Bias for the underserved

It was only very recently that I learned that the lowly suka or vinegar can be used to detect cervical cancer.

Suka contains acetic acid which is what is being used in what I find a revolutionary approach to treating the disease that remains to be the No. 2 killer of Filipino women, next to breast cancer.

I’m sure I’m not the only one ignorant about the powers of acetic acid. And I learned about it only because I attended a forum “The Cervical Cancer Prevention Network program” two weeks ago at the Asian Hospital in Muntinlupa.

CECAP’s aim is to make the Philippines a cervical cancer-free country.

It’s an attainable vision because cervical cancer, caused by human papilloma virus or HPV, is highly preventable. It has a long pre-cancerous (as long as 10 or even 30 years) period during which it can be detected and stopped.

CECAP’s strategy to prevent cervical cancer is three-pronged. One, promote healthy lifestyle through an education and information campaign. Two, train on cervical cancer screening through visual inspection with acetic acid, Pap smear, HPV typing, and treatment with emphasis on cryotherapy in a single visit approach. Three, conduct research and experiment on HPV vaccines and later immunization.

The CECAP also aims to provide the standard center not only for service but also for research, education and training for the medical staff, supportive groups and the public.

It shall be a model and referral center for the care and prevention of cervical center especially for the underserved.

CECAP’s bias for the “underserved” is what makes me biased for this program. Dr. Cecilia Llave, chair of the PGH Cancer Institute, and who is the driving force of this program (from whose paper many of the data in this article were culled) gave a picture of the cervical cancer burden in the Philippines:

“One thing is clear: 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 percent or 1 of every 3 die within one year, and 73 percent 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.

“Growing at an annual rate of more than 2 percent 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 percent 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 grand multiparity.

“But while there is a big population of Filipino women who are and will be at risk of cervical cancer, only 12 percent 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., grand multiparity, 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 ant-cervical cancer campaign is essentially a pro-poor and anti-poverty campaign.”

A study conducted by Department of Health and the University of the Philippines in 1998-2000 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 percent) that was quite acceptable.

Compared with the other screening methods, the AAW test also required less training, equipment and facilities to administer.

Aware that the poor Filipino women are averse to frequent visits to clinics, CECAP (which is the project of PGH-Cancer Institute with The Johns Hopkins University-affiliated JHPIEGO) is pushing for a Single-Visit Approach in which women who visit a clinic for AAW test will be treated, if tested positive, with cryotherapy during the same visit. (In cryotherapy, abnormal cells are killed by freezing them with a special instrument.).

One important component of this simple, cheap and effective method is competent health workers who will be conducting the tests. That is part of CECAP’s program.