The Poor Sister of Breast Cancer

This article was written in 2011 but has never been published in full before. Nearly four years later, the general message, that there’s a lot of work to be done to reduce the incidence of cervical cancer, particularly in the so-called developing countries, remains relevant.

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Dr. Gordon Narayansingh used his characteristic dry humour to illustrate why cervical cancer should rightly be described as the “Poor Sister of Breast Cancer.”

Dr. Narayansingh was speaking at the first Oncology Update Conference at the Hyatt last Sunday when he pointed out that this year breast cancer had a Breast Cancer Month. In previous years they had Breast Cancer Week and Breast Cancer Day. Next year, he added, might be Breast Cancer Year.

But who is running for Cervical Cancer?

The doctor, Trinidad’s only gynae-oncologist at present, made his point with statistics collected from our Cancer Registry over 1997-2006. During this time breast cancer accounted for 2960 cases of which 44 women died but cervical cancer claimed 55 lives despite only 1226 cases.

With a higher number of deaths from fewer cases, clearly cervical cancer is the more deadly of the two for us here in Trinidad and Tobago.

He supported this observation with more extensive data from Central and South America where cervical cancer accounts for vastly fewer cases but similar numbers of deaths compared to breast cancer.

While we panic about young women getting breast cancer, 15% of breast cancer cases are under 50 whereas 50% of cervical cancer cases are under age 50.

The tragedy of this is that it can be prevented. In the United States cervical cancer is the thirteenth most frequent cancer among women whereas it ranks as the No.2 most frequent in Trinidad and other less developed nations.

Why? Dr. Narayansingh explains that two-thirds of all local cases are diagnosed in an advanced stage so complete cure is less likely. This is so because only 25% of our women go for regular Pap smears.

He told a heart breaking true story of a 40 year old mother of two who went for her Pap smear only to be turned away repeatedly from the health centre because she was having “vaginal bleeding”.

The take home lesson for all of us is that all abnormal bleeding must be assessed by a doctor. This story reflects a clear deficiency in the knowledge and understanding of the workers who turned the client away. They may not have been able to do the Pap smear but she should have been assessed and treated.

Even when clients are properly channeled, due to lack of technical skills, Pap smear reports are delayed and so are follow-up investigations. We have a need for more skilled cytotechnicians to read Pap smears and gynaecologists who can perform colposcopy, an investigative procedure that may be needed after an abnormal Pap smear.

So laboratory and medical students, and those in planning and management pay attention!

Dr. Naraynsingh lamented that in the public sector, Pap smear reports can take up to three months with existing ineffeciencies. He emphasized that he was not to be accused of running a smear campaign against the system though! By stating the facts he hoped to stimulate a “Pap Smear campaign,” instead.

He estimated that in addition to regular Pap smears, we could follow the example of the developed countries and include routine vaccinations against HPV (the human papilloma virus) believed to be the underlying cause of cervical cancer.

Since most people who are sexually active will contract strains of the HPV virus during their lifetime, some of which are cancer promoting , he advocated vaccinating young girls in the 9-15 category to stimulate immunity against HPV before they become sexually active.

He said bluntly that we are a society of “hypocrites”. We say “my daughter is not going to have sex” yet our culture is one of “wining and prancing” on Carnival day.

Introducing the HPV vaccine should not be about sex but about saving lives. He felt that with bulk purchases, a rough estimate of the cost of annually vaccinating our Form One school girls would be just TT$9.6 Million, significantly lower than the cost of providing laptops at TT$35 Million.

He estimated we could save three lives per year that way.

Not one for mincing words or keeping his opinions to himself, Dr. Narayansingh couldn’t help but add that of the eight graduates of the University of the West-Indies Medical Faculty who went on to become gynae-oncologists, he was the only one serving in Trinidad.

He described the “pain” of the situation and called for a programme to encourage locals to come back to Trinidad and Tobago to serve their country, not merely in sub-specialties like gynae-oncology but across the board.

Notwithstanding word from the “developed world” that T&T can now boast of being a developed country, Dr. Naraynsingh suggested that our progress in defeating cervical cancer should be a marker for true development.

Dr Gordon Narayansingh

Dr. Gordon Narayansingh

I agree with him and by that measure, we are not there yet.

Since the emerging youth are going to be the ones with a key role in changing this I hoped there were lots of student doctors, nurses and pharmacists in training present and internalizing the message.

The 1st Oncology Update Conference was facilitated by the Trinidad and Tobago Medical Association under the auspices of the University of the West-Indies.

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The HPV vaccine was made available in the public health sector of Trinidad and Tobago the following year (2012), though its introduction was not without controversy and there remains such opposition to it. The HPV vaccine had been available to private clients who were able and willing to pay for it prior to 2012.

The Pap smear, which is an established tool in reducing the incidence of cervical cancer when used effectively in screening programmes worldwide, remains underutilised in Trinidad and Tobago. For many women, the steep cost of having the test done privately is prohibitive and the local health centres are yet to make the service widely available via a dedicated service.

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