The Star Early Edition - - NEWS - IN­TER­VEN­TIONS preven­tion. de­tec­tion early treat­ment and pal­lia­tive care RE­VISED AND UP­DATED CER­VI­CAL CAN­CER POL­ICY AND GUIDE­LINES

CER­VI­CAL can­cer is the sec­ond most com­mon can­cer among women in South Africa, af­ter breast can­cer and is of­ten fa­tal.

In 2012, there were 5785 new cases of cer­vi­cal can­cer.

It oc­curs as a re­sult of in­fec­tion with the hu­man pa­pil­loma virus (HPV). This virus is sex­u­ally trans­mit­ted and in South Africa, there are very high in­fec­tion rates with HPV. Cer­vi­cal can­cer is a rel­a­tively unique can­cer in that it has a long “pre­cur­sor” or early phase, dur­ing which risk and ab­nor­mal­i­ties can be de­tected by screen­ing.

If a pos­i­tive screen­ing test is left un­treated, a woman is at high risk of de­vel­op­ing cer­vi­cal can­cer over a five to 30 year pe­riod.

If cer­vi­cal can­cer is iden­ti­fied soon af­ter an in­fec­tion oc­curs, pro­gres­sion to in­va­sive can­cer of the cervix can be pre­vented.

So what is the health sys­tem do­ing around cer­vi­cal can­cer? There are three main in­ter­ven­tions.

Firstly and most im­por­tantly is In 2014, the Na­tional Department of Health in­tro­duced a new vac­cine, the HPV vac­cine, which is given to girls in grade 4 as part of the In­te­grated School Health Pro­gramme.

This vac­cine is given to girls who are not yet sex­u­ally ac­tive to pre­vent in­fec­tion with HPV and in the long term will have the ef­fect of re­duc­ing the num­bers of women who de­velop cer­vi­cal can­cer.

Another ac­tiv­ity that is used to pre­vent cer­vi­cal can­cer is to pro­mote aware­ness of how the can­cer oc­curs and to en­cour­age preven­tion of get­ting HPV in­fec­tion through safe sex prac­tices and dual pro­tec­tion (reg­u­lar use of con­doms plus other meth­ods of con­tra­cep­tion). Sec­ondly there is

and treat­ment of what is called “cer­vi­cal pre-can­cer”, when the cells in the cervix are not yet fully ma­lig­nant but well on their way to be­ing so.

South Africa has a pol­icy that makes pro­vi­sion for all women over the age of 30 years to have three free cer­vi­cal can­cer screen­ing tests. Ide­ally these are done at ten year in­ter­vals in the pub­lic health sec­tor at ages thirty, forty and fifty.

Women who are HIV pos­i­tive are more likely to de­velop cer­vi­cal can­cer and should have more fre­quent screen­ing.

Or­gan­ised cer­vi­cal can­cer screen­ing for el­i­gi­ble women is the cen­tral el­e­ment within the department’s cer­vi­cal can­cer sec­ondary preven­tion strat­egy. If a woman is di­ag­nosed as pre-can­cer­ous she is re­ferred for fur­ther test­ing and treat­ment. The third in­ter­ven­tion is to pro­vide timely

for in­va­sive cer­vi­cal can­cer that has spread be­yond the cervix.

This re­quires re­fer­ral to so­phis­ti­cated can­cer treat­ment in usu­ally big re­fer­ral hos­pi­tals where a range of treat­ments in­clud­ing surgery, ra­dio­ther­apy and chemo­ther­apy are avail­able.

The Department of Health has re­cently re­viewed and up­dated its cer­vi­cal can­cer.

One of the prin­ci­ples is to en­sure that the avail­able re­sources are used op­ti­mally and that each woman in South Africa has a fair chance of re­ceiv­ing the ben­e­fits of preven­tion, screen­ing and treat­ment ac­cord­ing to her needs.

For ex­am­ple in line with the guide­lines of the World Health Or­gan­i­sa­tion, women liv­ing with HIV, women with other im­muno­sup­pres­sive con­di­tions, sex work­ers, ado­les­cents, and mi­grants all have spe­cial dif­fer­ent needs and these are catered for in the pol­icy.

The pol­icy pro­vides for the train­ing of health staff to ef­fec­tively screen, di­ag­nose, man­age and treat cer­vi­cal pre-can­cer and guide­lines for re­fer­ral to en­sure con­ti­nu­ity of care for women with pos­i­tive screen­ing test re­sults.

Fi­nally it em­pha­sises the im­por­tance of com­mu­nity mo­bil­i­sa­tion to en­cour­age women to go to fa­cil­i­ties for cer­vi­cal screen­ing tests.

It ex­plains the role of civil so­ci­ety or­gan­i­sa­tions and pro­vides for a com­mu­ni­ca­tion strat­egy to in­crease aware­ness of cer­vi­cal can­cer at the com­mu­nity level as well as in­crease de­mand for and util­i­sa­tion of cer­vi­cal can­cer preven­tion and con­trol ser­vices. FACTORS CON­TRIBUT­ING TO HIGH CER­VI­CAL CAN­CER

IN­CI­DENCE IN SOUTH AFRICA The fol­low­ing factors con­trib­ute to high in­ci­dence rates, es­pe­cially among black and HIV-pos­i­tive women. These factors have there­fore been taken into con­sid­er­a­tion in this re­vised pol­icy: So­cio eco­nomic sta­tus and place of res­i­dence (ur­ban ver­sus ru­ral): Women who live in ru­ral ar­eas are dis­ad­van­taged re­gard­ing ac­cess to ap­pro­pri­ate in­for­ma­tion and ac­cess to ser­vices. Even in some cases where a woman has ac­cess to a pri­mary health­care fa­cil­ity for screen­ing, her re­fer­ral to the next level of care is de­layed due to poverty or fi­nan­cial chal­lenges. Ed­u­ca­tional level: The de­fault com­mu­nity mes­sag­ing strat­egy is through writ­ten ma­te­rial. Fur­ther­more the medium of com­mu­ni­ca­tion is in English, which ex­cludes most of the women liv­ing in ru­ral ar­eas, whose first lan­guage of com­mu­ni­ca­tion is not English. So­cial ar­range­ment of the fam­ily: Women in some com­mu­ni­ties are largely not de­ci­sion mak­ers in re­la­tion to health seek­ing pat­terns, es­pe­cially for sex­ual and re­pro­duc­tive health is­sues, due to their eco­nomic re­liance on their male part­ners. In other com­mu­ni­ties the de­ci­sion to seek med­i­cal ad­vice is made by the el­derly woman in the fam­ily who may not be ad­e­quately in­formed. Ac­cess to ser­vices: The health­care sys­tem in South Africa is still largely hospi-cen­tric with a fo­cus on cu­ra­tive care. In ad­di­tion, the avail­abil­ity of spe­cialised health care ser­vices in South Africa is not eq­ui­tably dis­trib­uted ac­cord­ing the needs of the com­mu­nity. Thus there are ar­eas where ad­vanced ser­vices are avail­able and ac­ces­si­ble while other parts of the coun­try only of­fer ba­sic health­care ser­vices. The sit­u­a­tion is ex­ac­er­bated by the se­vere short­age of spe­cial­ists such as on­col­o­gists, ra­di­a­tion on­col­o­gists, ap­pro­pri­ately trained sur­gi­cal spe­cial­ists and nurses trained in on­col­ogy. Health­care worker skills: Weak health worker com­pe­ten­cies at­trib­ut­able to in­ad­e­quate train­ing con­trib­utes to a de­lay in di­ag­no­sis and re­fer­ral to the next level of care for de­fin­i­tive treat­ment. Stigma: Due to the stigma as­so­ci­ated with cer­vi­cal can­cer, pa­tients tend to de­lay seek­ing treat­ment early or even dis­clos­ing the con­di­tion.

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