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By Rowena Singh

NOUMEA, New Caledonia (July 4, 2000 – Secretariat of the Pacific Community)---"In the Pacific region, cervical cancer is among the top three reported cancers among women," says Dr. Ezekiel Nukuro, Secretariat of the Pacific Community (SPC).

Cancer of the cervix (the neck of the womb) is the third most common type of cancer in women. According to the World Health Organization (WHO), about 450,000 new cases of cervical cancers are reported every year. Around 2-3 percent of all women over 40 will develop some form of cervical cancer. The average age at diagnosis is 45 years. In the Pacific region it has been found in women under 35 years old.

The main cause of cervical cancer, according to WHO, is the human papilloma virus. However, a number of risk factors have been identified. These include multiple sexual partners, early onset of sexual activity (less than 18 years), early and frequent childbearing (less than 16 years), smoking and sexually transmitted diseases.

Women whose immune systems are weakened are more likely than others to develop cervical cancer. For example women who have the HIV virus, which causes AIDS, are at increased risk. Women also are at increased risk if their partners began having unsafe sexual intercourse at a young age with women who have themselves had many sexual partners.

A few studies have suggested some risk of cervical cancer in women who use oral contraceptives (the pill) consistently for more than five years. However, this remains to be further investigated, as other studies have not shown this result.

In many cases, cervical cancer develops when two or more risk factors act together.

The development of cervical cancer is gradual and may take many years. If abnormal cells spread deeper into the cervix or to other tissues or organs, the disease is then called advanced or invasive cervical cancer.

At present, very early detection and treatment of cervical cancer and of the conditions that lead to it, remain the most effective ways of preventing and curing the disease.

Women need to have regular check-ups, including a pelvic examination and a Pap smear test, if they have been exposed to the risk factors mentioned above. All sexually active women over 35 years should have at least a Pap smear test every three to five years.

Routine Pap smears are very effective at detecting abnormal cells. The Pap smear test is a simple, painless test to detect abnormal cells in and around the cervix.

There are no symptoms in the early stages of cervical cancer and frequently symptoms don't appear until after the invasive cancer begins to erode tiny blood vessels within the cervix. The absence of symptoms allows the unsuspecting person to postpone a much-needed visit to the doctor. Proper treatment of cervical cancer that has only progressed to this early stage can save 80% of women. If, however, the cancer spreads to other organs before treatment is initiated, the survival rate drops significantly.

The Pacific region has a poor turnout of women going for Pap smears. The reasons for this vary from shyness, traditional and cultural stigmas to omission of Pap smear as a routine procedure in the public health sector. This is combined with a lack of awareness about the importance of the Pap smear and economic factors like the cost of traveling to a health center.

"I believe we have health workers in all the Pacific Island countries that can take Pap smears," says Dr. Nukuro. "The problem in some countries though is the lack of trained people and equipment to analyze and interpret the results of the Pap smears. The Pap smears in such cases have to be sent overseas for this purpose."

Research done by UNFPA shows that in the Solomon Islands, as with most Pacific Island countries, there is a major problem of patients seeking medical assistance only in the later stages of the disease.

Women only seek medical advice when they are sick. Most are not sure where to go for a medical check-up and Pap smear tests.

In the Solomon Islands, Pap smear tests are not readily available in the rural areas. They are available only on a limited basis at the National Hospital in Honiara and some provincial hospitals. Health services are not easily accessible, especially in remote inland areas.

Fears of going to hospital because of unfounded rumors and of being diagnosed with cancer, also acts as a deterrent.

In some areas women prefer to first seek advice from traditional healers and some healers discourage their patients from going to the hospital.

Symptoms of the cancer do not appear until abnormal cervical cells become cancerous and invade nearby tissue. When this happens, the most common symptom is abnormal bleeding. Bleeding after menopause also may be a symptom of cervical cancer. Increased vaginal discharge is another symptom of cervical cancer.

Women with cervical cancer need to learn all they can about their disease and treatment choices so they can take an active part in decisions about their medical care.

Warning signs for cervical cancer include some changes in the cells that make up the woman's cervix. These 'pre-cancerous' cells can be found by the Pap smear test and can then be removed to prevent the cancer developing further.

Simple methods of removing these cells without harming healthy tissue nearby include cryosurgery (applying a freezing substance to the cells to be removed), cauterization (burning) or laser surgery. The doctor can also remove a small area of abnormal tissue around the cervix. This operation is called a cone biopsy.

Treatment for more advanced cervical cancer involves surgery, use of drugs and radiation therapy. Doctors may decide to use one treatment method or a combination of methods, depending mostly on the stage of the cancer. Side effects of surgery may include cramping or other pain, bleeding, or a watery discharge, which should disappear over time.

In some cases, a woman may have a hysterectomy (removal of the womb), particularly if abnormal cells are found inside the opening of the cervix. This surgery is more likely to be done when the woman does not want to have children in the future.

Some patients are required to be at the hospital for a number of weeks while others can be seen as outpatients depending on the treatment administered.

In some Pacific countries patients have to be referred overseas for treatment as their own hospitals lack the equipment and specialists to carry out the treatment. This is expensive and can use up a lot of the hospital’s treatment budget.

In the Solomon Islands, the government has an agreement with New Zealand for a number of patients to be treated each year in New Zealand free of charge.

The major constraints most Pacific countries face in the implementation of cancer control programs are the high cost of management and treatment, lack of qualified technicians, shortage of obstetricians and gynecologists, insufficient supplies and equipment (including Pap smear kits) and the high cost of transfer and referral.

Regular follow-up exams are very important for any woman who has been treated for pre-cancerous changes or for cervical cancer. Cancer treatment may cause side effects many years later. For this reason, patients need to continue regular check-ups and report any health problems that appear.

However in the Pacific there are insufficient programs to follow up cancer patients to assist and support them to improve quality of their lives.

A typical cervical cancer prevention and control program has the following features:

· Development of a cancer registration so that every cancer case is registered according to sex, age and place of residence.

· Awareness of factors associated with cervical cancer and through this possible prevention of the cancer.

· Creating a protocol for screening which includes use of Pap smears as the means of screening for abnormal cells in and around the cervix, identification of target group to be screened, and frequency of Pap smears depending on age, risk factors and results of the tests (to curb costs).

· Close monitoring of program in terms of assessing and evaluating progress, and that the program be made available at the primary care level as soon as possible.

· The training of nurses and doctors, proper examination room and facilities including equipment and supplies.

Due to limited funds there is a need for Pacific Island governments and non-governmental organizations to seek funding through various international organizations to be able to implement screenings, treatments and follow-up therapy locally.

The success of cervical cancer prevention and treatment largely rests on knowledge and awareness of risks and the disease, early diagnosis and treatment. It is imperative for the sake of the women in the Pacific that through international governmental and community support, these are made available to them.

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