If the number is anything to go by, Bhutan has come a long way in providing pap smear test to women in the country.

The number of pap smear slides (tests) increased from 18,371 in 2013 to 36,897 in 2017.

A gynecologic oncologist with the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Dr Ugyen Tshomo, said that the number of slides did not represent the actual number of women who did Pap smear test because some would have done the test more than once.

“By 2018, about 40,000 slides were done,” Dr Ugyen Tshomo said at the national workshop for cervical cancer elimination in Thimphu last week.

When the pap smear programme was started in the country, she said that the pap smear coverage was less than five percent and the number of slides used to be less than 5,000. “Of which, many were kept in the health centres without transporting to the cytology centres, resulting in no reports.”

In the past, Bhutan had only one cytology centre, at the national referral hospital in Thimphu. Currently, the country has 14 cytology centres and six colposcopy or LEEP (loop electrosurgical excision procedure) centres.

“In 1999, when I visited Gelephu hospital, they had thousands of slides that were not transported to JDWNRH and the slides were collecting fungus,” Dr Ugyen Tshomo said.

That was the situation in the 1990s.

The national pap smear programme was launched in October 1999.

The programme was piloted in three districts for three years and then went nationwide in 2006.

Health Minister Dechen Wangmo said that after more than a decade after introducing the service, Bhutan had a pap smear coverage of 56 percent. “And this is not acceptable.”

Lyonpo said that the coverage could increase to 60 percent even if nothing was done. “It would increase just from the sheer changes that are happening around.”

Dr Ugyen Tshomo said that cervical cancer prevention had taken a back seat because of lack of support. “Health assistants and cytology technicians are left to do what they want.”

She said that no one cared whether women were coming forward for pap smear test or if they were collecting the reports. “The slides have to be transported to the cytology centres, which doesn’t happen. The reporting time is longer because there is no coordination in the districts because the key people are not involved.”

Coverage remained low due to various factors.

“Improving coverage is essentially important if cervical cancer is to be prevented,” said Dr Ugyen Tshomo.

A screening programme takes 15 years to show results.

Dr Ugyen Tshomo said that Bhutan was in the 13th year. “So, in the next two years, our cervical cancer rate should drop down drastically if this pap smear programme is working.”

It takes 70 percent coverage for cervical cancer to come down.

Social and political barriers of screening

Dr Ugyen Tshomo said that education and literacy made impact. “Women are not aware about screening and, therefore, the lack of demand.”

Women unable to travel for screening or to follow up is also one of the barriers.

“Majority of the women are also shy to come forward for the test,” said Dr Ugyen Tshomo. She said that there was no local or national supervision and monitoring.

REACH Bhutan study 2016 shows that women aged 50 years and above think that they are too old for the test. Distance from health centres, especially in rural areas, misconception about pap smear being connected to family planning and women who are not married but sexually active, among others, are some of the factors for why women do not participate in screening.

Another study carried out in Thimphu in 2012 found that women who were educated and who were in business were not coming forward for the screening. This means timing inconvenience was also there, Dr Ugyen Tshomo said.

Recently, two health officials were sent for supervision in Wangdue, Punakha, Trongsa, and Bumthang, who found that guidelines and pamphlets were not available in all the centres.

It was also found that pap smears were done infrequently with very few clients in a month and the coverage was not calculated.

Dr Ugyen Tshomo said that every health centre knew how many households are there in their area and details about the women living there.

“The information about the eligible women in his or her community, the number of pap smear test conducted, among others, should be at your fingertips,” she told dzongkhag health officers and chief medical officers at the workshop.

This information, she said, was not available and smear taking was also not uniform. There were no proper registers and no proper data-keeping.

She said another important finding was that cytology technicians were not given time for cytology, and so, many slides remained pending.

Some centres were not reporting abnormalities.

Dr Ugyen Tshomo said that Punakha had no abnormal pap smears while Punakha reported a higher number of cervical cancers in the last five years. “This means the health assistants are not taking pap smears properly or the cytology technicians are not reading properly.”

There were many factors that affected the quality of the programme, she said.

Of the seven dzongkhags that refers patients with abnormal pap smear reports to JDWNRH for colposcopy, Paro recorded the highest. She said this meant Paro was actively doing pap smear tests, was catching abnormal pap smear, and was sending them for colposcopy.

Wangdue and Trongsa were picking up, she said.

“Colposcopy is very important. The number of colposcopy shows if pap smear test is being carried out,” she said.

The number of colposcopies has also increased over the years. In 2002, less than 100 colposcopies were carried out, which increased to more than 800 in 2014. Now, more than 1,000 colposcopies are being carried out annually at JDWNRH alone.

In JDWNRH, LEEP, which is a treatment for cervical pre-cancer, is the second most common minor surgery done after abortion complications.

Way Forward

Providing information on cervical cancer, screening and treating are the three important things in the prevention of cervical cancer.

Reaching the unreached and improving the coverage, making colposcopy and pre-cancer treatment accessible to women with abnormal pap reports are the way forward to eliminate cervical cancer in the country.

The definition of elimination is bringing down the incidence of cervical cancer to less than four per 100,000 women by 2030. Currently, the country has the incidence rate of 20 per 100,000 women.

“We have lot of homework to do,” Dr Ugyen Tshomo said.

Dechen Tshomo