Cervical cancer, a deadly yet treatable cancer?

Cervical cancer, a deadly yet treatable cancer?

Each year, more than 300,000 women die from cervical cancer with 80% of these deaths occurring in Low- and Middle-Income Countries (1).

This year, cervical cancer awareness month is launched under three key messages by the World Health Organization (WHO) that are “Get informed”, “Get screened” and “Get vaccinated”. A regional cervical cancer strategy is currently being adopted in the Eastern Mediterranean Region (EMR) to introduce the “90-70-90″ targets set by WHO in 2020 to eliminate cervical cancer. The target “90-70-90″ stands for:

• 90% of girls are fully vaccinated with human papillomavirus (HPV) vaccine by 15 years of age.
• 70% of women are screened by 35 years of age and again by 45 years of age.
• 90% of women with pre-cancer are treated, and 90% of women with invasive cancer are managed.

What is Cervical Cancer?

Cervical cancer is a type of cancer that hits the cervix area which is the lower end part of the uterus that connects to the vagina (2). Signs and symptoms of cervical cancer are irregular bleeding (after intercourse, between periods or after menopause), increased vaginal discharge usually with a foolodor and unexplained pain in the back and the pelvic area (1; 3; 4).

This cancer, which ranks4^th in mortality rates globally, ismainly caused by a sexually transmitted viral infection called Human Papillomavirus (HPV) (5). There exist other risk factors such as smoking or being a second-hand smoker, having a poorimmune system and being sexually active at an early age (2). However, HPV remains the leadingcause of cervical cancer development, infectingalmost all sexually active women. Specifically, two high risk types of this virus cause cervical cancer which are HPV16 and HPV18. A systematic review and meta-analysis showed that in the Middle East and North Africa (MENA) region, HPV16 is the most frequently detected type (6).

Cervical cancer, a treatable cancer?

Cervical cancer can be prevented and treated effectively through early detection of HPV infection. Prevention, screening, and treatment can save 90% of deaths due to cervical cancer among women (1). Even if the disease was detected at a later stage, palliative care and specific treatment can treat the disease (6).

The Center for Disease Control and Prevention (CDC) recommends that girls and boys get the HPV vaccineat11 or 12 years of age, meaning before they become sexually active. If vaccination was not done, the vaccine is recommended until 26 years. After this age,doctor consultations are advisable to know about therisk of new HPV infection between27 years old until menopause and the necessity to take the HPV vaccine.

Regular screenings for cervical cancer through HPV tests and Pap tests are also essential for the detection and treatment of the cancer. Besides, since HPV is a sexually transmitted disease, sexual preventative measures such as wearing contraceptives should be taken to limit the transmission of the HPV infection.

Lower vaccine coverage due to stigmatization in the Middle East and North Africa region?

Despite being the 6^th most common cancer in Eastern Mediterranean Region (EMR) causing the death of more than 47,500 women in 2020, HPV vaccination programs remain nascent (1; 6; 7). Most of EMR countries, more precisely in the MENA, lack effective, integrated, and accessible vaccination programs to their population. For instance, only Libya and the United Arab Emirates have integrated HPV vaccine in their health programs. Other countries such as Qatar, Morocco and Algeria have also included vaccination programs in their health programs but that are not readily available to all the population (6; 7). The reason behind this low prevention and screening programsimplementation is the existing stigma among Arab populations about HPV, a sexually transmitted disease. In such countries, mostly known to share conservative values, sexually transmitted diseases are a taboo subject that brings shame to the women who discuss it. Hence,HPV remains silenced in these countries and screening is usually avoided by the conservative communities. This also partially explains the low HPV reported cases in the MENA due to low screening rates by the population (6; 7; 8).
In fact, there is a dearth of systematic research studies assessing the level of knowledge, awareness, attitudes, and practices towards HPV vaccination in the MENA region. One systematic review covering 9 Arab countries in the MENA region for the period January 2010 to April 2017, highlighted a low to moderate knowledge of HPV infection and vaccination. This was coupled with an elevated levels of HPV vaccine acceptability among women and their willingness to learn and get vaccinated or to get their daughters vaccinated with HPV vaccine (9). More recent studies revealed similar findings concerning limited knowledge and awareness about HPV infection and vaccination which emphasize the need for public sensitization and awareness about the topic (8; 9). Based on the available evidence, limited knowledge was found to be the main factor creating hesitancy about vaccination uptake (8; 9). Here stands the role of healthcare practitioners and public health experts in raising awareness concerning HPV vaccination and combatting this public health emergency that is expected to rise especially after vaccination disruption and anti-vaccination movements during COVID-19 pandemic (1; 11).

Therefore, tailoring culturally acceptable awareness and screening programs stands at the core of preventing cervical cancer among women in conservative settings. Integrating HPV vaccination in the national vaccination program and having an organized screening program while also mobilizing the community into HPV vaccine uptake is essential to fight cervical cancer. The latter cannot be achieved without political willingness and national healthcare reforms. Finally, there is a need to build capacity among communities and healthcare providers in the MENA to increase the knowledge and raise awareness about HPV while also reducing the stigma around sexually transmitted diseases.

References:

1. WHO (2023). Cervical Cancer Awareness month 2023. Non-Communicable Diseases. Retrieved from https://www.emro.who.int/noncommunicable-diseases/campaigns/cervical-cancer-awareness-month-2023.html
2. NIH (2022). Cervical cancer causes, risk factors, and prevention. National Cancer Institute. Retrieved from https://www.cancer.gov/types/cervical/causes-risk-prevention
3. ASCO (2022). Cervical cancer – symptoms and signs. Cancer.Net. Retrieved from https://www.cancer.net/cancer-types/cervical-cancer/symptoms-and-signs
4. Butler, K. (2022). Cervical cancer. Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/cervical-cancer/symptoms-causes/syc-20352501
5. Sung, H., Ferlay, J., Siegel, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., & Bray, F. (2021). Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.CA: a cancer journal for clinicians,71(3), 209-249.
6. Obeid, D. A.,Almatrrouk, S. A.,Alfageeh, M. B., Al-Ahdal, M. N., &Alhamlan, F. S. (2020).Human papillomavirus epidemiology in populations with normal or abnormal cervical cytology or cervical cancer in the Middle East and North Africa: A systematic review and meta-analysis.Journal of Infection and Public Health,13(9), 1304-1313.
7. Fernandes, Q., Allouch, S., Gupta, I., Elmakaty, I., Elzawawi, K. E., Amarah, A., Al-Thawadi, H., Al-Farsi, H., Vranic, S., & Al Moustafa, A. E. (2022). Human Papillomaviruses-Related Cancers: An Update on the Presence and Prevention Strategies in the Middle East and North African Regions.Pathogens (Basel, Switzerland),11(11), 1380. https://doi.org/10.3390/pathogens11111380
8. Alsous, M. M., Ali, A. A., Al-Azzam, S. I., Abdel Jalil, M. H., Al-Obaidi, H. J., Al-Abbadi, E. I., Hussain, Z. K., & Jirjees, F. J. (2021). Knowledge and awareness about human papillomavirus infection and its vaccination among women in Arab communities. Scientific reports. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7804285/
9. Gamaoun, R. (2018). Knowledge, awareness and acceptability of anti-HPV vaccine in the Arab states of the Middle East and North Africa Region: a systematic.Eastern Mediterranean Health Journal,24(6), 538-548.
10. Elshami, M., Abukmail, H., Al-Slaibi, I., Alser, M., Radaydeh, A., Alfuqaha, A., … & Bottcher,B. (2022). Awareness of human papillomavirus and acceptability of the vaccine among women in Palestine: is it time for policy adjustment?.BMC Women’s Health,22(1), 1-11.
11. Galal, B., Lazieh, S., Al-Ali, S., & Khoshnood, K. (2022). Assessing vaccine hesitancy in Arab countries in the Middle East and North Africa (MENA) region: a scoping review BMJ open,12(2), e045348.