TOTALLY PREVENTABLE

Local women’s health experts are urging girls and women – particularly those aged 15 to 26 and in their reproductive years – to protect themselves against the human papillomavirus (HPV), which can cause several diseases, including cervical, vaginal, vulvar, anal and oral cancers.

Cervical cancer remains the second most common cancer affecting women in Jamaica. The ICO/IARC Information Centre on HPV and Cancer notes in its 2023 Jamaica Fact Sheet that annually, some 390 new cases of cervical cancer are diagnosed in the island and nearly 250 deaths recorded.

While preventable, uptake of screenings like Pap smears is low, with estimates suggesting only 20 to 25 per cent of eligible women are screened.

Senior medical experts at The University Hospital of the West Indies (UHWI) are warning that far too many cases are being detected at advanced stages and are encouraging those who are not yet sexually active to take the HPV vaccine.

They note that the vaccine has been successfully used in some countries to significantly reduce, and in some cases virtually eliminate, the incidence of cervical cancer. In several jurisdictions, vaccination is recommended for individuals between the ages of nine and 45. In the local public system, HPV vaccination for both boys and girls begins at nine.

Consultant obstetrician and gynaecologist Dr Natalie Medley said many women who present with the disease have never had a Pap smear and are unaware of the HPV vaccine.

“Unfortunately, most of our patients are diagnosed late. Some estimates state about 80 per cent of women we actually see are beyond the point at which we can actually operate on, or some figures say at least stage three or more – it’s actually started to spread beyond the cervix to involve surrounding tissues. So, most of our patients, unfortunately, have advanced stage disease,” she told The Sunday Gleaner.

Medley explained that in early stage cervical cancer, it’s confined to the cervix and is usually a process that starts from microscopic disease – where it cannot be seen with the naked eye. It may, however, be picked up in a Pap smear.

Continuing, she said: “And these are usually early stage – stage one. When you do progress to have an obvious lesion seen, that’s also stage one and we can operate on these persons. We can even offer them surgery that can save the uterus or fertility, sparing if it’s found early enough. But unfortunately, by the time we see patients, most of them, the disease has spread beyond the cervix – the tissues are around the cervix, the vagina, or in structures we call lymph nodes.”

Medley, who is also a gynaecologic oncologist, explained that lymph nodes are small, bean-shaped immune organs found throughout the body that filter lymph fluid and house white blood cells to fight infections.

“And once cancer is present in the lymph nodes, it means it’s already in other areas of the body. Even if it’s not spread beyond the cervix, they may have involvement of other areas in the body, especially these lymph nodes, which upstages them. And oftentimes, by the time we do diagnose patients, unfortunately, they are at this point where they have some type of local spread, which will make surgery very difficult … ,” she said.

At that stage, the recommendation is for radiotherapy.

The HPV Information Centre notes that while data is not yet available on HPV burden in the general population of Jamaica, about 15.8 per cent of women in the general Caribbean population are estimated to harbour cervical HPV-16/18 infection at a given time and 60.2 per cent of invasive cervical cancers are attributed to HPV 16 or 18.

Exposure increases with sexual activity

Consultant gynaecologist Dr Ian Bambury said not all women are at risk in the early stages, but exposure increases with sexual activity.

“For those who have never had sexual intercourse and don’t have risk factors, then certainly, we would not want to start [testing] because the hymen is still intact and we probably wouldn’t want to interfere with such, not at this point, because their risk would have been quite low. Because for the most part, cervical cancer is an acquired disease, most often due to penetrative sex, but of course, we know it can be acquired through skin-to-skin contact. So if there are high-risk behaviours, then that would have to be taken into consideration,” he told The Sunday Gleaner.

Explaining further, he said some individuals may avoid penetrative sex but still be exposed.

“There are some persons or some women who may not necessarily want to do penetrative sex, but they can do skin-to-skin genitalia and the disease can be spread through the mucosal area.

“For women who have sex with women, and if one is a carrier of the HPV, there’s a possibility that the other person can acquire the HPV once there are some high-risk behaviours going on,” he explained.

Men, he added, are also key players in the transmission of the virus.

“So the most important risk factor is HPV, and also is it the men who are the vectors? Are the men carrying the HPV? But for the women, we do know what the risk factors are, and the next question is, how is it acquired? Is it through penetrative sex? But it can be acquired through different areas as well,” he said.

Men infected with HPV can develop penile warts, as well as penile, anal and throat cancers. Those cases are typically managed by urologists.

Charge Nurse Shailendra Murdock, who is in charge of the gynae-oncology clinic and the colposcopy unit at the UHWI, underscored the importance of screening and early detection.

“When you get an abnormal Pap smear, you need investigation. You need a direct look at the cervix, a specialised look under a special microscope, the colposcope. Then we add dyes and we can then see exactly what is happening to the cervix. We are then able to do a biopsy if necessary and continue on to treatment,” she explained.

She reiterated that cervical cancer is entirely preventable.

Early treatment is possible, but ...

“Early treatment is possible, but we want to prevent it. We don’t want it to happen any at all and the key to that is the HPV vaccination, because we know that most, almost all cervical cancers start with the HPV infection, human papillomavirus. They have designed a vaccine that is readily available in Jamaica, which is Gardasil,” she said.

Murdock explained that the vaccine has evolved over time.

“Gardasil started with what was called Gardasil 4 for two types of coverage within the vaccine for genital warts. And then another two types for the most prevalent cause strains of the HPV that would lead to cervical cancer, but then they upped their game. And so now they have a Gardasil 9, which covers the same two for genital warts, but then an additional seven for the types of HPV that would be the most likely cause of cervical cancer,” she said.

She also addressed concerns about the vaccine.

“HPV vaccine … is not a live vaccine. You cannot get HPV from it. We are trying to tell the body – just like all other vaccines – that you have gotten this virus. And when we give it before you’re exposed, your body thinks you have gotten the virus. It makes a memory of it so that when you’re older, when our children are older and do get exposed to HPV, they already have this benefit on board. So now they can fight it off … ,” she explained.

A Ministry of Health-supported programme to vaccinate young girls in schools in 2017 faced resistance, with some critics arguing that it could encourage promiscuity. The initiative required parental consent and did not receive full support at the time.

Murdock noted that in some countries, the HPV vaccine is now part of routine childhood immunisation schedules, alongside vaccines for diseases such as measles, mumps and whooping cough.

In Jamaica, Gardasil is available at most health centres as well as some private medical offices. The public system offers Gardasil 4 at no cost, while Gardasil 9 is available privately for a fee.

Paediatricians and gynaecologists continue to administer the vaccine, with the Ministry of Health encouraging wider uptake as part of efforts to reduce the burden of cervical cancer locally.

Meanwhile, pleas for Pap smears may face new challenges, as the South East Regional Health Authority (SEHRA) says the departure of Cuban cytologists and pathologists will force it to outsource screening.

The Sunday Gleaner was told that at least four cytologists and two pathologists — who handled much of the public health system’s workload — recently returned to Cuba after the termination of the Cuban medical programme. The health ministry has acknowledged the impact of their exit.

“The impact of the cytologists will be felt in SEHRA as the other regions outsource their pap smear readings. SEHRA needs to fill the gap by outsourcing as well. The region will outsource also, until we can engage directly,” the ministry said.

erica.virtue@gleanerjm.com