Ramsha Zafar ( 5th Year MBBS Student, Dow University of Health Sciences, Karachi, Pakistan. )
Asma Burney ( 5th Year MBBS Student, Dow University of Health Sciences, Karachi, Pakistan. )
Dear Editor, Cervical cancer is the second most prevalent cancer in Pakistani women of the reproductive age group (15-44 years), while in women of all ages, it ranks as the third most common. It is estimated that around 20 women are found to have cervical cancer per day, ranking Pakistan in the top 10 countries with the highest cancer-related mortality rates.1 In 2020 alone, cervical cancer took the lives of 341, 831 women, 90% of whom belonged to developing countries including Pakistan. In the same year, it affected 604, 127 women, from which only 12% were from regions like North America and Europe, while the remaining belonged to the developing world.2 This startling disparity can be attributed to the introduction of pap smears in the developing world, like the United States and the United Kingdom, which saw >70% decline in cervical cancer mortality since screening through Pap smears was initiated in these countries.3
In Pakistan, several studies have shown that women of the reproductive age group lack basic awareness regarding cervical cancer and screening via Pap smears. A survey on 873 women between 18-28 years found 70.1% of the participants were completely unaware of cancer.4 A more extensive study consisting of 1070 women between ages 21-30 years found that only 2.2% of their study's population was able to identify the symptoms and risk factors for cervical cancer, while Pap smear was recognized as a screening test by only 2.5% of the same. The Pap smear uptake in this population was 2%.5
This lack of knowledge regarding screening can be credited to several factors such as the low educational status of developing countries, little information communicated by the healthcare workers, and the insufficient knowledge of preventive measures amongst them. Other screening barriers include misconceptions about testing guidelines, the socioeconomic status of low-income families, lack of access to testing facilities, personal reluctance due to embarrassment, and family trends of not getting tested due to cultural taboos.5
It is crucial to overcome the aforementioned obstacles in order to ensure early screening and treatment of precancerous lesions in women. Early identification of cervical cancer would allow timely intervention, improve morbidity, mortality and reduce the financial burden associated with the disease.
Government and NGOs should work together to mobilize community health workers in the country for this purpose. A recent cluster RCT from Hong Kong involving over 300 South Asian women tested this approach. Their intervention group was given relevant education regarding cervical cancer, regular follow-ups via phone calls, assistance with booking and navigation for screening appointments through community health workers. Their findings showed a significantly higher screening uptake by the intervention group (97.9%) compared to the control (52.6%). We believe a similar approach should be adopted on a larger scale in Pakistan.6
Health care providers should be trained to disseminate knowledge regarding cervical cancer and the importance of regular screening, mainly targeting the rural areas where most of the Pakistani population resides. This approach will have a trickle-down effect on the masses and help combat the negligence and reluctance to screening in the general population. It can further be supplemented by organizing mass awareness campaigns at the governmental level- both on-ground in the form of screening camps and door-to-door campaigns, as well as using media platforms such as television, radio, and social media. The month of January is “Cervical Cancer Awareness Month” and can be used to dedicate maximum effort in raising awareness about the disease, as is done for breast cancer during October.
Moreover, government resources should be allocated to ensure access to screening facilities that are affordable to the general population. Utilizing the already existing clinics and establishing new ones, where necessary, as awareness centres and safe spaces for women to discuss and be educated on this matter will help counter the reluctance and cultural taboo associated with discussing women’s reproductive health in a conservative society. By investing time and resources into such initiatives, developing countries like Pakistan can overcome the high mortality rate linked with this fatal yet preventable disease.
Conflict of Interest: None.
Funding Disclosure: None.
1. Batool SA, Sajjad S, Malik H. Cervical cancer in Pakistan: A review. J Pak Med Assoc 2017;67:1074-7.
2. International Agency for Research on Cancer, World Health Organization (WHO). Cervix uteri Source: Globocan 2020. [Online] 2021 [Cited 2021 June 10]. Available from URL: https://gco.iarc.fr/today/data/factsheets/cancers/23-Cervix-uteri-fact-sheet.pdf
3. McGraw SL, Ferrante JM. Update on prevention and screening of cervical cancer. World J Clin Oncol 2014;5:744-52. doi: 10.5306/wjco.v5.i4.744.
4. Khan GJ, Naeem HS, Khan S, Jamshaid T, Sajid MI, Bashir I, et al. Understanding and responsiveness level about cervical cancer and its avoidance among young women of Pakistan. Asian Pac J Cancer Prev 2014;15:4877-83. doi: 10.7314/apjcp.2014.15.12.4877.
5. Sultana R, Hafeez M, Shafiq S. Awareness about cervical cancer in Pakistani women. Pak Armed Forces Med J 2019;69:21-5.
6. Wong CL, Choi KC, Chen J, Law BMH, Chan DNS, So WKW. A Community Health Worker-Led Multicomponent Program to Promote Cervical Cancer Screening in South Asian Women: A Cluster RCT. Am J Prev Med 2021;61:136-45. doi: 10.1016/j.amepre.2021.01.031.