The Burden of Cervical Cancer in the Philippines and Efforts to Combat the Disease

by Dr. Cecilia A. Ladines-Llave,chair of the UP-PGH Cancer Institute

(This paper was presented at the John Hopkins-JHPIEGO Global Conference on Low-Resource Setting Cervical Cancer Prevention, held in Bangkok, Thailand on Dec. 4, 2005)

Incidence

Worldwide, one woman dies of cervical cancer every 2 minutes, and some 500 thousand new cases of this disease are seen every year.

About 80% or 400 thousand of these new cases are in developing countries. Of these 400 thousand, 50% or 200 thousand are in Asia.

In the Philippines, conservative estimates in 2000 placed the number of cervical cancer cases at between 35 thousand and 70 thousand, to which almost 7 thousand new cases are added every year.

In the Philippines and in many parts of the world, cervical cancer is second only to breast cancer as the most common malignancy that afflicts and kills women. In terms of virulence, however, cervical cancer is a more deadly disease: for every 4 Filipino women who survive cancer of the breast, only 2 or 3 will survive cancer of the cervix.

In the Philippines and in many parts of the world, cervical cancer is second only to breast cancer as the most common malignancy that afflicts and kills women. In terms of virulence,however, cervical cancer is a more deadly disease: for every 4 Filipino women who survive cancer of the breast, only 2 or 3 will survive cancer of the cervix.

Cost of the disease

Cervical cancer is not a disease of old age. The big majority of its victims are women who are at the peak of their biologically and economically productive ages. When a woman dies of this cancer, therefore, a life is not simply lost. Rather, a husband loses a wife, the children lose a mother, and the family is destabilized psychologically, financially and socially.

The economy, meanwhile, loses a productive pair of hands.
More than a pair of productive hands, however, is lost to the state, which inevitably pays a big part of the cost of treating this disease. Depending on the stage of the disease, the cost of treatment per patient ranges from P35 thousand to more than P703 thousand. These amounts are prohibitive even to those with income, considering that the national annual average
savings per family is only P24 thousand. One way or another, therefore, the government subsidizes a considerable portion of the cost for these families.

But for a big part of the population who lives below the poverty level, and who must be treated as charity patients,the government must shoulder all these costs.

This is an irony, because the cost of preventing cervical cancer through early screening could only be as high as P800 for a Conventional Pap Smear test in private hospitals, and –through an inexpensive acetic acid-based visualization screening method that is being introduced in developing countries worldwide – it could be as low as P50 only.

Preventability

Cervical cancer is highly preventable because it has a long pre-cancerous period during
which it may be detected and stopped, and every woman can assess her likelihood of being
a victim of this cancer.

Pre-cancerous stage. Cervical cancer generally takes as long as 10 years, and may even take 30 years, to develop into a full-fledged malignancy. It begins as an abnormality in cervical cells, and this abnormality is detectable through screening tests that are painless, quick, and affordable.

At this pre-malignant stage, the disease is highly curable. If every woman
who is at risk of developing this disease and who would subject herself to periodic screening tests, therefore, has a good chance during that big, 10-year window of opportunity to detect and stop this disease before it becomes fatal or more costly to treat.

Risk factors

Every woman may gauge her susceptibility to this disease. This cancer is
likely to afflict a woman who:
– has warts of the high risk human papilloma virus (HPV) types, in the anal and
genital areas
– started having sex soon after she began her first menstruation
– has or had several sexual partners
– has or had a sexually transmitted disease
– has or had a partner with sexually transmitted disease
– is a previous or current smoker, or is regularly exposed to secondary smoke
– used diethylstilbestrol (DES), a drug for preventing miscarriage of pregnancy, or
her mother used it when pregnant with her
– has five children or more
– belongs in the low socio-economic class
– has compromised immune status or poor resistance to diseases
When a woman notes that any of these factors applies to her, she should promptly seek a
test for the presence of cervical cancer or its pre-cancerous signs.

Key to Prevention

Early detection and treatment is the key to preventing cervical cancer. Developing countries
that applied this concept by means of a sustained national anti-cervical cancer screening
program have greatly benefited. The incidence of cervical cancer in those countries has
been reduced by as much as 90%, and the number of deaths due to cervical cancer has decreased by 70%.

Continuing Menace

Developing countries that lack such sustained national screening programs continue to be
menaced by cervical cancer. For the past many decades in the Philippines, for instance, cervical cancer has remained as the second most common cancer among Filipino women.
The recorded incidence of this disease in the country has even increased from an annual
average of 4,536 new cases in 1998 to 7,277 new cases in 2005. The specific reason behind this rise is unclear; it may simply be due to improved reporting, or to increasingly unhealthy lifestyle, or to the rise in carcinogens in an industrializing environment, or to an increase in the sexually transmitted spread of carcinogenic types of HPV warts.

One thing is clear, however: Filipino women are dying of this disease at a rate that has
remained unchanged for the past 20 years: of the total new cases of cervical cancer each
year, 33% or 1 of every 3 die within one year, and 73% or nearly 3 of every 4 of the new cases die within 5 years. The reason for this is the late detection of the disease: in 2 of every 3 new cases diagnosed each year, the malignancy was already at its advanced or fatal stage by the time it was detected.

Population at Risk

Growing at an annual rate of more than 2% during the past decades, the Philippine
population is estimated at more than 87 million as of 2005. Of this, 28 million are females aged 15 to 64 years old – the age bracket during which cervical cancer arises.

The number of women in this group is expected to grow further as the large young segment of the Philippine population matures and is promptly replaced by an even bigger population of infants within a cycle that is largely influenced by a high birth rate and a religious orientation that frowns upon artificial birth control methods.

Among Filipino women aged 15-24 years old, 23% or about 1 of every 4 have had sexual
contact, exposing them to cervical cancer’s risk factors such as early onset of sexual activity, STDs, carcinogenic HPV, and the likelihood of promiscuity and grandmultiparity.

But while there is a big population of Filipino women who are and will be at risk of cervical cancer, only 12% of them have been screened for this malignancy.
Cervical cancer has an inherently anti-poor bias, so women in low-income families constitute another segment of the population that is particularly at risk of contracting this malignancy.

This bias is not only because some of the major factors associated with this cancer are
quite common among the poor (e.g., grandmultiparity, poor resistance to disease and, to
some extent, early onset of sexual activity and – among women who resort to prostitution
for income – having multiple partners and exposure to STDs). Rather, this bias against the poor also stems from their lack of the opportunity to benefit from early detection and treatment of the disease.

Due to geography and lack of access to the media, the poor are generally
untouched by anti-cancer information campaigns. When such campaigns reach them,
their lack of education prevents them from fully appreciating the campaigns’ message.

And among those who understood the message, their lack of funds and the inaccessibility of government-subsidized facilities may still prevent the poor from seeking early screening and treatment services. Hence, this disease represents a particular onus on the poor and adds to their feeling of being disadvantaged and neglected. In this context, therefore, any anticervical cancer campaign is essentially a pro-poor and anti-poverty campaign.

Combatting the Disease

Early efforts. The high incidence and high mortality rates of cervical cancer in the country has continued because initial attempts to fight this disease had been disparate and limited in scope and duration. An effort to correct this was made in the early 1990s through an integrated national anticancer program that included a manual for cervical cancer screening. But, as a joint review by the Philippine Department of Health and the Asian Development Bank showed in 1996, the national cancer control plan had not succeeded, its implementation hindered by:

lack of funds and personnel;
reliance on midwives in Rural Health Units and Barangay Health Centers, who lacked training for the task;
inadequate training in cancer prevention for physicians who will implement the program, as we as for medical students who will eventually implement it;
insufficient services for follow-up diagnosis and treatment;
lack of quality control for Pap Smear analysis;
diversion of government funds for the health sector to other projects, as a result of the
“devolution” of certain political and fiscal powers from the national to local government units;
And continuing low level of public awareness of cancer risk factors and screening tests.

Recent efforts

The Department of Health and the University of the Philippines undertook a
study in 1998-2000 to resolve the above problems. The study aimed at: detecting the cancer at its pre-malignant and early stages, thereby removing the major cause of this disease’s high incidence and mortality rates and reducing the need for expensive treatment facilities and services for advanced cancer cases; overcoming the high costs and high level of skills required by the Pap Smear and other commonly used screening methods; and making screening tests widely available particularly in rural and low-cost settings.

The DOH-PGH study concluded that the acetic acid wash (AAW) test was the most cost effective among available screening tests, was more sensitive than the Pap Smear test, and had a specificity (94%) that was quite acceptable. Compared with the other screening methods, the AAW test also required less training, equipment and facilities to administer. The DOH-PGH study, therefore, endorsed AAW as the primary screening tool for a nationwide anti-cervical screening program, particularly in low-income areas and communities that are distant from major hospitals, clinics and laboratories.

The DOH-UP team called for a new national health policy that will:establish clinics, or a unit within reach clinic, that will be dedicated to cervical cancer screening and will use the AAW method; mandate that a cancer-positive finding through AAW be confirmed by colposcopy with biopsy; focus on women who are 25 to 55 years old as subject for screening; require that women who tested negative for the disease to be retested every 5 to 7 years; and direct the gradual implementation of the screening program such that only 1 to 4 municipalities will be covered during the initial year, and each province will be completely covered by the program in 5 to 7 years.

Taking into account its other findings, the DOH-UP team also recommended changes in
the national health policy to:

encourage continuing medical education in cervical cancer;
organize and sustain wide-scale public information and education campaigns on the disease;
include those of high school age as target of cervical cancer-related information and education campaigns;
include cervical cancer prevention and treatment in the curricula of medical, nursing, and
midwifery schools;
monitor and ensure the high quality of screening tests for cervical cancer;
include the costs of anti-cervical cancer screening and diagnostic procedures in the coverage of health and medical insurance plans; and
establish and maintain local and national cervical cancer screening registries.

The Cancer Institute’s subsequent reviews of these recommendations resulted in the
following additional suggestions:

adoption of the “single visit” approach, wherein a patient who tested positive will be
treated of her pre-malignant cervical lesion during that same visit – an approach that
is appropriate for developing countries as it reduces both the patient’s transportation
costs and the likelihood that she would not return for the follow-up treatment;
use of the AAW test as a screening tool and cryotherapy as treatment mode in the single visit approach – a combination that previous studies had found highly cost-effective;
launching wide-scale public information and screening campaigns only after diagnostic
and therapeutic facilities and services have been put in place – a chronological imperative
to ensure that women who respond to the campaigns will be accommodated;
and training midwives and barangay health workers in cervical cancer prevention and
screening under the supervision of the municipal health doctor — a strategic response
to the alarming rate at which Filipino doctors and nurses (the traditional implementers
of anti-cervical cancer programs) are leaving the country for better-paying jobs
abroad.

Pilot Project

In 2002, the DOH, the Philippine Society of Cervical Pathology and Colposcopy
(PSCPC), and the DOH-CHD-Cebu with the Vicente Sotto Memorial Medical Center
(VSMMC) in Cebu City collaborated to establish in Cebu Province a project that will serve as a model for the eventual implementation of a sustained nationwide anti-cervical cancer screening program.

The project took into account the findings and recommendations of the DOH-UP
study. To date, the ongoing pilot project has achieved the following:

obtained a profile of Cebu’s assets and deficiencies in relation to conducting a sustained
cervical cancer control program, and identified/implemented solutions to the deficiencies;
trained 60 medical personnel to conduct cervical screening test with emphasis on the use
of the AAW test;
formed a widely representative multi-sectoral Cebu Task Force for Cervical Control to
lead the local policy formulation, fund generation, and implementation of the screening
program; and
established the VSMMC as a model referral clinic for cervical cancer cases and other
women’s reproductive health diseases.

National Policy

Subsequent to the DOH-UP study and the pilot screening project in Cebu, the DOH issued Administrative Order No. 2005-006 which declared the policy of establishing an organized anti-cervical cancer screening program using the AAW test as the primary screening tool in local health units.

The AO directed the creation of local registries of women 25-55 years of age, and the coverage of each province by the screening program within the next 7 years.

The AO declared other policies and guidelines that likewise reflected the recommendations of the DOH-UP study.

Current Efforts

The most recent effort toward reducing the incidence and mortality rates of cervical cancer in the country began in early 2006. The Johns Hopkins University-affiliated JHPIEGO, and the University of the Philippines-Philippine General Hospital’s Cancer Institute (CI), agreed on a project to enhance the country’s preparedness and ability to implement a nationwide cervical cancer prevention program. The project subscribes to the use of the AAW test as primary screening tool as advocated by the UP-DOH study and the DOH AO.

To this strategy, however, the JHPIEGO-CI initiative adds an innovation: the single visit approach (SVA) in which women who visit a clinic for AAW test will be treated, if tested positive, with cryotherapy during the same visit.

JHPIEGO, which is world renowned for introducing and establishing the basic and adaptable mechanics for the SVA-AAW-cryotheraphy approach, will lead in the Philippine project’s training, capacity-building and interface aspects. The CI, established in 1938, will contribute its expertise as the country’s prime training ground for physician specialists in cancer prevention and treatment, its experience in local cancer research and anti-cancer projects, as well as provide its Cervical Cancer Prevention (CECAP) Center as the project’s home and secretariat.

The JHPIEGO-CI project will be implemented in several selected Philippine mucipalities
which could benefit from a cervical cancer prevention approach that requires little resources.

The core capacities established in these areas will be monitored and continuously improved for eventual adoption nationwide.

Conclusion

Cervical cancer has long been a major threat to the health of Filipino women and, by extension, to the health of the Philippine nation. Concerned sectors in the government and in the health community had long been aware that this threat is rooted to the late detection of this disease, and efforts have been addressed to resolve this in the past decades.

Initial efforts had failed due to lack of focus, funds, personnel, and other logistical and cultural reasons. New efforts began in the late 1990s and continue today. These efforts view cervical cancer more critically from the perspective of national realities and offer more realistic strategies and solutions.

The prospects of success of these new efforts are indicated by several milestones:
a team from the Department of Health and the University of the Philippines has
studied the problem and recommended realistic solutions; the Department of Health has declared national policies and strategies that reflect these recommendations; a pilot project in Cebu uses approaches that reflect the DOH policy and is showing the feasibility of a locally based and sustained anti-cervical cancer campaign at the provincial level; and a new project with international linkages is expanding the potentials of current local approaches by implementing the innovative single-visit approach to test its adaptability in low-resource Philippine settings.