Thursday, June 7, 2012

Education in conjunction with consistent Screening and Treatment= Reduced Incidences of HPV-related Cervical Cancer in Developing Nations?

My partner Kayla Ehring and I are studying viruses and how they lead to cancer. Particularly, our focus has been on the HPV virus and its link to cervical cancer, especially in developing countries.

Case studies:
I recently stumbled upon a 2010 study entitled, Examining attitudes about HPV and cervical cancer risk among female clinic attendees in Johannesburg, South Africa. It got me thinking about possible solutions to solve this sad development in developing nations, especially those in Africa, a place very close to my heart.
 In the 2010 study  it is revealed that developing countries account for up to 85% of the approximate 500,000 cases per year of cervical cancer globally. Approximately 250,000 of these deaths occur in Sub Saharan Africa, South Asia and Latin America. One suggested cause for the high rates of cervical cancer in developing countries may be attributed to the lack of efficient methods of screening for and treating HPV and cervical cancer. 
According to the WHO, cervical cancer is treatable, but many women in developing countries do not have access to effective screening programs, thus explaining the high incidences of cancer in developing countries. Furthermore, according to studies published by the NIH in 2001, incidences of cervical cancer are so high in developing countries primarily because of the lack of effective screening programs aimed at detecting and then treating precancerous conditions. In  the study, an estimated 5% of females in developing countries had been screened for cervical dysplasia in 5 sequential years, where as in developed nations at least 40%-50% of the women had been screened for cervical dysplasia. 
Furthermore, while developing nations do offer pap smear services, in many cases, these tests are only available to a small number of women, via private health care. In short lack of technology, lack of follow up diagnostics and treatments are largely to blame for the high incidences and prevalence of cervical cancer in developing nations. The graph below graphically represents this point very well.

Figure 2

Furthermore, in the  2010 study in South Africa, 86 women aged 18-44 with at least one offspring, were enlisted to take part in a survey which aimed to understand the attitudes and knowledge women in South Africa had about HPV, cervical cancer and the HPV vaccine. The results reflected that a significant portion of the participants were not familiar with HPV, the vaccine and cervical cancer, they were however concerned about the risk to both them and their offspring of acquiring HPV and cervical cancer. The study also reflected the fact that many of these women faced barriers towards receiving screening for cervical cancer but were willing to get their offspring vaccinated. This study reflects the need for education in developing nations such as South Africa about HPV, how it is contracted and how it can lead to cancer. Such invaluable knowledge could offer a major break through in terms of reducing incidences of cervical cancer in the developing nations.
Below is a sample of some of the results from the survey and study:
Womens' knowledge about HPV:

Table 1:Sample interview and results on HPV
Participants’ response
C1. Have you ever heard of HPV infection
29% (n = 86) yes
C2. HPV is a sexually transmitted disease/infection
79% answered true
C3. There is no cure for HPV but it can be controlled
33% answered true
C4. Having HPV puts one at risk for cervical cancer
67% answered true
C5. HPV is an infection that only affects women
17% answered false
C6. HPV is spread through sexual contact
71% answered true
C7. Condoms offer some protection from HPV
75% answered true

Table2. Women's knowledge of cervical cancer.
Participants’ response
B1. Have you ever heard of cervical cancer?
61% yes (n = 86)
B2.The Pap smear test is used to see if a woman has unhealthy cells in their cervix. Have you had a Pap smear test?
41% yes
34% of those who answered yes had one in the last year
B3. There is no known way to prevent cervical cancer
39% false

As illustrated by the results above, what is simple knowledge in the developed world is very much replaced by ignorance in developing countries.

More Research, Reflections and Questions:

The studies above sadden me when I think of the many lives that can be saved by simply aiding developing countries financially and intellectually. The major reason behind lower incidences of cervical cancer in developed countries is mainly due to the fact that developing countries are wealthy and can thus, afford to do research, to provide efficient and affordable screening against cancers and to ultimately, prevent cases of cervical cancer by administering vaccines like Gardasil that prevent HPV
(a leading cause of cervical cancer). 
It seems simple according to research- simply eliminate the lack of sexual education and efficient screening, and you will conquer cervical cancer in developing nations right? Sounds too easy, I believe that the problem with the case studies I've used in this blog entry and many others out there about HPV- induced cervical cancers in the developing nations, is that they seem to rule out a lot of other possibilities that may be contributing to cervical cancer, they amplifying the issues of wealth and education as the main cause of cervical cancer in these nations. My question is what about ethnicity, and environmental factors, what if these factors play a larger role than we thought they did when it comes to the acquisition of High Risk HPV which then leads to cancer. What if the screening and educational part in its glory plays just a small role towards the development of cervical cancer. From research done for our wiki, my partner found many other factors that play a role in the development of HPV and its related cancers. 
For example, 
some factors that increase the risk of an individual developing HPV and that HPV turning into cancer include:

-Smoking. According to Robert A. Weinberg, mutagenic carcinogens like those present in the tar found in tobacco for example, stimulate the activation of previously dormant retroviruses derived from within the organism in question. The resulting viral matter begins to proliferate rapidly and then go on to cause cancer. A separate study found that, women who smoked while simultaneously being affected by HPV increased their risk for cervical cancer by up to 27-fold.((Cancer Epidemiol Biomarkers Prev. 2006;15:2141-2147)
-Having a weakened immune system (HIV) A study found that HIV activates dormant HPV cells which the go on to lead to the complications of HPV related disease, additionally, because HIV is accompanied by the suppression of the immune system, the immune system becomes less efficient at destroying tumor cells because HIV weakens the immune systems's ability to control the HPV virus. Furthermore, individuals with weakened immune systems risk contracting the HPV virus, via long term stress, and immune system-suppressing drugs, a few other examples of factors that contribute to the weakening of the immune system.(Mayo Clinic).Furthermore, in a study conducted in the Kiambu district of Central Kenya, between June 2009 and September 2010, HIV infected women visiting the ART clinic at the Nazareth Hospital in the district were studied in order to assess their disposition towards precancerous cervical cancer lesions. The women were inbetween the ages of 18 and 69 years of age. In 1993, cervical cancer was proclaimed an acquired immunodeficiency syndrome(AIDS) defining illness. HIV positivity implies, higher prevalence and incidences of cervical cancer in positive women than in HIV negative women. The study notes that HIV positive women have a 2 to 4 fold greater rate of HPV infection as well. HPV prevalence amongst HIV positive women is often associated with low CD47 counts vital for the immune system.

-Having many sexual partnersmayo clinic has pointed out a relationship between the number of sexual partners an individual has and his/ her chances of contracting HPV, the more partners one has, the greater his/ her chances of contractng HPV are.

-Having too many children: Another possible cause is related to multiple child births in women. Developing countries are synonymous with high birth rates. This can be tied in to multiple sex partners which infers, higher risks of contracting HPV, which increases risks for cervical cancer. Studies show that women who have had 7 or more children have doubled their risk then those who had only had 1-2 children. Other research has observed that having a baby before the age of 17 doubles the risk compared to having your first child around 25 years old or older.

-Chronic Inflammation

-Poor hygiene
: Long Term oral contraceptive use: The results are unclear as too why this increases risk, however, studies do show that the risk of cervical cancer begins to decrease when the patient stops taking the pill. After 10 years the risk stabilizes to when it was as if you never had taken the pill.


I therefore, commend the people who carried out the studies discussed in this article for doing so, but I believe that if they fail to point out other factors, like the ones I mention above, they may mislead people as far as the spread of HPV and HPV related cancers in the developing world is concerned.
 I therefore, feel that more studies should be carried out especially in developing nations before any solid conclusions can be reached about associated risk factors for HPV in developing countries.
Thanks for reading!