuppressive therapy are all at risk,” he said.

He said screening is one of the many ways to beat cancer, noting that early detection is key.

“Pap smear is a strategy used to detect things that may lead to cervical cancer. Once detected, these stages can be treated through various mechanisms before getting to a full blown cancer,” he said.

Mr Ikaraoha, the programme officer, also said in the absence of HPV vaccines, regular screening is an alternative form of prevention.

He said early detection of cervical cancer is key to eradicating the disease. “This can only be achieved when people make themselves available for screening.”