UNDER THE MICROSCOPE
Cervical Cancer is the second most frequent cancer (after breast cancer) and the most common cause of death from cancer in Filipino women. In 2020, the Philippines recorded almost 8,000 new cervical cancer cases and more than 4,000 deaths alone. It is of high public health concern.
Around 37.8 million women are at risk for cervical cancer and there has been a significant increase in cervical cancer incidence in the Philippines. Yet, we have the lowest screening rates of breast and cervical cancer in the world, with only one percent or 540,000 out of 54 million women undergoing screening. Cervical cancer diagnosis usually occurs at a very late stage, thus treatment is more expensive and not too effective.
The two major screening methods are the Papanicolaou (Pap) smear and Human Papilloma Virus (HPV) testing. The Pap smear is usually done at a visit to the gynecologist’s clinic, but majority of Filipino women don’t have access to this screening method for several reasons: Embarrassment, ignorance, poor access especially in remote areas, functional or physical limitations as well as cultural and religious reasons. Another stumbling block is the requirement of pathologists to screen Pap smears, which is laborious and time-consuming, and therefore precludes effective mass screening.
The HPV test is also done on a cervical sample and has the same reasons for lack of access. It is a point-of-care molecular test for HPV types 16 and 18 plus some other high risk but less common HPV types. These high-risk HPV types are strongly associated with cervical cancer development and if detected early, can be followed up with annual Pap smears to detect early developing cervical cancers which can be treated successfully compared to late-stage cancers. A negative HPV test in young girls and women presents an opportunity for HPV vaccination to prevent infection later in life once immunity has been achieved. This is primary prevention which can have maximum impact in cancer prevention, not just for cervical cancer but also for head and neck, and anal cancers in both men and women.
Recently, I attended a presentation of a self-collection kit for cervical samples which can be processed as a liquid-based cytology (LBC) slide instead of the traditional manual smears. It can likewise be used for HPV testing, therefore achieving two tests with the same sample. Another innovation is the automated screening of LBC Pap smears using artificial intelligence (AI), which can be used for mass-screening for cervical cancer. For me, it was an exciting discovery which I postulate can be a game-changer in cervical cancer screening in resource-limited countries like the Philippines.
The self-collection kit enables women to collect their own samples in privacy thus precluding the many reasons for poor uptake of cervical cancer screening. It likewise has very high acceptability in the target population. Studies have shown similar efficacy of self-collection to gynecologist-collected samples in terms of cervical cancer screening by Pap smears and HPV tests, and therefore can be employed as a mass screening tool in public health programs.
Coupled with the liquid-based Pap smear which can be screened quickly and accurately with the AI-assisted automated imaging system and the HPV test, the self-collection kit has the capacity to expand the cervical screening program exponentially.
Currently, there is no real mass screening program for cervical cancer in the Philippines. Based on DOH AO No. 2015-0120 Guidelines on Free Cervical Cancer Screening in DOH Hospitals, free cervical cancer screening will be done once a week in May which is designated as Cervical Cancer Awareness Month in DOH hospitals. It is hardly feasible to screen large numbers of women who are at risk for cervical cancer.
A more rational approach will be to employ self-collection by women who will submit their samples to the local health facility. This will enable more women to avail of cervical cancer screening without the attendant embarrassment and fear that may be felt during a clinic visit. Samples can be gathered and sent to a central processing facility for LBC and HPV screening.
The central facility, which should be provided with personnel trained in liquid-based cytology preparation and the automated AI-assisted screening system, can process the samples. The few abnormal results flagged by the AI-system can then be checked by the pathologist.
The system thus removes obstacles to access by women, reduces the number of medical personnel needed and will produce results faster than a clinic-collected sample at a markedly reduced cost if employed as a mass screening tool.
It is high time we ramp up cervical cancer screening. Cervical cancer rates will only go up since women engage in sex at earlier ages with increasing promiscuity and increased risk of HIV infection, which are co-factors in cervical cancer development.
How about it, DOH? Maybe the LGUs?