A Global Outlook Regarding the Treatment/Prevention/Stigmas of Cervical Cancer: A Review

Constance Waldrop and Dr Lopamudra Das Roy

Published 2021

ABSTRACT

Cervical cancer is a detrimental disease that results in more than 300,000 deaths every year. Many treatment, screening, and prevention options are available for use in the developed world, unfortunately this is not the case for the developing world. The aim of this research is to assess the treatment, prevention, and stigmas associated with cervical cancer in a global perspective; including all demographics of individuals from the developed and developing world. To conduct this research, a database search was conducted in sources such as PubMed and other notable cancer institutes. From these database searches, numerous literature/resource reviews were conducted to determine articles relevant to the aim of the paper. The literature reviews showed that there was a large discrepancy in the availability of quality prevention and treatment methods in the developed vs. the developing worlds. Additionally they emphasized the importance of proper awareness on the dangers of cancer as false information could lead to inaccurate rumors and stigmas that cause many to deny prevention or treatment for cervical cancer. It is likely that if emphasis was aimed towards the education on cancer (causes, prevention, treatment, ect.) worldwide, more people would take the precautions necessary to screen and prevent the onset of cervical cancer knowing that these tests/procedures would only help not harm. Nonetheless, innovations towards the prevention and treatment of cervical cancer in all areas of the world is still ongoing, it is foreseeable that with proper awareness, a more minute portion of the global population will be affected by the burdens associated with cervical cancer.

INTRODUCTION

According to a 2020 statistic, cervical cancer killed 340,000 women around the world, emphasizing the urgency needed to take proper precautionary measures. See Pie Chart 1 in the Appendix.

About the Cancer:

Cervical Cancer is located in the region located on the tip of the uterus connecting into the vagina.
There are two types of cervical cancer: Squamous Cell Carcinoma: originating within the squamous cells lining the outer part of the cervix, projecting into the vagina and Adenocarcinoma: originating within the column-shaped glandular cells that line the cervical canal.
For around 70% of cervical cancer incidences, the primary cause is due to the infection of HPV.
Usually, women from ages 35-44 contract cervical cancer due to risk factors such as early sexual activity, numerous sexual partners, long term use of birth control, multiple pregnancies, other STIs (increase the risk of HPV), weakened immune systems, smoking, and exposure to DES (miscarriage prevention drug).
Some of the symptoms associated with cervical cancer are abnormal vaginal bleeding, excessive discharge, pelvic pain, difficulty urinating and/or defecating, fatigue, and weight loss.
To prevent cervical cancer incedence one should ask their doctor about the HPV vaccine, have routine PAP tests, practice safe sex, and not smoke. Close to all cervical cancer incidences are due to an individual’s lifestyle, studies have shown no known correlation between cervical cancer incidence with one’s environment or genetics.[1.9]

Hormone Therapies and Cervical Cancer:

Besides lifestyle practices, another factor to consider is hormone therapies. When undergoing estrogen therapy or consuming estrogen supplements, studies have demonstrated a correlation with their use and the stimulation of oncogenes in the cervix. Oncogenes are DNA that have the potential to develop into a cancer cell. If this stimulation occurs, the chance that a cancerous cervical cell will develop into cervical cancer greatly increases. Despite the findings on estrogen therapy contributing to the development of cervical cancer, testosterone therapy, at current, does not display any distinct relation to the development of cervical cancer. Should a transgender male undergo testosterone therapy, their cervix will atrophy, or in other words, their cervix tissues will thin. Though this is not harmful to their body, they should still take routine PAP tests to ensure that the development of cervical cancer does not occur.[2-3]

Despite current knowledge on the current risk factors associated with cervical cancer, it is still the fourth most common cancer amongst women worldwide. Among these cases, most of the incidences and mortalities occur within the developing world rather than the developed world. This is due primarily to a lack of awareness regarding cervical cancer and minimal access to screening and treatment technology. Alongside these limiting factors are the stigmas that follow the screening process and the term “cancer” which hinders women from undergoing the proper treatments.

Many studies have been performed on cervical cancer in the developed and developing worlds. The objective of this study is to take a qualitative and quantitative analysis to understand the current state of the treatment, preventions, and stigmas around cervical cancer in a holistic outlook, accounting for all demographics and ethnicities utilizing previous studies.

METHODS

Using the database Pubmed, in addition to other cancer institutes, an in depth search was performed to procure articles of interest in regards to the topic: the global status of cervical cancer. First, keywords were entered into a database and/or search engine to extract articles related to the topic, a global overview of cervical cancer. This process was repeated until a total of 50 articles and resources were procured based on their content, titles, and/or abstracts.

Next, the 50 articles and resources were sorted through literature and resource reviews based on their use to the topic and/or introductions, conclusion, methods, discussion, and results sections. During each review, the article/resource was scanned for relevancy, if it was deemed not as useful as other sources, it was discarded. Should the article/resource provide useful information, then the article received an in depth analysis, recording minute details that would prove useful towards the topic.

From this selection process, a total of 8 resources and 10 articles were procured for use and received in depth analyses. The findings from the reviews were split up into three sections: Demographics, Detection/Screening, and Taboo/Stigma. For each section, a different method approach for analysis was utilized to achieve a more comprehensive analysis. The Demographics section was analyzed by reviewing ethnicity and socioeconomic status, the Detection/Screening section was analyzed by comparing the developed and developing worlds, and the Taboo/Stigma section focused on a qualitative analysis from the experiences of cervical cancer survivors and families in the developing world. The complete findings from the reviews conducted during this phase will be presented in the Results section of this paper.

RESULTS

Demographics and Causations for Cervical Cancer Incidences

The demographics of individuals affected by cervical cancer was analyzed by considering one’s ethnicity/race and economic status. From the reviews mentioned above, 87% of deaths and 85% of incidences occur among women living in low-middle income countries.2 Of these developing countries, most of the mortalities and incidences were centralized in South America, South Asia, Southeast Asia, and Sub-Saharan Africa. See Heatmaps 1 and 2 in the Appendix. The primary causes for this disproportion in cases was due to limited awareness on cervical cancer, HPV vaccination availability, resource barriers, and/or stigmas related to some of the prevention processes such as: vaccination, scanning, and the term “cancer” [4,8].

Within developed countries, a closer analysis was taken to analyze the prevalence of cervical cancer amongst individuals with different races and socioeconomic statuses as many countries consisted of a multitude of demographics. A study performed on a US hospital program provided statistics stating that of the sample population 39% of Blacks, 51% of Hispanics, and 29% of Whites tested positive for HPV, a major causation for the onset of cervical cancer. Additionally, the study noted that underprivileged individuals were more unlikely to pay for the treatment of HPV than privileged individuals. In cases where HPV goes untreated, it has the potential to develop cancers in certain regions of the body such as the cervix, vagina, penis, and anus [5].

When taking the above information into account, 2018 surveys conducted by the CDC showed that Whites, Blacks, and Hispanics were the top 3 races that contracted cervical cancer in the US. See Chart 1 in the Appendix. This information also correlates to another 2018 survey conducted by the CDC showing how Whites, Blacks, and Hispanics also had the most mortalities from cervical cancer. See Chart 2 in the Appendix.

Detection/Screening in the Developed vs. Developing Worlds

Screening, Detection, and Treatments in the Developed World

The detection/screening rates were evaluated by considering the developed and developing countries separate from each other. Within the developed world, many individuals have access to screening opportunities and cancer treatment. This is additionally reflected in the statistics showing how 13% of deaths and 15% of incidents caused by cervical cancer are from the developed world.4

As of current, the main method of screening individuals for cervical cancer in the developed world is through the usage of PAP tests. PAP tests are both a reliable and safe method to detect abnormal cervix tissue/cells in a woman. To conduct PAP tests; a trained professional will take a swab of cells from a woman’s cervix, place the swab into a liquid substance in a container, and then send the sample to the lab for testing. PAP test results appear as “Normal/Negative” or “Abnormal/Positive”. Though should an individual receive an “Abnormal/Positive” result, it does not instantly indicate that cancer was detected but that unusual cells were detected. In these circumstances, professionals will identify the type of abnormal cells that may have been discovered, but should squamous cell cancer or adenocarcinoma cells appear, there is a high chance that cancer is present.6

If an individual is found with squamous cell cancer or adenocarcinoma cells, the professional will recommend a course of action. Some methods of treatment for cervical cancer in the developed world are:

Chemotherapy - Anti cancer drugs
Laser Ablation - Burning off abnormal cells
Hysterectomy - Removal of the uterus
Trachelectomy - Removal of the cervix
Radiation therapy - High energy x-rays used to kill the cancer
Targeted Therapy - Drugs that target the specific cancer
Immunotherapy - Drugs that stimulate the immune system

With current innovations, cervical cancer is easily treatable should it be detected during the early stages of development, emphasizing the urgency to take PAP tests when recommended.11

Despite this widespread access to detection/screening appliances, many individuals living in the rural areas of the developed world do not or are not able to take advantage of these opportunities due to clinics or hospitals not being located close enough to them. A US study conducted in 2018 demonstrated how there was a higher density of cervical cancer incidences and deaths within the southern-midwestern portion of the US, where many rural areas are located. See Heatmaps 3 and 4 in the Appendix.

Screening, Detection, and Treatments in the Developing World

In the developing world, access to PAP test technology and cancer treatment is not often seen due to a lack of trained professionals, resource barriers, and a low awareness of cervical cancer amongst women. Studies performed in Sub-Saharan Africa showed that screening rates for many countries were not available, but the countries that did report had rates ranging from 8.2-64% which is quite low.4

Despite these statistics, solutions to increase the screening rates in developing countries have been implemented producing positive results. Two widely used methods of detection that are used are VIAI (Visual Inspection with Lugol’s Iodine) and/or VIA (Visual Inspection with Acetic Acid). To conduct these tests, Lugol’s iodine or acetic acid are applied directly onto the cervix immediately turning precancerous/cancerous lesions white. Should individuals test positive for cervical cancer, they will be referred to the closest hospital/clinic to receive proper treatment.4 Though these are affordable and quick methods of screening for cervical cancer, they serve as easy alternatives to hospital screenings and treatment. Many individuals in the developing world have to make sacrifices or earn assistance from external sources to obtain proper treatment and screening opportunities.

Taboo/Stigma in the Developing World

The taboo/stigmas section focused on a qualitative analysis from the experiences of cervical cancer survivors and families in the developing world. A focus is set on the developing world due to many individuals not being exposed to the resources that could educate them on the causes and dangers of different types of cancers. This lack of awareness could potentially lead to false stigmas and taboos to develop in societies preventing individuals from taking the proper precautions to prevent/treat cancer. This unfortunate occurrence is present all throughout the developing world and is preventing individuals from getting the help they need.

In Nepal, a qualitative survey was performed recording the thoughts of cervical cancer survivors, family, and others. From the survey there was a multitude of responses that express how the stigmas revolving around “cancer” and the female genitalia affected individuals:

“Women are not comfortable showing their private parts to others. Even when we know about the medical camps in the nearby hospital or health post, we pretended to be fine if we were asked by someone else and avoid going for the screening programs.” [45-year-old]8

“During my chemotherapy, I lost my hair and my neighbors believed it was happening due to my cancer. I don’t know why but they [neighbors] always gave me a disgusting look when I said I am undergoing radiotherapy. I felt like everyone hated me.” [47-year-old]8

The results of the stigmas associated with cervical cancer caused many to fear that they would experience social isolation, verbal abuse, and a loss of social support should they take the risk in receiving treatment or diagnosis. These potential consequences not only occur in Nepal (the location where the study was conducted) but also in many other societies where people are not fully aware of the dangers of cancer.

DISCUSSION

Implications

In summary, cervical cancer serves to be a formidable opponent amongst developing countries, rural locations, and underprivileged individuals. This finding indicates that cervical cancer is an ailment that is a result of one’s lifestyle, as many of the demographics associated with the peoples affected heavily by cervical cancer are not ones with a unified genetic pool or environment. The primary cause for late detection in these areas are the stigmas revolving around cervical cancer, lack of awareness regarding preventions such as vaccines and screening, and resource barriers. These factors holding back cervical cancer prevention, early detection, and treatment are ones that, with organized efforts, can be overcome.

Recommendations

To help reduce mortality rate and incidences associated with cervical cancer, global programs should look to not only work on administering vaccines and screening/treatment clinics, but also help to educate and refute the false stigmas and rumors associated with cervical cancer. Doing this will help to increase the amount of individuals who get screened and treated, as they will not have to fear any of the social repercussions associated with the stigmas around cervical cancer.

In addition to encouraging programs to refute false rumors and stigmas, more research and innovation should be performed to find affordable and effective methods of treatment for all stages of cervical cancer. At current many underprivileged individuals have to go through great hardships to receive screening and/or treatment opportunities. So to counter this challenge, a form of easily admissible and affordable procedure or medication should be looked into.

CONCLUSION

The goal of this study was to assess the demographics and factors that impact the detection and screening rates for cervical cancer in a global perspective. It was discovered that a majority of the cervical cancer incidences and deaths occur in the developing parts of the world. The primary causations for this phenomenon are resource barriers and stigmas. Going forwards organizations should aim at not only providing screening and treatment opportunities but also an anti-stigma or awareness program to help refute any false rumors preventing individuals from seeking help. If actions like this are performed, then many more individuals will seek help without fear of the potential social consequences that may occur.

APPENDIX

Pie Chart 1: Estimated Number 2020 Deaths from Cervical Cancer (GLOBOCAN 2020)

Pie Chart 2: Estimated Number 2020 Cervical Cancer Incidences (GLOBOCAN 2020)

Heatmap 1: Estimated Number of New 2020 Cervical Cancer Cases (GLOBOCAN 2020)

Heatmap 2: Estimated Number of 2020 Cervical Cancer Mortalities (GLOBOCAN 2020)

Heatmap 3: US Cervical Cancer Deaths (U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool 2018)

Heatmap 4: US Cervical Cancer Incidences (U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool 2018)

Chart 1: Number of 2018 Cervical Cancer Incidences by Race and Ethnicity (U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool 2018)

Chart 2: Number of 2018 Cervical Cancer Deaths by Race and Ethnicity (U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool 2018)

ACKNOWLEDGEMENTS

The author would like to thank Dr. Lopamurda Das Roy for giving her the honor to participate in the Breast Cancer Hub Internship Program. Dr. Lopa helped to advise and guide the coalition of this manuscript over the course of 2 months.

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