Healthcare Professionals should join hand to diagnose, treat and manage complications of cervical cancer-Prof. Shereen Bhutta

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 Healthcare Professionals should join hand to 
diagnose, treat and manage complications 
of cervical cancer- Prof. Shereen Bhutta

VIA is simple, inexpensive, accurate method for screening cervical
cancer and Results are observer dependent-Haleema Yasmin

HPV vaccination against cervical cancer should be
included in EPI programme - Sadiah Ashan Pal

KARACHI: Association of Mothers and New Born (AMAN) in collaboration with Society of Obstetricians and Gynaecologist of Pakistan organized an awareness seminar on cervical cancer at JPMC auditorium on January 30, 2016. The presentations were followed by panel discussion by a multidisciplinary group of experts. The seminar was very well attended by Obstetricians &Gynaecologist, Paediatrician, and Oncologists besides representatives from the civil society. Dr. Sadiah Ahsan Pal was the moderator of the session.

Prof. Shereen Bhutta Prof. of Obstetrics and Gynaecology from JPMC was the first speaker who in her presentation pointed out that about twenty women die of cervical cancer in Pakistan every day. Now it is being diagnosed in very young women while in the past it used to be the disease of postmenopausal women.  As such now young women are dying. The solution lies in eliminating the HPV 16 and 18 which will go a long way to control cervical cancer. There is lot of morbidity associated with it which affects the quality of life. Those who suffer from cervical cancer also suffer from financial, social, psychological problems. Its treatment is not available everywhere. It also leads to lot of anxiety and sexual problems in marriage. She made a passionate appeal that let all healthcare professionals which includes Family Physicians, General Practitioners, Psychiatrists, Obstetricians &Gynaecologist, Oncologists should join hand to diagnose, treat and manage complications of cervical cancer.

Dr. Haleema Yasmin obstetrician and Gynaecologist from JPMC spoke about PAP smear and VIA technique for screening. She pointed out that almost 80% cervical cancer is seen in developing countries and almost two third are diagnosed in an advanced stage. According to some reports almost 5,233 women are diagnosed and 2,876 women die of cervical cancer every year in Pakistan. Highlighting the importance of screening for cervical cancer, she opined that screening method should be sensitive, affordable and feasible. VIA technique, she further stated,was not only inexpensive which can be done by rapid eye scanning of cervix. It is also an alternative to PAP smear test.  It also gives better results than cervical cytology because most often the cytologists reporting are under trained, they are overburdened and it also requires very expensive equipment as compared to VIA technique which requires just routine instruments used in Gynae clinic. VIA screening for cervical cancer can be effectively performed by trained doctors, nurses, midwives. They can do the screening after simple training and they can be made efficient. However, it is less effective in elderly women after the age of fifty or sixty years.

Continuing Dr. Haleema Yasmin said that results of VIA screening test are dependent on who is doing the reporting. Once training is imparted, it can be performed any time. One should take proper menstrual history, bleeding pattern, clinical data, family history of cancer and spouse. She also showed the anterior and posterior lip of cervix and demonstrated how to see any lesion in this area, infection, discharge, leukoplakia, bleeding from cervix, all these needs to be reported. Make a careful observation see if there is any growth, do colposcopy and refer the patient for treatment if need be. Her conclusions were that VIA is simple, inexpensive, accurate method for screening for cervical cancer. Results are however, observer dependent, hence proper training and ongoing quality control were extremely important.

Dr. Sadiah Ahsan Pal talked about HPV vaccination for primary prevention of cervical cancer. She pointed out that now HPV immunization is available. We as healthcare professionals have some responsibility whether we are Family Physicians, General Practitioners, Gynaecologist or Oncologists. Surgery was not an option, hence Chemotherapy and Radiotherapy was the only answer. She suggested one PAP smear test at the age of thirty five years. Girls between theages of 9-14 years can be prescribed two doses of HPV vaccine at 0-6 months schedule.  However, three doses will be required after the age of 15-26 years preferably before marriage. After marriage screening should be performed every three to five years with PAP smear or VIA technique. She also gave details of the suggested Cervical Cancer Prevention Protocol for Pakistan.  Continuing, she said that 16and 18 were the most oncogenic viruses. First intercourse should be delayed after teen age. Cervix is susceptible for cancer.

Talking about preventive and protective measures she mentioned about reduced number of sex partners, safe sex, regular Pap smear, vaccination, quitting smoking and refrain from use of Pan and Guttka. In Pakistan most often it is opportunistic screening for cervical cancer. Vaccinated women has reduced recurrences. Ever since I started vaccination, I have administered two hundred doses to date. There have been no problems and no adverse effects. Male vaccination is done in some countries. She suggested that HPV vaccine for cervical cancer should be included in EPI programme.  Young adolescent girls should be our first target before marriage. We should vaccinate young girls. Doctors should discuss it with young women. Assure them that vaccination is safe. Screening for Cervical Cancer and Vaccination was the most cost effective approach, she added.

This was followed by speechby a survivor of cervical cancer who narrated her story that how she suffered at the hands of well-known obstetricians and gynecologists who failed to make timely diagnosis and kept on asking him to remain under observation and kept on taking PAP Smears. After having failed to get any satisfactory treatment from three noted gynecologists, I changed my doctor again and luckily she was able to make proper diagnosis. I had colposcopy, biopsy and got satisfactory treatment. Throughout this period I had to undergo lot of agony, pain and sufferings including psychological problems. She was of the view that doctors should be careful and they should not keep on waiting. If they cannot manage some patient, they should not hesitate to refer the patient to their colleagues who are better trained and educated. She further opined that Pap smear should be advised after consultation.

Panel Discussion

Members of the expert’s panel included Prof.S.H. Manzoor Zaidi, Dr. Najib Naimatullah, Dr. Nadeem Abbasi, Dr. Muhammad Ali Memon, Prof. Aisha Mehnaz, Prof D.S.Akram, Prof.Sadiqua Jafarey, Dr. Azra Ahsan, Prof.Razia Korejo, Dr.Shershah Syed, Dr.Ayesha Khan, Dr.Alia Begum, Ms Shaheen Salahuddin,  Ms.Zubaida Tariq, Ms.Khursheed Hyder, Mr.Shehzad Roy and Dr.Haleema Yasmin.

During the panel discussion it was pointed out that Pakistan Paediatric Associationshould become a part of routine Gynae practice. Dr. Haleema said that we do not get screened ourselves.  Students should be taught about it and it should be a part of comprehensive Gynaecology examination. We do not allow our postgraduates to conduct delivery unless they have gone through the four stations which includes how to performPap smear, examination of the patient and history taking. Prof.Razia Korejo said that doctors should encourage HPV vaccination. We need to educate our doctors as well and Pap smear reporting should be realistic and authentic. Dr. Aliya said that surgery for cervical cancer could cost about four to five lacs in a private tertiary healthcare facility which is very expensive. Chemo and radiotherapy is also quite expensive. Now more trained gynecologists are doing radical hysterectomy. If we cannot do it, it is better to refer the patient to other colleagues who can do it better. We must think about the patients and understand our limitations.

Dr.Ayesha fromDUHS said that cervical cancer patients usually come very late and VIA technique for screening should be promoted. Dr. Azra Ahsan said that VIA technique could be an alternative to Pap smear. Patients usually do not take interest in prevention but are more interested in treatment. Dr. Sher Shah Syed said that training of our doctors was not up to the mark and they are not properly trained to diagnose cervical cancer. They are too busy and have very little time for the patient. Talking aboutpreventable cancers is doctor’s responsibility.Prof. D. S.Akram said that HPV vaccination can be included in the EPI provided we have some sound scientific data and convince the concerned authorities with facts and figures. From various studies she said it was the third most common cancer in women in Pakistan. We need to provide them evidence, details about the economic burden on families and the country, only then they will listen. We also need to reduce the cost of vaccination and vaccination should be promoted but without any incentives from the vaccine manufacturers.Prof.Aisha Mehnaz opined that we must improve HPV vaccination coverage. Adolescent population is most often neglected. We also need some national data base on cervical cancer.Dr. Najib and Dr. Muhammad Ali Memon remarked that chemotherapy and radiotherapy is quite expensive for the patient.  Facilities available free at public healthcare facilities like JPMC and at Kiran were not enough and the doctors working there are too much overburdened. Palliative therapy is quite expensive while curative therapy has good results. We must ensure that the treatment is cost effective.

 It was also pointed out that there are Radiation oncologists and Medical Oncologists. It is the technicians who are known as radiotherapists. Almost 40% of cancers are preventable. Nurses are an important member of the healthcare team and they should be invited to such meetings. Hospital waste management also needs to be looked into. There was also a need for cancer registry in Pakistan. Dr. Nadeem Abbasi said that it was a crime to treat any cancer patient without discussing in the tumor board meeting where all the experts from various specialties are present.  It is our responsibility. We have a regular Gynae Tumor Board meeting at AKUH and doctors are most welcome to attend it. Prof. S.H. Manzoor Zaidi talked about the cost of treatment and said that JPMC was the only center offering free service while all other centers charge. Treatment is very expensive. He emphasized on early diagnosis, prevention and creating awareness. It is a preventable disease and its incidence is not more than 2-5% of all malignancies. It is not so common and we should not be misled by foreign agencies, websites, he remarked.

Oncologists, it was stated, see more   ovarian cancer than cancer of the cervix. It is easily treated and cure rate is almost 80-90% up to stage two but stage three results are not so good. We see colorectal cancer and breast cancer at young age but   cervical cancer is not so common. Prof. Sadiqua Jafarey said that while at the JPMC they used to see lot of cancer of the cervix but now working at a private hospital we see lot of ovarian cancer.