Eliminating Cervical Cancer in Malaysia and Globally
By Associate Professor Dr Ganesh Ramachandran and Associate Professor Dr Khine Pwint Phyu – School of Medicine, Faculty of Health & Medical Sciences at Taylor’s University.
Cervical cancer is the fourth most common cancer among women worldwide, with approximately 660,000 new cases in 2022. Low- and middle-income countries, particularly in Sub-Saharan Africa, Central America, and Southeast Asia, bear the highest incidence rates due to socio-economic factors, affecting vaccination uptakes, screening, and treatment. 1
In Malaysia, 1,740 new cases were reported in 2020 with a mortality rate of 57%. 2 This cancer, primarily linked to Human Papillomavirus (HPV) infection (especially types 16 and 18), is influenced by risk factors such as early sexual activity, pregnancy before the age of 20, promiscuity, unprotected sex, multiple full-term pregnancies, smoking, long-term oral contraceptive use, Human Immunodeficiency Virus (HIV) infection, and sexually transmitted infections. These factors are often exacerbated in lower socio-economic communities, increasing their vulnerability.
Global efforts and WHO’s call to action
The World Health Organization (WHO) issued a bold call for the global elimination of cervical cancer by 2030, achievable through effective HPV vaccination, screening mechanisms for detecting pre-cancerous and early cancer stages, and access to treatment. Elimination implies less than 4 cases per 100,000 population. WHO’s targets include fully vaccinating 90% of girls by age 15, ensuring 70% of women undergo high-performance screening by ages 35 and once more at 45, and treating 90% of women with cervical cancer.3 High-performance testing, which includes HPV testing alongside pap smears or visual inspections of the cervix with acetic acid, should be done every five years. Self-testing kits can improve screening uptake by eliminating the need to visit a health care provider thus saving time and addressing the stigma associated with the disease.
Malaysian scenario
Cancer of the cervix stands out as the second most common cancer among Malaysian women aged 15 to 44, primarily caused by HPV. The disease is largely preventable through vaccination, screening, and treatment. Up to 1% of women may carry the virus, with 40% potentially becoming chronic carriers. 4These women are at high risk of developing cervical cancer.
Malaysia has implemented an HPV vaccination or primary prevention programme since 2010, targeting 13-year-old girls in schools. The WHO reported that 80% of girls received the final dose by age 15 in Malaysia. Although the COVID-19 pandemic slowed the programme, the untiring efforts of the Ministry of Health and non-governmental organizations (NGOs) such as the National Cancer Society of Malaysia in providing catch-up vaccination should ensure that Malaysia is likely to continue to do well in vaccinating the population at risk.
The Ministry of Health recommends yearly pap smears for sexually active women aged 21 to 65 for two years, followed by every three years if initial smears are normal as a secondary prevention method. High-performance HPV testing is recommended every five years and for women above the age of 65 who have never been screened. Despite the existence of a government-run cervical screening programme since 1969 and the availability of free screening since 1995, uptake remains poor at 35% to 48% which is far below the WHO requirements. A 2020 WHO report indicated only 4 in 10 women had been screened in the previous five years with educational status, awareness of the availability and the effectiveness of screening, knowledge of the disease, and family support being likely factors in determining access to screening. Other factors hindering screening were time constraints, embarrassment, and lack of knowledge.
Improving screening uptake
To improve screening acceptance, education about cervical cancer must begin early, and the stigma and embarrassment associated with pap smears must be addressed. This requires educating not only girls and women but also men, who play an important facilitative role.
Many women face significant barriers such as fear of discomfort from the invasive procedure and cultural sensitivities about male doctors. There are also technical challenges with the procedure that may necessitate retakes thus inconveniencing patients. Hence, accommodating patient preferences, such as the availability of female practitioners, improving procedural techniques, allaying anxiety, and promoting the use of less invasive HPV DNA testing and making available self-testing kits, can enhance the screening experience.
The final piece of the puzzle for eliminating cervical cancer is the availability and accessibility of diagnostic and treatment facilities. While diagnostic and treatment facilities exist in both the government and private sectors, costs are high in the private sector and waiting times are long in the public sector which compounds the problem. Smart partnerships between the government, private sector, and NGOs are being put into place to optimise resources, which will positively impact combating cervical cancer in the coming years.
High vaccination rates are a success story in Malaysia’s initiative to eliminate cervical cancer. Improving screening acceptance and building capacity in the form of gynaecological oncology surgeons, radiation, and medical oncologists are crucial to effectively combat cervical cancer and achieve the goal of elimination by 2030. With concerted efforts, collaboration, and education, we can indeed win the battle against cervical cancer.
Sources:
- https://www.who.int/news-room/fact-sheets/detail/cervical-cancer
- https://www.thestar.com.my/news/nation/2024/01/14/statistics-on-cervical-cancer-in-malaysia-alarming
- https://www.who.int/initiatives/cervical-cancer-elimination-initiative
- https://hpvcentre.net/statistics/reports/MYS_FS.pdf?t=1557678064474
Category: MJN enews
