The study was undertaken on the topic cervical cancer in Botswana that is, the people at risk of cervical sarcoma together with the incidence and prevalence rates of cervical cancer in Botswana. The study was further more described by briefly stating and discussing elements responsible for the occurrence of cervical sarcoma in the population. In making study more understandable the study was demonstrated using a model of causation called web causation theory clearly illustrating the causes of cervical cancer. Interventions currently done in Botswana were discussed using the Leavell’s theory on the levels of prevention and also describing the public health surveillance system used by ministry of health in Botswana.
Background
Cervical cancer
This is the cancer that transpires in the cells of the cervix, which is the lower part of the uterus that joins to the vagina. Human papillomavirus is a sexually transmitted infection that plays a major part on the cause of cervical cancer. These signs and symptoms include blood spots or menstrual flow that is extended and heavier than usual, bleeding after intercourse, discomfort during sexual intercourse, bleeding after menopause, and unexplained persistent pelvic.
It has four stages which are used to identify how much of the cancer cells are in the body. These stages are; Stage(i),Stage(ii),Stage(iii) and Stage(iv). Below is an image that shows these stages: Source: https://www.moderncancerhospital.com/cancer-staging/cervical-cancer-staging/
Globally
Worldwide 266 000 women died due to cervical cancer in 2012 and 90% of these mortality cases were in low and middle-income countries. According to WHO (2019), “cervical cancer is the fourth most cancer in women with estimated number of 570 000 new cases in 2018 and 90% of death were caused by cervical sarcoma in low & middle-income countries.”
Cervical cancer is midst the most commonly diagnosed cancers in women worldwide. Globogam (2018) estimate that 567 847 incidence of cervical cancer worldwide which is the fourth leading cancer, 615 072 new cases were reported in Europe and in 2015 these were an predictable 311 365 deaths from cervical cancer worldwide and 7.5% of the total number of cancer decreases in women.
The prevalence of cervical cancer of women who were alive after 8 years diagnosed with cervical cancer in 2018 estimate at 1 474 268 worldwide, 190 814 in Europe. In 2018 the collective risk of cervical cancer in women aged less than 75 years was 1.36% globally and 1.09% in Europe.
Botswana
Botswana obligates high rate of cervical cancer due to barriers of cancer screening programs and high HIV frequency. Starting from 2015, girls in schools were vaccinated against Human Papilloma Virus. Approximately 60% people living with HIV are cancer patients. In Botswana, cervical cancer is one of the leading causes of death among women. Between the years 2003 and 2011, 26% was recorded for all cancers among women of which 14% was cervical cancer, and the mean age of women affected by cervical cancer was 52years. According to Tapera.R et al “over 250 000 women in Botswana are in the age group 30-49 years and around 25% of total female population and are at high risk of developing cervical cancer.” Women are at a high possibility of acquiring cervical sarcoma and it will continue to rise until active interventions are put into work.
Risk factors of cervical cancer
Socio-economic factors
Cervical cancer is the most common among women who have low access to health services like (screening cancer). Therefore it put them at risk of be exposed to cervical cancer.
Reproductive and sexual factors
An increased risk of cervical cancer is mostly observed by people with multiple sexual partners hence the increased risk is attributable to an increase of Human papilomavirus (HPV).
Sexually transmitted infections (STIs)
Human papillomavirus (HPV)
These is one of the risk factors for cervical cancer and it is common in people who are affected with HPV once they are sexually active because it is a virus that is mostly diagnosed in some of the sexual transmitted infections (STIs) hence they start sex at an early age and have multiple concurrent partners that put them at a great risk of being infected with HPV.
Most cases of cervical cancer occur as a result of infection with HPV, the infection is usually transmitted by sexual contact which causes progression of squamous cells on the surface of the cervix and they mostly appear after 6months due to immunological intervention. The most prevalence of HPV occurs at the age of 25years, which can be related to sexual behavior and it is also observed at the age of 45years and the permanent infection with the high risk of HPV over time leads to development of the unusual growth of cells on the surface of the cervix that could potentially lead to cervical cancer; cervical intraepithelial neoplasia (CIN).
Oral contraceptives (OC) pills
The usage of combined oral contraceptives method is linked with increased risk of cervical cancer. Women who tend to use OC method than 5years or more can double the risk of cervical cancer.
Immune system deficiency
Women with lower immune systems are at high risk of developing cervical cancer because a lowered immune system can be caused by immune suppression or human deficiency virus (HIV), therefore when a woman is HIV positive her immune system is less able to fight off early cancer.
General factors
Genetics/family history
A female who has had a mother or aunt with cervical cancer is at risk of developing cervical cancer.
Pregnancy
Women who had their pregnancy before 17 years of age have higher chances or possibility of acquiring cervical cancer.
Behavioral factors
Smoking
Smoking may lead to cervical cancer, women who smoke are likely to get cervical cancer because tobacco products have been found in the cervical mucus of women who smoke and these substances harm the Deoxyribonucleic acid (DNA) of the cervix hence contributing to growth of cervical cancer.
Obesity
Due to conversion of androgen to estrogen in the peripheral adipose tissue, obesity especially after menopause it is considered to be increasing sex hormone levels. Therefore obese women are likely to seek screening for cervical cancer; the reasons be that obese women have to delay to receiving services due to their physical image, shame, and lack of willingness to lose weight. Even the technical problems of performing pep smear in obese women such as their anatomy can impact them to seek effective screening, hence be exposed to cervical cancer.
Disease causation (web of causation model)
It is a model that shows the interrelationship of multiple factors that add to the occurrence of a health issue or disease. It is usually used when a disease has no single factor that causes it or if the causes of the disease are interacting in various pathways. The web of causation model seeks to show the relationship between the social, biological, socio-economic, and physical causal processes. Below is the web of causation model showing the causation process of cervical cancer?
(Sexually active) (Pregnancy)(Multi-concurrent partners)(Human immune deficiency syndrome)(Smoking)(Human Papillomavirus)(Cervical cancer) (Obesity) (Lack of exercise)(Lack of access to health services) (Family history & background)
Levels of prevention
Primary prevention
Hpv vaccination
In Botswana the vaccination was introduced in 2015, where 9-13 years old girls in primary schools and those not attending schools were given the HPV vaccine, first dose which is given at first contact with the girl, second dose is administered 2 months after the first dose and third dose which is given 4months after the 2nd dose.
Awareness about cervical cancer
Students are also educated about cervical cancer at schools and ways of preventing themselves from the risk of developing cervical cancer and the health talks are conducted in clinics to raise understanding to the community about cervical cancer
Abstinence from sexual intercourse
Abstaining prevents one from being at risk of developing cervical cancer because the HPV virus which is responsible for formation of cervical cancer is transmitted through sexual intercourse therefore if a girl child or woman is abstaining from sex, the chances of her be at risk are low compared to individual who is sexual active.
Provide contraceptive counseling and services including condom
Women who are sexually active and using condom are at a lesser risk of developing cervical cancer compared to individual who don’t use protection because these condoms prevent them from getting the HPV which cause the cervical cancer.
Secondary prevention
It comprises of screening asymptotic patients or carrying out tests in symphonic or screen-positive patients to pick up precancerous lesions before they cause cancer. Cervical cancer screening involves detection of cancer in women who may not have symptoms and feel fit. Pre-cancerous lesions can be treated and development to cancer can be avoided when detected at an early stage. If it is identified at an early stage there is a high likelihood of it being cured. World Health Organization recently recommends two types of tests which are HPV testing and the Pap smear. Repeated screening is vital for every woman above age of 30 because cancer cells take several years to mature.
In Botswana, the Pap smear is the only available technique for screening of cervical cancer and has been introduced to all government hospitals to make it easily accessible to every client who wishes to do the check-ups for the past 20 years. It is a time consuming technique and there are high chances of loss of follow-up due to waiting a long time for the results. Even though the government has made it easy to do this check-up, they face a challenge of increased mortality rates caused by cervical cancer because patients may not go back to the hospitals to get their results, resulting in them only realizing they are infected at a later/advanced stage.
Tertiary prevention
According to Grover.S et al, “tertiary prevention involves the treating cervical sarcoma after diagnosis. Treatment consists of radiation therapy and chemotherapy rather than surgical procedure because there are no gynecological oncologists in Botswana. Patients who are assumed to have cervical cancer are referred to gynecology for further check-ups.” If the disease advances the government of Botswana refers the patient to take radiation therapy at Gaborone Private Hospital (GPH) at no cost all because it is the only facility in Botswana with the radiation machine.
Surveillance
Facility level
Data can be collected from variety of sources, therefore under facility-level cervical cancer data is collected using a register. Data from medical registry can be used to monitor cervical cancer trends, determine disease patterns, and also to guide planning and evaluation of disease control programs for example to see if whether prevention, screening and treatment of cervical cancer is making a difference or not. For instance in facility-level women are advised to do the cervical cancer screening and girls to take the HPV vaccine in order to prevent the disease hence clinical records, patient interviews can help in interpretation, and analysis of cervical cancer data in order to help in planning, implementation as well as evaluation in public health practice. There is also displaying of cervical cancer pamphlets in IEC corner and information displayed to empower the community with knowledge about cervical cancer.
DHMT level
All facilities are supposed to submit their reports to the district health management team about cervical cancer. DHMTs are responsible for training nurses in health facilities on how to perform Pap smear and they also ensure that they order enough HPV vaccines for the district.
Ministry level
The district health management teams report to the Ministry of Health and the ministry ensures that cervical cancer screening and treatment services are introduced to the public health facilities so that more women can have access to the services. They have to make sure that screening and treatment are done at the best basic infrastructure and by professional personnel; they are also responsible for buying medication and vaccine for cervical cancer, funding of cervical cancer workshop campaigns.
Critique
Limitations
There is lack of cervical cancer materials therefore these limit people to be equipped with knowledge on how to prevent cervical cancer.
Loss of skilled personnel to perform Pap smear can be limitation as now screening of cervical cancer will not be done.
Some of the services of cervical cancer can only be found in urban areas and big villages which limit women who stay in rural areas to access those services.
Lack of financial resources to do some of the cervical cancer programs and services that prevent cervical cancer.
Strengths
Involving key stakeholders like women organizations, community-based organizations, government officials, and health workers because cervical cancer prevention programs have to address the factors that determine whether women use screening services and improving accessibility of screening services.
Implementation of cervical cancer educational services in order to increase the number of women partaking in cervical cancer screening programs.
Recommendation
Government should consider training gynecological oncologists who can perform surgery on patients diagnosed with cervical cancer to remove the tumors from the cervix. It should also ruminate about installing radiation therapy machines in public health facilities, especially referral hospitals.
Conclusion
Cervical cancer is a great concern within the country and worldwide, as it has claimed so many lives and still does. It is the responsibility of women to take care of themselves and also encourage their children to go for Pap smear check-ups regularly.
References
Aggarwal P, (October 2014) world journal of clinical oncology, cervical cancer, issue 5 Volume (4) pp: 775–780, available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129540/
Denny. L, (2008), international journal of sexual reproductive health and right, prevention of cancer, Available https://www.tandfoline.com>doi>pdf, accessed on the 19 September 2019
Grover.S, (2015), cervical cancer in Botswana current state and future steps for screening and treatment programs, Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4630577/
Maseko. F, Chirwa. M and Muula. A, 9 January 2018), health systems challenges in cervical cancer prevention. Article in global health action,