How cervical cancer became leading killer

When Ruth Kiwanuka, a resident of Entebbe, was diagnosed with cancer of the cervix about 11 years ago, she was afraid her life had ended.

“I was so afraid. I thought I would die. I started crying because I felt my days are numbered,” she told our reporter this week at Hospice Africa Uganda in Kampala, where she is volunteering. The centre provides palliative care to those with life-threatening or life-limiting illnesses such as cancer, sickle cells and HIV/Aids.

“They told me the cancer was at stage IIA [or 2A]. I feared. I had to call my father. He told me he would look after me,” Ms Kiwanuka narrates, adding: “They [doctors] told me they were going to remove the uterus. I refused.”

She says all her four children (boys) died.

According to information from cancer specialists, Stage IIA is when the cancer is limited to the upper two-thirds of a woman’s private part (vagina). There are four stages of cancer of the cervix, with stage IVB [4B] referring to the late stage when cancer has spread to other parts of the body and may not be cured.

The palliative care volunteer said what increased her fears was the number of people who were dying of cancer at the Uganda Cancer Institute (UCI), the place where she got treatment.

“I had a very good friend of mine, who had spent three months at UCI without being operated on. The day she went for it, she died. That is when I refused to go for the operation,” she remembers. “I told my father that I don’t want surgery.”

Ms Kiwanuka says she stayed home for some time. “Then when I went for medical review, I was told I was on stage IIB [or 2B], meaning the cancer had increased. I felt like I was in my last moment on earth. So, I accepted treatment,” she adds.

Ms Kiwanuka says she underwent chemotherapy [treatment using drugs] and radiotherapy for 14 days. “But the worst experience was the side effects. It was too much. You get sores and you have to hide and open up your dress to get fresh air,” she adds.

“Urine and other things [bleeding] would come out uncontrollably. I would pray to God to heal me. I told God that I would support other people if he healed me, and it is now like 10 years and I am volunteering here,” she adds.

Dr Martin Origa, a specialist in cancer of the female reproductive system at UCI, says patients with cervix cancer struggle with stigma and many die because of late diagnosis and initiation into care.

“When a woman is experiencing [heavy] bleeding and having vaginal smell (smell coming out of her private part due to cancer), they won’t easily come out. They will try all other ways to manage it in a convenient way, including using herbal medicines,” he says.

“By the time she is coming for proper examination in the hospital, we have lost a lot of time and the stage of the disease has gone up,” he adds.

The specialist reveals that the most common symptoms of the disease, include vaginal bleeding, especially during sexual intercourse or when cleaning her private parts. “They may see blood on their finger. But there is also a foul smell that comes out of the (private part) vagina. But there is also painful sexual intercourse,” Dr Origa explains.

But by the time a patient sees these symptoms, the disease has already broken out. “We want all women to come when they have no symptoms. There are no symptoms in its early stages, called pre-cancer,” he says.

According to information from the Ministry of Health, women should start screening for cancer of the cervix between the age of 25 and 30.

“They should do it every three to five years until they are about 65 years. But in Uganda where our screening is still not systematic, we will even screen older women.  We want to make sure women screen at least three times in their lifetime. But in Uganda, whereas we have improved, we are still at the low end –between 4 and 25 percent [in terms of rate of screening among women who are eligible for screening],” Dr Origa says.

According to figures from the UCI, last year alone, about 6,900 women were diagnosed with cancer of the cervix, of which 4,300 died.

“This means more 50 percent of the women who are diagnosed, die. That tells you that majority of the women who come are at the advanced stage of cancer –that is stage 3 and 4. This means we are no longer talking about a cure [in this situation] but treating the disease and providing palliative care, comfort. This cancer can be prevented through a vaccine which is there but the cancer can also be detected early [and cured],” Dr Origa explains.

The specialist also says the virus, responsible for 95 percent of cancer of the cervix, is transmitted during sexual intercourse with a man harbouring the virus in his private part (penis).

“When you talk about cancer, there is always a mix of genetics and environment. What is unique about the cancer of the cervix is that the cause is in the environment, it is not inherited. The organism implicated here is human papillomavirus (HPV) which is sexually transmitted. Most of the people that develop cervical cancer are sexually-active, it is never seen in those who are sexually naïve,” Dr Origa says.

According to information from the World Health Organisation, women with HIV/Aids are six times more likely to develop cancer of the cervix than those who are HIV-negative.

Dr Origa adds that the virus multiplies faster in those with poor viral suppression because of their reduced immunity.

The 2011 report by Cecily Banura of Makerere University, shows that among HIV-negative adult women, the prevalence of high-risk (HR) HPV infections ranged from 10 to 40 percent compared to 37 to 100 percent among HIV-positive women.

“Among uncircumcised adult HIV positive males, HR-HPV prevalence ranged from 55 percent-76.6 percent compared to 38.6 percent -47.6 percent in HIV negative males,” the report reads.

Information from the Uganda National Institute of Public Health also indicates that although there are more than 100 types of HPV, two types (high-risk types) of the virus account for about 70 percent of cancer of the cervix in Uganda. These are the types targeted in the vaccination drive.

Experts say

Dr Michael Baganizi, the head of the immunisation programme at the Ministry of Health, says the uptake of the two-dose HPV vaccine meant to protect women from cancer of the cervix, is not at the required level. The second dose is given after six months.

“Vaccination of persons above one and two years age bracket is a kind of new phenomenon for most people. So we need to educate people to embrace such vaccination. And many didn’t understand why they have to come and complete the vaccination,” he says.

“Over 95 percent of vaccinations happen in schools. Uganda targets 10-year-olds as the entry point and most of them are in schools. In this current year, the first dose coverage is 95 percent but the second dose coverage is about 70 percent. Out-of-school girls are very few but they are also not coming to health facilities for vaccination,” he adds.

Other cancers caused by HPV include anal, vulva, vaginal, penile, oropharyngeal, oral cavity, and laryngeal cancers.

Dr Martin Origa, a specialist in cancer of the female reproductive system at UCI, says sexual orientation or way of intercourse predisposes people to HPV infection.

Dr Origa also says the other risk factors for cancer of the cervix, include smoking, use of hormonal contraceptives and producing more than five children.

STUDY

According to information in the 2022 report by researchers from Makerere University Medical School and another one by Uganda National Institute of Public Health (UNIPH) of the Health Ministry, the completion rate for the second dose (HPV-2) is under 50 percent or 43 percent to be specific. Uganda, according to UNIPH, introduced the vaccine in 2014.

“This study, as has been shown by other studies, found that knowledge about the vaccine, positive peer influence and promotive health worker education and recommendation regarding the vaccine were identified as promoters of vaccination uptake,” the researchers wrote.

“The study likewise, as has been reported elsewhere, found some factors that are barriers to higher vaccine uptakes, including prevailing community concerns about vaccine safety and adverse events following immunisation, vaccine supply stock outs and inadequate information about vaccines,” they add.