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What can be done
Worldwide Screening
Even in western countries with well organized health care systems, it is difficult to screen every woman with the pap smear method who runs the risk of cervical cancer. Therefore it is obvious that it would be practically impossible to organize such medical examinations of the total population in all developing countries. They would over burden the medical facilities. The distance to the nearest medical facility often is too great, the knowledge and technology are not available and the essential information campaigns for large groups of women are not easy to organize. There
are also cultural issues; examining genitals is simply taboo in many cultures. Also, women in many cultures do not have equal status with men. These are reasons why prevention and early detection of cervical cancer do not always get the (political) priority they deserve. The effect in developing countries is that cervical cancer is often not discovered until women start to suffer the symptoms. In those cases, it is usually too late for effective treatment. In Indonesia for example, more than 40,000 women are diagnosed with cervical cancer annually, while 32,000 women die from the disease every year, of whom 80% never sought medical help.
Early Detection and screening approaches
The process of this malignant change is supposed to take between 8 to 15 years, which means that the original cause of the infection can hardly ever be identified. This period, in which cells in the cervix are gradually changing into cancer cells, allows for screening which can detect the disease at a premalignant or a very early stage. In most western countries, every woman above the age of 30 has regular check ups by means of a Pap smear test, which is named after the man who developed this procedure - the greek doctor Papanilolaou. Cells are scraped from the cervix with a brush or wooden spatula, colored and examined under a microscope. The vast majority of cases of cervical cancer are discovered with this procedure before it has settled in the surrounding tissues or lymph vessels, often even in the pre malignant stage. Due to the screening, cervical cancer is now very rarely a fatal disease in the Western countries. But there are two disadvantages within this screening method: expensive and difficult. That is why these medical examinations of the population never reach woman living in low resource setting. It is a tragic fact that particularly those women run a high risk of developing cervical cancer can often not be reached.
Visual inspection with acetic acid (VIA) has been shown to be a promising screening approach for identifying women with high-grade precancerous lesions. VIA involves swabbing the cervix with a 3- to 5-percent acetic acid (vinegar) solution prior to visual examination. Many aspects of VIA make it an appealing approach for use in the targeted low-resource areas. VIA is a relatively simple, easy to-learn approach that is only somewhat reliant upon infrastructure for its adequate performance, assuming that sufficiently trained providers are available. The approach does not require laboratory involvement; furthermore, non-physicians can perform the procedure, provided that they receive adequate and ongoing training. The results of the procedure are available immediately, making it possible to provide further management, including immediate treatment of the suspected precancerous lesions during the same visit or referral for further testing.
Worldwide interest in HPV testing has grown in the latest ten years. At the same time, many questions remain about how HPV test might be used because of uncertainty about which women with HPV might develop cancer. In some developing countries the test is already being incorporated as a trial and mostly combined with the existing papsmear screening tool. In the next coming year a HPV test will be developed which needs less technical experience and diagnostic time and reduces costs.
Opportunities for Prevention
The current state of science only offers two ways of preventing a global epidemic of cervical cancer: safe sex and screening. we have already discussed the impossibility of medically examining the entire female population in Third World countries. Every effort to encourage men and women to practice safer sex is valuable. However, despite the global threat of HIV, little change is evident in terms of safe sex. In many developing countries countries, the availability of condoms is limited and their use conflicts with cultural and religious values. Both ways of preventing cervical cancer are therefore only partly applicable in those countries where prevention is most urgently needed.
Preventive vaccination
The only way to eradicate cervical cancer is identical to the way in which mankind has overcome smallpox: vaccination. Recent developments in immunology have raised hopes that it could be possible to develop and effective vaccine against cervical cancer. This vaccine would support the immune system to fight against the cells that are affected with HPV.
Because HPV is found in more than 95% of all cervical cancer cells, the vaccine could contribute to destroying cancer cells and thus curingcervical cancer. The most important benefit of vaccination in terms of women's health is the possibility of prevention. A preventive vaccine could be administered at an age before women become sexually active, to protect them from the consequences of an HPV infection. Eventually, this approach could lead to banishing cervical cancer from the world. In the short term, it would be immensely valuable if the number of patients suffering from this disease could be substantially reduced.