USEFUL OPTION
Acetic acid visualization is an effective alternative to Pap smear for cervical cancer detection
By Jin Paul de Guzman
Dr. Wyda Beriña, coordinator of the Women's Cancer Program of the Department of Health, says that one reason behind the high incidence of cancer in women, especially breast and cervical cancer, is a woman's decision to belittle or even ignore what she's feeling so she could go on serving her family. "We have this value that women put family first," she explains. "If somebody's sick in the family, even if the woman feels sick herself, she'd rather bring the husband or the son or the daughter to the doctor [first]."
Of course, this is just one of the reasons. In a 1989 cross-sectional survey conducted in Metro Manila under the leadership of oncologist Corazon Ngelangel of the University of the Philippines-Philippine General Hospital (UP-PGH), not even 40 percent had ever had a Pap smear, considered a highly sensitive tool in detecting cervical cancer. While most of the respondents who had never had a Pap smear done on them said they were busy, others expressed reservations about the expense involved, or showed fear of possible outcomes, or felt shame about having to be examined by a male doctor, or pointed to the absence of perceptible symptoms or the prematurity of having to go through with it. The rest said they had no idea what a Pap smear was.
The problems that confronted the old national cancer control program also played a major role in the rise in cervical cancer cases.
Problem Pile-up
Beriña herself admits that the old cervical cancer-screening program was "a failure" because of many factors; after all, screening alone does not guarantee the eradication of disease. A cervical cancer-control program must be three-tiered: there must be a primary level where all screening will be done; a secondary level where the screen-positive patients are made to undergo further tests (viz., colposcopy) to confirm the diagnosis; and a tertiary level, where precursor lesions to cervical cancer or actual cervical cancer shall receive the treatment it warrants. What happened was there were breaks in the continuity of the tiers-if patients made it to the first level at all.
To be fair, there were several health centers perfectly capable of cytological screening. They had the equipment and the qualified personnel to conduct and evaluate Pap smears. The problem was few screen-positive cases could be referred to the secondary level to confirm the results, since the number of institutions with colposcopes and trained colposcopists was limited. Fewer still were those patients who had access to the tertiary level; besides, only a small number could afford to undergo surgery or chemotherapy. "Those who turned out to be positive did not have anywhere to go," Beriña said.
The consistent lack in financial resources, of course, was at the bottom of this. And with the logistical nightmare-not to mention the seething opposition-that came with the implementation of Republic Act 7160 or the Local Government Code in the early 1990s came the challenge of adapting existing health projects to a decentralized system.
Dr. Cecilia Llave, head of the UP Cancer Institute, says there were studies that looked into why the old cervical cancer program had failed. She says: "The program [was] very good, but the problem was
parang hindi na-organize mabuti, hindi natutukan, hindi na-monitor…Ang [main reason]
siguro ay yung organization. Dapat naka-streamline."
Meantime, more than 2,000 cervical cancer deaths occur in the country every year, making it the second deadliest cancer in women, next only to breast cancer.
Overhaul
In 1998 a team of researchers from the UP-PGH led by Ngelangel and gynecologic oncologist Genara Limson tried to find out what setup would work best in fighting the national cervical cancer problem. Done under the initiative of the DoH-Women's Health and Safe Motherhood Project and in collaboration with the Philippine Cancer Control Program and the Department of Interior and Local Government, the Cervical Cancer-Screening Health Operations Research Project (CCSHOR) first tried to identify an approach to screening that would be "feasible, cost-effective, and replicable."
While the Pap smear was considered the ideal screening tool, not all health centers in the country had the equipment or the qualified personnel to perform this. In addition, it would require some expense; at the PGH, for example, the PhP100 billed per Pap smear only covers the cost of processing the specimen, since all other fees are waived. Now if this were done nationwide, with all the additional expenses of equipping centers with the appropriate tools and personnel among others, this would add up to something large enough to set back the budget for health-care services.
So one of the options was visual screening with acetic acid wash. There had been studies looking into the effectiveness of visual screening. Although studies had pointed out that visual screening is inferior to the Pap smear in detecting early-stage cancer, they also saw it as a "helpful supplement," a "useful option where cytological screening is not possible." In addition, the method is inexpensive, noninvasive, easy to perform, and yields immediate results.
The randomized, controlled trial conducted by Ngelangel et al. for the CCSHOR involved close to 15,000 women from seven different areas in the country. Using colposcopy as the gold standard, the study compared four methods with one another: acetic acid visualization, magnified acetic acid visualization, Pap smear taken by a spatula and cotton swab, and Pap smear taken by cervical brush. Acetic acid visualization turned out to have the highest sensitivity in detecting cervical cancer precursor and very early lesions (50 percent) compared with the other three (49, 21, and 17 percent). A cost-benefit analysis also revealed that whether in ideal or less than ideal situations, acetic acid visualization yielded the highest net benefit.
And so acetic acid visualization was recommended by the study as a the screening method of choice for the country, with colposcopy with Pap smear or biopsy being used as the appropriate diagnostic test following a positive screen.
After this the same team of researchers came up with a comprehensive proposal on how to carry out an organized cervical cancer program in the country. All ground was covered: from the appropriation of funds for the program to how they would be distributed among the different program-components, from the delineation of government roles to the establishment of public-private sector collaboration, from the standardization of screen and referral methods to public information. The goal was to ensure that between 50 and 70 percent of women from 25 to 55 years-totaling to more than 12 million-would be screened. And for those patients who would be screen-positive, all the other components of the program-from referral centers, medical specialists, and others-would be in place. In other words, the proposed cervical cancer-screening program was virtually inch-perfect.
The results of the study and the details of the proposal were unveiled in 2001, with the DoH announcing the adoption of the recommendations as national policy and setting a precedent of sorts: the Philippines became the first country in the world to adopt acetic acid visualization as a national policy for cervical cancer screening.
Update
It's been two years since the unveiling of the program; what has happened to it?
After some more changes in the DoH setup-the cervical cancer program became part of the Women's Cancer Program, which in turn is part of the Family and Environmental Health Office of the DoH National Center for Disease Control-the cervical cancer-screening project started taking shape. Implementation, however, was done step by cautious step, so as not to fall into the same problems that had beset the old program, or worse.
Beriña explains: "In implementing a program we have to look at it from a wider perspective. [We] have to consider the realities of the situation." And the reality is that it would be too rash to implement the program on the national level at this point; implementing it too soon on a national level, she says, might "boomerang on the program." There's still much of the groundwork that needs to be laid-the presence of trained personnel, for example, or the streamlining of the different phases (screening to confirmation of diagnosis to treatment), or the seamless coordination between government and private sectors, local and national levels.
And so the solution was to pilot the program, with Cebu province winning the bidding. Beriña, who became coordinator of the program when she joined the DoH central office in 2001, says that the pilot project was started late last year, with training, networking, and other aspects of the program now starting its run. "Cebu is ideal for the implementation of the project because they are very willing to adopt it," she says.
Now after convincing the different municipalities of the pilot area, the training of every doctor, nurse, and midwife in each community health center started. Referral centers are also being identified, so those who would screen positive will have somewhere to go. The various government and private laboratories/hospitals capable of doing histopathology/biopsy/colposcoy have been identified, as well as the different specialists who can perform them. Although the number of colposcopes and trained colposcopists in the province is very limited, the DoH has set up two colposcopes in two-one in the north and another in the south-district hospitals. Vicente Sotto Memorial Medical Center serves as the main referral center. Lastly, the collaboration among the different stakeholders-the DoH, the local government units, the private and government medical practitioners, different nongovernment organizations and other concerned groups-is becoming more clearly defined. Also, the workplace and the school-not to mention the mass media-would play a big role in educating patients.
The first phase of the project, which involves the training of the field implementers and the future trainers, is set to run until the end of the year-if the program could buff its financial resources. Beriña is hopeful: "Initial funding is good for up to three trainings only. We have 10 trainings but we are still sourcing out, so we will probably need a lot of help from the NGOs, everybody who's interested to help this project." Llave, head of the Philippine Society of Cervical Pathology and Colposcopy (which is actively involved in the training of the field implementers, future trainers, and colposcopists), stresses the importance of training. "You empower them," she explains. "You empower everybody-it becomes a domino effect."
A national cervical cancer registry, which Beriña calls the "backbone" for all the activities, is also being set up now. Beriña says that the days are gone when a woman submits to screening every time a medical mission comes to town-even if each happens within the same month. Aside from preventing the possibility of duplicating target populations, the registry will coordinate the activities of all concerned groups to ensure that time, effort, and resources are not wasted.
Once finished, the Cebu pilot project will then be used as a blueprint for the cervical cancer-screening program that will be adopted by the rest of the country.
Some Clarifications
Although it is recommended by the program, acetic acid visualization does not supplant the role of cell cytology. If any given area is perfectly capable of doing and evaluating Pap smear exams, not to mention if the woman prefers the Pap smear to other methods, Beriña says there's no reason why a Pap smear cannot be done. Also, even if someone who is older than 55 comes for screening, she will still be screened. "The target population is the priority, but everybody gets to be screened," she explains.
The good thing about the cervical cancer-screening program is that it is going to be integrated with the other health projects of the government-from breast cancer testing, family planning advice, to the promotion of healthy lifestyle. The community health center then becomes a one-stop shop of sorts.
But how to get women to go to the centers and be screened? Increasing awareness is one issue to be addressed; shattering myths is another. But it can be done. Says Llave: "Women's attitudes towards Pap smear are acquired, not inborn. That means we can teach women to acquire new and positive attitude towards the Pap smear or similar tests." She also says that public information efforts should not be trained exclusively on women: "Men are, or will be, the boyfriends or husbands of women who need to undergo Pap smear test. If the men understand that [cervical cancer] can make them widowers in advance or in fact, then these men could be very influential in convincing their partners to have Pap smear test regularly."
Up in Arms
In April President Gloria Arroyo issued Proclamation 368, which declares May of every year as "Cervical Cancer Consciousness Month." Signed through the efforts of the Philippine Obstetrical and Gynecological Society (POGS), the declaration aims to ensure that cervical cancer is detected early and then cured. The different POGS chapters are actively involved in conducting free Pap smear exams. And to ensure that more women are screened, POGS collaborated with Sanofi-Synthelabo for a project called "A Peso to Detect, a Peso to Protect," to which Sanofi-Synthelabo donates a peso to the project every time a consumer buys a bottle of Lactacyd.
General practitioners and family physicians also play a major role in curbing cervical cancer. Says Llave: "They play a big role primarily because many such physicians practice in rural areas and low-income areas and therefore they are more accessible to women than gynecologists." She also adds that since all doctors are taught to perform a Pap smear during residency, they may do it. But if there are things that prevent them from doing a Pap smear, Llave advises them to identify who among their patients are at risk of cervical cancer, and refer them to the appropriate centers.
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