anuary is the cervical cancer awareness month. The purpose is to promote awareness globally and highlight work that needs to be done to eliminate cervical cancer. In 2020, 604,000 new cases of cervical cancer were identified, a majority of those in low-middle-income countries globally; 342,000 people lost their lives due to it.

In Pakistan, 68.6 million women aged 15 years and older are at risk of developing cervical cancer. This makes it the third most common cancer among women in Pakistan and the second most frequent cancer in women between 15 and 44 years of age. Yearly, around 5,008 women are diagnosed with cervical cancer, out of which 3,197 die from the disease. About 88.1 percent of invasive cervical cancers can be attributed to HPVs 16 or 18. At a given time, around 0.5 percent of women in the general population are likely to have cervical HPV-16/ 18 infection.

In order to understand cervical cancer better, let’s start with the basics. In terms of human anatomy, what is a cervix? The uterine cervix or ‘cervix’ is part of the female reproductive system. It is a cylindrical shaped structure which forms part of the birth canal. It has an internal os (opening) and an external os (opening). The lining (epithelium) of the cervix consists of two types of cells, mucous-secreting glands made up of columnar cells lining the upper part and stratified cells occupying the lower part of the cervix. The transition zone (TZ) is where the two linings meet. It is the site of origin of the most common type of cervical cancer called squamous type cervical cancer, seen in 90 percent of cases.

What causes cervical cancer? Risk factors include human papilloma virus (HPV), smoking, low socioeconomic status, multiple sexual partners, etc. Women who are sexually active and have been on long-term (5 years or longer) combined oral contraceptives are advised to have regular cervical smears.

Human papilloma virus (HPV) affects various parts of the body, including the genital tract. It is acquired sexually and has many types. However, types 16 and 18 are ‘high risk’ and responsible for 80 percent of cervical cancers. The body has the ability to eliminate HPV however when it persists, it can lead to changes in the cells lining the cervix leading to cancer.

Sexually active women aged 30 to 45 years are most commonly affected. In some parts of the world, women aged 25-29 years can get affected. How can cervical cancer be prevented? Primary prevention is achieved through vaccination against HPV strains, smoking cessation advice and promoting the use of condoms or male circumcision.

It can take 15-20 years post HPV infection for malignant changes to take place in cervical cells. Cancer can develop earlier if one has poor immunity, as in the case of HIV infections. The HPV vaccine is available to protect against cancers caused by HPV. In addition to the cervix, HPV (high risk) has been associated with vaginal, vulval, anal, penile and head and neck cancers.

Cervarix and Gardasil are two types of vaccines protecting against cancer-causing (oncogenic) HPV types. Cervarix prevents the development of cervical cancer due to HPV types 16 and 18. Gardasil offers protection against 4 HPV strains, Types 6, 11, 16, 18. Gardasil 9 protects against nine types of HPV strains: 6, 11, 16, 18, 31, 33, 45, 52 and 58.

Who can get vaccinated? Girls and boys aged 12-13 years can be vaccinated. There are other groups of people who can be vaccinated. For more details, contact your physician.

Early detection of cancer can be done through cervical smear tests, which can detect abnormal changes in cervical cells. This test is done as an outpatient procedure. Cervical cancer screening can save lives as this will help in the early detection of abnormal cervical lesions and cancers. Various barriers have been identified as reason for the low uptake of the cervical screening and HPV vaccination in Pakistani population.

Apart from financial reasons and limited access to healthcare, those with multiple chronic conditions could also be reluctant to have cervical screening. Emotional barriers like fear, embarrassment and anticipated shame may also contribute to both low screening and low HPV intake.

A document, titled Primary health care vital signs profile assessment for Pakistan 2022, prepared by the Ministry of National Health Services Regulation and Coordination (MoNHSR&C) explains the national health vision for the population. According to this document, universal health coverage prioritises four groups of integrated essential healthcare services: reproductive, maternal and newborn/ child health, infectious diseases, non-communicable diseases and service access at all levels of healthcare delivery and through both public and private sector hospitals. Cervical cancer screening is included in NCDs.

Vaccination, screening and treatments are available for this cancer; however, early detection is the key to better prognosis and survival. This emphasises the importance of incorporating such health promotion and prevention strategies as part of chronic disease management.

Community engagement to improve knowledge and understanding of cervical cancer may help to improve their perception. Training health professionals, including primary care physicians, community nurses and lady health visitors, can help improve patients’ experience and encourage them to attend regularly for their screening.

Parents and school teachers should also be involved in health promotion strategies and increase their knowledge about screening and vaccination, as this may also help.

The aim of introducing HPV vaccines is to reduce the incidence of cervical cancer. Despite this Pakistan lacks an effective HPV vaccination programme. Understanding of the local community, identification of elements that can help promote vaccine use and tailoring counselling techniques according to the local population can be effective strategies. Collective efforts in the form of multidisciplinary teams, both hospital and community-based, like primary care physicians and other healthcare professionals, can help alleviate the burden of this cancer and improve outcomes.

The availability of the HPV vaccine as the primary prevention of this cancer and its inclusion in the expanded programme of immunisation must be considered.

Dr Hina Jawaid is an associate professor in family medicine at University of Health Sciences, Lahore

Dr Abdul Jalil Khan is an assistant professor in family medicine at Khyber Medical University, Peshawar