Dr. Shivani Samlall, MBBS, is a specialist in Obstetrics and Gynaecology with a sub-specialty in Gynaecology Oncology, and with over 10 years of medical practice. Dr Samlall can be contacted at drshivanisamlall26@gmail.com.

This week’s column concludes my series of articles on Cervical Cancer. While this article highlights information regarding Cervical Cancer (risk factors, symptoms), its primary focus is exploring the WHO’s ultimate pillar – the 90/70/90 target which states, “90 per cent women should have access to Cervical Precancer and Cancer and Palliative Care”.

RISK FACTORS FOR CERVICAL CANCER
– early initiation of sexual activity
– multiple sexual partners or a high-risk sexual partner (e.g., a partner with multiple sexual partners or known HPV infection)
– history of sexually transmitted infections (e.g., gonorrhea, herpes)
– young age at the time of first delivery and multiple deliveries (three or more)
– low socioeconomic status
– prolonged use of oral contraceptives (greater than or equal to five years)
– multiple births.
Other risks include: an immune-suppressed state such as being HIV positive, treatment with immune-suppressants and smoking.

SYMPTOMS AND SIGNS OF CERVICAL CANCER
Unfortunately, Cervical Cancer presents with symptoms in advanced/late stages which is why screening is important. Early detection means a higher survival chance. Signs include:
– abnormal menstrual bleeding: spotting between periods, heavy bleeding, bleeding after sexual intercourse, bleeding in post-menopausal women.
– vaginal discharge with strong odour
– pain or discomfort during sexual intercourse.
– unexplained, persistent pelvic and/or back pain.

NINETY PER CENT (90 PER CENT) ACCESS TO TREATMENT OF PRECANCEROUS LESIONS
The goal here is reducing the number of Cervical Cancer cases and deaths. To achieve WHO’s 90 percent treatment of precancerous lesions, there must be an increase in screening that matches treatment, as screening women without access to treatment is unethical. To facilitate this, we can adopt a screen-and-treat approach and must ensure that there is adequate assessment of biopsies.
Various treatment options exist to manage Cervical precancerous lesions, including cryotherapy (freezing of the cells of the cervix), ablation or LEEP, conisation, etc.

NINETY PER CENT (90 PER CENT) ACCESS TO TREATMENT OR INVASIVE CANCER
Women suspected of Cervical Cancer should have timely assessment and referral to save lives and prevent disability. According to WHO, comprehensive management of Invasive Cervical Cancer requires well-equipped, appropriately qualified health providers and access to surgical, radiotherapy and chemotherapy services. Management of cases depends on the stage of the disease. Therefore, adequate management is crucial.

Improved access to Surgeries
Cervical Cancer can often be cured by surgery alone, if diagnosed and treated early. However, in Lower Middle-Income Countries (LMCs) the healthcare providers performing oncologic procedures are general doctors / practitioners without formal, certified subspecialty training, who provide cancer care out of necessity. According to the National Comprehensive Cancer Network, survival of Cervical Cancer patients improve and relapses decrease when surgeries are performed by Gynaecologists Oncologists.
In Guyana, while we are fortunate to have person(s) with this type of training, the sad reality is that Cervical Cancers are still being managed by generalists and the human resources are either underutilised and/or inadequately compensated.
Improve access to Radiotherapy and Chemotherapy

Most cancers in LMICs present at stages that require radiation, so sustainable capacity for curative radiation therapy (external beam and brachytherapy) is critical. In Guyana, while we have access to both Radiotherapy and Chemotherapy, there are still limitations in accessing timely and effective treatment. For treatments to be effective, they must be administered concurrently; however, patients struggle to afford their radiation treatment although it is subsidised.

NINETY PER CENT (90 PER CENT) ACCESS TO PALLIATIVE CARE
Symptom-control is the essence of palliative care and is integral in maintaining dignity and quality of life. As the disease progresses, patients may present with a wide range of symptoms associated with the disease, or with the treatments that were employed.
It becomes critical that palliative care is integrated into the treatment plan and provided throughout the course of the disease. Currently, very few LMICs have palliative programmes in place, including Guyana. WHO encourages expansion of the availability of palliative services, which could readily be extended to other forms of advanced cancers and to non-malignant, debilitating diseases.
Common treatment-related effects experienced by long-term cervical cancer survivors that affect quality of life include bladder dysfunction, bowel dysfunction, sexual dysfunction, lymphedema, and psychosocial problems.
Therefore, in addition to managing pain and other distressing symptoms, supportive care must be given to address patients’ and their families psychosocial and spiritual needs.

CONCLUSION
If we are to achieve WHO’s third pillar, we must understand the barriers to accessing services. Government must work closely with NGOs, private and civil society. Local communities, must also be engaged and empowered to lead the development of these critical programmes, serve as allies, counter misinformation and support those needing more complex treatment. Increasing health literacy, knowledge of rights and Cervical Cancer prevention and control will help to mobilise, empower and engage communities and civil society, and ultimately women.