Cervical cancer could challenge meeting SDGs

Health: The health sector could be Bhutan’s hurdle in meeting the country’s sustainable development goals (SDG) post 2015, health officials say.

A specific SDG target on maternal mortality under the health goal, based on the World Health Organisation’s Ending Preventable Maternal Mortality (EPMM) initiative, is reducing it to less than 70 per 100, 000 live births by 2030.

Other goals in the sector include achieving universal health coverage, and ensuring universal access to sexual and reproductive health-care services, family planning, information and education, and the integration of reproductive health into national strategies and programmes.

However, the country with one of the highest rates of cervical cancer could miss the target if not given adequate resources and attention.

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Cervical cancer is the most common cancer among women in Bhutan with about 20.4 per 100,000 person years. It is the second most prevalent cancer in the country.

Between 2008 and 2014, health officials detected 400 cases of which 135 died.  Trashigang, Thimphu and Wangdue have the highest number of cases and deaths in the country and the trend is increasing.

All women between 25-65 years, even those vaccinated, who are or were ever sexually active, must have Pap test once every three years.

Treatment is available before it evolves into cancer. Early childbirth, smoking and long-term use of contraceptive pills raises the risk of developing cervical cancer.

A cervical cytology or conventional Pap smear screening programme has been expanding from pilot projects since 1999, but still has limited coverage.

In 2010, human papillomavirus (HPV) HPV vaccine was delivered to 47,000 girls aged between 12 and 18, through a predominantly school-based programme.

From 2011, 12-year-old girls continued to be vaccinated through routine immunization till 2015 since when vaccination is again delivered in schools. Today, all classes VI girls are being vaccinated with support from the Australian Cervical Cancer Foundation regardless of their age.

Gyne-Oncologist Dr Ugyen Tshomo said, “The vaccination campaign is expected to have an important impact on the future burden of cervical cancer, but this impact will not be seen for  a few decades.”

However, the short-term impact on HPV infection can be monitored through periodic prevalence studies.

More than 50 percent of women diagnosed with cervical cancer were below 50 years. Therefore, it kills women while they are still socially productive and their children are dependent on them.

Unless 70 percent of women in the target age group of 25-65 years come forward for Pap smear, cervical cancer will continue to kill women.

Poor coverage by screening is the main reason for cervical cancer being common in the country.

However, Bhutan is not alone facing such challenges. Most of the countries in the region share similar challenges in achieving this goal.

Maternal mortality has fallen by almost 50 percent between 1990 and 2015 against Millennium Development Goals target of 75 percent.

South Asian Federation of Obstetricians and Gynaecologist (SAFOG) council member, Professor Lubna Hassan said, “Rates of maternal mortality in Asia are 19 times higher than  in developed countries.”

“Women in rural areas are still up to three times more likely to die.”

She said that there is a need to develop innovative education, screening and management approaches, as well as appropriate clinical guidelines and protocols.

“We are leaving those who deserve it the most behind. Unless we bring them in, no MDG or SDG is going to work,” she said.

Failure to address a core principle of the SDG agenda that is to ‘leave no one behind’ will limit prospects for all.

Tshering Palden

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