Cervical cancer has killed more women than pregnancy complications in Bhutan, according to gynecologist with the national referral hospital in Thimphu, Dr Ugyen Tshomo said.
Cervical cancer, which occurs in the cells of the cervix is sexually transmitted and caused by the Human Papillomavirus.
Records with the cancer registry at the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) show that about 226 new cervical cancer cases were registered since the establishment of the registry in 2014.
Of the total cervical cancer patients, 154 were referred to Kolkata while it was fatal for at least 84 women.
Dr Ugyen Tshomo said that only about one fourth of the cancer patients die in hospitals.
“We give palliative care to cancer patients at the last stage but we don’t encourage them to stay in the hospital where visitors are restricted,” Dr Ugyen Tshomo said. “We advise them to be comfortable at home with their families in the last few days.”
Of the total 1,939 new cancer patients registered since 2014, cervical cancer constitutes 11.65 percent.
Dr Ugyen Tshomo said that cancer patients who were diagnosed before but died after the establishment of the registry were also recorded in the list. “The number of women with cervical cancer has not gone down but deaths due to cervical cancer has started declining since 2015.”
To prevent cervical cancer in the country, the Human Papilloma Virus (HPV) vaccine programme was started in Bhutan in 2010 with support from Australian Cervical Cancer Foundation. About 42,863 girls between 12 and 18 years were vaccinated. From 2011, the vaccine was introduced into the routine immunization services and in schools where class VI girls irrespective of their age were vaccinated since 2014.
Deputy chief programme officer with the vaccine preventable disease programme, Tshewang Tamang, said that for girls out of schools, vaccination strategy remains through hospitals, Basic Health Units (BHUs) and out-reach clinic services. “However, almost 97 percent of the target population for HPV vaccination is in the schools.”
Dr Ugyen Tshomo said it is early to see the impact of HPV vaccines on reducing the number of cervical cancers in the country now because the girls who were given the vaccination are still unmarried. “For now we have to continue with the screening test to prevent women from dying of cervical cancer.”
Most cervical cancers are diagnosed in women who are in their 50’s while few are in their 20s and 30s.
Dr Ugyen Tshomo said that cervical cancer patients were the most referred patients before 2008. “Now we do the surgery in the country and those diagnosed at later stages who need chemotherapy are also treated here. Only those cervical cancer patients who need radiation therapy are referred to Kolkata.”
Cervical cancer is the sixth most referred case after breast, lung, head and neck, blood and thyroid cancers.
However, the incidence of cervical cancer is the second highest after stomach cancers in the country.
Diagnosing Cervical Cancer
Screenings for cervical cancer include HPV testing, visual inspections with acetic acid (VIA) and Pap smear tests.
Dr Ugyen Tshomo said that except for Bhutan and Sri Lanka, most countries in the region use VIA test for screening cervical cancer while the developed countries in the West use HPV testing.
“HPV testing is the right method of screening where there is HPV vaccination,” Dr Ugyen Tshomo said. “If we ever change our screening method, we might go for HPV testing.”
There are two HPV testing machines in the country, one at the JDWNRH and the other at the Mongar regional referral hospital. “HPV testing kits are expensive and are not easily available, which is why we are doing HPV testing for research purpose since 2011.”
Despite various awareness measures on cervical cancer screenings, making the public aware of the disease and educating them on the importance of Pap smear is still a challenge for the health sector.
Dr Ugyen Tshomo said a self-sampling study was carried out for 2,500 rural women in 15 BHUs in the country last year, which shows that more than 50 percent of the women did pap smear test. “However, women are not understanding why they are doing the test.”
Health workers went door to door and invited all women between 30 and 60 years of age. Only about 70 percent of the women participated in the study, Dr Ugyen Tshomo said.
She said that embarrassment is one of the reasons women don’t do the test. In this study, women were asked to take their own sample for HPV testing. It was found that older age and distance from the BHU to their village were factored in availing the health service for rural women.
It was also found that the participation of women in 50s is poor.
Two women from the study area were diagnosed with late stage cervical cancer, a year after the study was conducted, Dr Ugyen Tshomo said. “When asked on why they did not come for the screening during the test, they said they did not know.”
She said women without children and those who have a family assume that Pap smear is not for them. “This attitude of our people towards availing the health services needs to be changed.”
Another study carried out in Thimphu in 2012 for 2,500 women found that only 60 percent of women had ever undergone a pap smear. The gynaecologist attributed this to lack of awareness. Even educated women were found to believe that Pap smear is done only if they are availing other services like antenatal care or family planning.
According to the studies, Dr Ugyen Tshomo said that in urban areas, younger women are reluctant to do the test while in rural areas it is the older women.
Dr Ugyen Tshomo said many women who get cervical cancer had done Pap smear in the past but some had never collected the report while some with abnormal reports despite advise did not come for treatment.
She pointed out that most women diagnosed with cervical cancer had done a pap smear but were irregular with their tests and hadn’t followed up. “Here, there is a fault of both patients and the health workers. The health workers need to tell patients why Pap smear is done and also the importance of collecting their test result.”
The test has to be done every three years and is recommended for women between 25 years – 65 years, if they are sexually active and irrespective of their marital status. “The reason for it being 25 years is because cervical cancer is rare in women who are below 25 years,” Dr Ugyen Tshomo said. “If the test result is abnormal then they have to come for colposcopy.”
Colposcopy is a procedure to closely examine a cervix, vagina and vulva for signs of disease and treat accordingly. There are different treatments for pre-cancer like cutting the cervix or burning it. “If timely treatment for pre cancer is not given, then they will anyway get cancer so the pap smear test is wasted.”
Dr Ugyen Tshomo said that while 60 percent of women do Pap smear tests, they still get cervical cancer because of poor follow ups. “Which means women still don’t understand why they are doing the test and the health workers have also not given much importance.”
She pointed out that Pap smear is one area that requires female health workers. BHUs with no female health workers have never started the Pap smear test.
“Women prefer female health worker for Pap smear so it’s very important that we have more female health workers in all health centres for acceptance of Pap smear and copper T,” she said.
Health minister Tandin Wangchuk said that despite the free availability of Papanicolaou test in the country, most cases of cervical cancers are diagnosed at a later stage. “Therefore, education to increase awareness of risk factors and promotion of early diagnosis are important aspects of prevention and control of this preventable cancer.”
Lyonpo said the HPV vaccination provides 97 percent prevention. “There are still chances that about three percent of those who received vaccination has the risk of getting cervical cancer.”