Cervical cancer awareness among women recently diagnosed with cervical cancer in South Africa and Zimbabwe

BackgroundIn South Africa, breast cancer is the most commonly diagnosed cancer and cervical cancer the leading cause of cancer mortality. Most cancers are diagnosed at a late-stage and following symptomatic presentation. The overall purpose of the study was to inform interventions aimed at improving timely diagnosis of breast and cervical cancer.MethodsIn-depth interviews were conducted with women with potential breast or cervical cancer symptoms from urban and rural South Africa. Participants were recruited from a community-based cross-sectional study on breast and cervical cancer awareness. Data were analysed using a thematic analysis approach.ResultsEighteen women were interviewed (10 urban, 8 rural): the median age was 34.5 years (range 22–58). Most were unemployed, and five were HIV positive. Themes included impact and attribution of bodily changes; influence of social networks and health messaging in help-seeking; management of symptoms and help-seeking barriers. Breast changes were often attributed to manual activities or possible cancer. Women were often unsure how to interpret vaginal symptoms, attributing them to HIV, hormonal contraceptives, or partner infidelity. Concerns about cancer were based on health information from the radio, social networks, or from primary care providers. Prompt care seeking was triggered by impact of symptoms on personal lives. Rural women, especially with possible symptoms of cervical cancer, experienced challenges during help-seeking including judgmental attitudes of clinic staff. Most participants were skeptical of traditional medicine.ConclusionsThis is the first study exploring interpretation of possible breast and cervical cancer symptoms at a community level in South Africa. The process of interpreting bodily changes, symptom attribution and help-seeking is complex and influenced by women’s everyday life experiences. Timely diagnosis interventions should not only include cancer symptom awareness but also address individual, structural and health systems related barriers to care.

Aim Cervical cancer is the second most common cancer and the top cause of cancer deaths amongst women in South Africa. Evidence-based interventions for secondary prevention of cervical cancer (cervical screening followed by treatment of identified pre-cancerous lesions) are available in South Africa’s health system, yet cervical cancer incidence remains high. This paper argues that this is partly due to implementation failure, i.e., deploying a good intervention ineffectively. Interventions found efficacious in controlled research settings may not achieve desired health outcomes when deployed in the real world due to implementation failure. Methods The field of implementation science offers frameworks for enhancing effective implementation. These frameworks guide the identification of implementation barriers and selection of context-relevant strategies for addressing them. This paper applies implementation science frameworks to secondary prevention in South Africa and promotes using such frameworks in cervical cancer prevention programming. Findings The problem of secondary prevention of cervical cancer in South Africa is contextualised. The paper conceptualises effective implementation as the attainment of implementation outcomes including acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, reach, and sustainability of evidence-based interventions. Drawing from the South African literature, examples of ineffective and failed implementation of secondary prevention interventions are presented including: low acceptability of screening by users and providers, sub-optimal adoption of screening provision by providers, low feasibility of hospital-centred pre-cancer treatment provision, low implementation fidelity, and limited reach of screening and pre-cancer treatment. Finally, using two examples, the paper provides practical guidance on how implementation science frameworks could be leveraged in South Africa to mitigate implementation failure. Conclusions Greater application of and capacity building in implementation science are recommended to contribute towards strengthening cervical cancer secondary prevention in South Africa.

Cervical cancer is the second most common cancer in South African women. Opportunistic screening for cervical cancer has been available for the last five decades. In 2000, the South African Department of Health launched a national cervical screening programme. However, this has not been fully implemented. South Africa has the largest expanding HIV burden in the world and it is estimated that 5.7 million South Africans are currently living with HIV/AIDS, of whom 60% are women. The high prevalence of HIV complicates the situation as HIV-infected women have greater rates of pre-invasive and invasive cervical cancer rates whereas HPV infection promotes the acquisition of HIV. In April 2011 the South African government launched the HIV Counseling and Testing (HCT) campaign, a new national drive to encourage people to know their HIV status and access counseling and treatment including cervical screening. In April 2014 the South African National Department of Health implemented a school-based HPV vaccination program for all girls 9 years and older, in grade 4. The rollout targeted 450 000 girls in 17 000 public schools. However, the reduction of cervical cancer and its precursor lesions due to HPV vaccination will only be realized in the coming decades. Thus screening for, and management of both pre-invasive and invasive cervical cancer needs to be enhanced. The South African National Department of Health will soon announce and implement a new cervical cancer control policy. This review discusses the history of cervical cancer in South Africa, current prevention strategies and suggestions for an improved cervical screening programme.

Cervical cancer (CC) is the leading cause of cancer death among female South Africans (SA). Improved access to reproductive health services following multi-ethnic democracy in 1994, HIV epidemic, and the initiation of CC population-based screening in early 2000s have influenced the epidemiology of CC in SA. We therefore evaluated the trends in CC age-standardised incidence (ASIR) (1994-2009) and mortality rates (ASMR) (2004-2012) using data from the South African National Cancer Registry and the Statistics South Africa, respectively. Five-year relative survival rates and average per cent change (AAPC) stratified by ethnicity and age-groups was determined. The average annual CC cases and mortalities were 4,694 (75,099 cases/16 years) and 2,789 (25,101 deaths/9 years), respectively. The ASIR was 22.1/100,000 in 1994 and 23.3/100,000 in 2009, with an average annual decline in incidence of 0.9% per annum (AAPC = -0.9%, p-value < 0.001). The ASMR decreased slightly by 0.6% per annum from 13.9/100,000 in 2004 to 13.1/100,000 in 2012 (AAPC = -0.6%, p-value < 0.001). In 2012, ASMR was 5.8-fold higher in Blacks than in Whites. The 5-year survival rates were higher in Whites and Indians/Asians (60-80%) than in Blacks and Coloureds (40-50%). The incidence rate increased (AAPC range: 1.1-3.1%, p-value < 0.001) among young women (25-34 years) from 2000 to 2009. Despite interventions, there were minimal changes in overall epidemiology of CC in SA but there were increased CC rates among young women and ethnic disparities in CC burden. A review of the CC national policy and directed CC prevention and treatment are required to positively impact the burden of CC in SA.

Despite the fact that cancer of the cervix is preventable, it is the commonest cancer cause of death in women in sub-Saharan Africa, Melanesia, South Central and South East Asia, the Caribbean and Latin America (Parkin et al., 2005). Southern Africa has one of the highest incident rates in the world, and in South Africa alone it caused the deaths of 3 700 women in 2002 (Denny, 2006). According to the International Agency for Research on Cancer (IARC), cervical cancer accounts for 23% of all cancers diagnosed in South Africa (International Agency for Research on Cancer, 2006 as cited in le Riche, 2006). Cervical cancer is the second most common cancer among South African women, with 1 in 41 women developing the disease in her lifetime (Sitas et al., 1998). Adar & Stevens (2000) noted that it was responsible for nearly 2% of deaths of women aged 15-44 years and 4% of women aged 45-59 years. In South Africa, the total age-adjusted incidence rate (ASIR) of cancer in Africans is far lower than that in the corresponding white population. According to the KwaZulu-Natal Department of Health (2004) in South Africa, cervical cancer accounts for 18.5% of female cancers, with approximately 5 000 new cases reported annually and black women being most at risk of getting cervical cancer compared to white and coloured women. African women seek help only when their particular disorder/disease is far advanced, thereby, as in the case of cervical cancer, rendering cure or control nearly impossible (Walker et al., 2002). A study done by De Jonge et al. (1999) found more aggressive tumours in black women compared to white women with cervical cancer in South Africa. In women of all race groups, the age specific cervical cancer rates for 1992 remained low up to 30 years of age, but thereafter increased rapidly until they peaked at 50 to 59 years (Denny, 2006). Similarly, Sitas et al. (1998) reported that the incidence of invasive cancer rises in the age group 35-39, with 87% of cases occurring in women over 35 years of age. It is a common cancer in poor women due to inadequate mass cervical cancer screening, and their cure rates are low as they present late (Denny, 2006).

Background:Cervical cancer in South Africa accounts for 15.85% of all female cancers and 30.29% of African female cancers, resulting in over 5000 deaths annually. South Africa’s proposed move towards universal healthcare places emphasis on health promotion through education and screening, but there is little data on the baseline levels of knowledge and screening uptake regarding cervical cancer. This study explored the levels of knowledge and screening rates of cervical cancer among vulnerable women living in the inner-city of Durban, South Africa.Methods:A mixed-method study was conducted within the context of a Women’s Health outreach initiative. Data were collected from women attending the outreach (n = 109), many of whom were from marginalized communities. A pre-intervention survey was used to collect the data. This was followed by cervical cancer education sessions and the opportunity for a free Pap smear.Results:Knowledge of cervical cancer was low (<25%) and only a third of the women had previously been screened. After the educational sessions, 64% of women (n = 70) took advantage of the opportunity for Pap smears, with many expressing the need for wider cervical cancer education, screening centres and support groups. Only 20% of the Pap smears were normal (n = 14). Half of the women tested positive for infections (n = 36; 51.4%), and a small proportion (n = 8; 11.4%) tested positive for human papilloma virus. Abnormal cervical intra-epithelial neoplasia (CIN1 and CIN 2) were also detected in this population (n = 12; 17.1%).Conclusion:Cervical cancer knowledge and screening among vulnerable women in Durban, South Africa, is inadequate, especially considering the high levels of abnormality found in the Pap smears. Education drives, accompanied with the provision of free testing, are required. Community health outreach initiatives in collaboration with non-government organizations set in accessible locations could be a possible course of action.

Cervical cancer is an important cause of death throughout the world, especially in less developed countries. Reports of trends in cervical cancer mortality from less developed countries have been limited by poor data quality and inaccurate population estimates. This paper examines trends in cervical cancer mortality in South Africa from 1949 to 1990 and discusses the impact of cytology screening on these trends. Analysis of national mortality statistics and reconstructed population data. The age-standardized mortality rates for Whites declined after the mid 1960s, while that for Coloureds rose, particularly before the 1970s. These trends were affected predominantly by trends among women in the 35-64 age range. The pattern of mortality in successive birth cohorts for Whites is consistent with a reduction in age-specific mortality following the advent of cytological screening. The same pattern is not evident in trends for Coloureds, among whom screening has apparently had a minor impact if any at all. The apparent lack of impact of screening in those groups of women most at risk of cervical cancer lends weight to demands for the implementation of equitable and rational screening programmes for cervical cancer in South Africa and internationally.

Cervical cancer is the second most common cancer in South African women but the most frequently encountered cancer in black women. In 2000, the South African Department of Health launched a national cervical screening program. However, this has not been fully implemented because of the chronic shortage of health care workers and a lack of essential medical equipment. In addition, there is also a high burden of infectious diseases in this country. South Africa has the largest expanding HIV burden in the world and it is estimated that 6.3 million people in South Africa were living with HIV in 2013, representing 18% of all people living with HIV worldwide. The high prevalence of HIV complicates the situation as HIV-infected women have greater rates of pre-invasive and invasive cervical cancer rates. In April 2011 the South African government launched the HIV Counseling and Testing (HCT) campaign, a new national drive to encourage people to know their HIV status and access counseling and treatment, including cervical screening. A universal test and treat (UTT) strategy was adopted in September 2016 after research showed that this type of program will reduce the chance of HIV transmission. The South African National Department of Health will soon announce and implement a new cervical cancer control policy. Over the past few years, the South African Department of Health has introduced several new policies regarding HIV testing and care, and plans to introduce a new cervical screening policy shortly. This overview discusses the progress as well as challenges the South African department of health has with the various programs.

Prevention of cervical cancer

Cervical cancer constitutes 20 - 25% of cancers in women in Sub-Saharan Africa. It is a preventable disease, subject to adequate screening, management and follow up. Nevertheless, more than half a million women worldwide develop invasive cervical cancer annually, with middle-and low-income countries achieving only 19% of successful screening coverage compared with high-income countries (63%). The age-standardised incidence rate for cervical cancer in South Africa is 24.71 per 100 000 women.

The notion that adolescent daughters can provide their mothers with health information that could actually impact the mothers' behavior is a novel area of health promotion research. The goal of this study is to explore the reasons why adolescent daughters would give their mothers cervical cancer information, and why mothers would have the intent to listen to advice to obtain a Pap smear. We randomly selected and interviewed 157 mother and daughter dyads in Cape Town, South Africa. Almost one-fourth of mothers (22%) indicated never having had a Pap smear, while 92% of their daughters said their mother has never talked to them about cervical cancer or a Pap smear. Willingness of daughters to ask their mothers to obtain a Pap smear was high (80%). Motivations included the important health benefit and the sense of responsibility to share life saving information. Most mothers said they would definitely obtain a Pap smear when advised by their daughter (74%), while 25% said they would have to think about it and 1% said they would not listen. Mothers' main motivations included the direct health benefit and a strong sense of duty and responsibility to listen to her daughter. This study provides important information about the reasons why an upward (child to parent) health intervention may be feasible. The values of duty and responsibility, especially as it manifests within the family, hold promise for informing health promotion interventions directed at multiple generations.

Cervical cancer is the second most common cancer amongst South African women and is the leading cause of cancer-associated mortality in this region. Several international studies on radiation-induced DNA damage in lymphocytes of cervical cancer patients have remained inconclusive. Despite the high incidence of cervical cancer in South Africa, and the extensive use of radiotherapy to treat it, the chromosomal radiosensitivity of South African cervical cancer patients has not been studied to date. Since a high number of these patients are human immunodeficiency virus (HIV)-positive, the effect of HIV infection on chromosomal radiosensitivity was also investigated. Blood samples from 35 cervical cancer patients (20 HIV-negative and 15 HIV-positive) and 20 healthy controls were exposed to X-rays at doses of 6 MV of 2 and 4 Gy in vitro. Chromosomal radiosensitivity was assessed using the micronucleus (MN) assay. MN scores were obtained using the Metafer 4 platform, an automated microscopic system. Three scoring methods of the MNScore module of Metafer were applied and compared. Cervical cancer patients had higher MN values than healthy controls, with HIV-positive patients having the highest MN values. Differences between groups were significant when using a scoring method that corrects for false positive and false negative MN. The present study suggested increased chromosomal radiosensitivity in HIV-positive South African cervical cancer patients.

We investigated the effect of Pap smear screening on the incidence of invasive cancer of the cervix in the Western Cape, South Africa where screening is limited. Data were derived from a case-control study of the association of hormonal contraceptives and invasive cervical cancer. Incident cases (n = 524) of invasive cervical cancer who presented at two tertiary hospitals and controls (n = 1540) series matched for age, race, and place of residence were interviewed. Information on a wide range of variables was collected including whether the women had previously had a Pap smear taken and the number and timing of smears. Odds ratios (OR) and 95% CI were calculated using multiple logistic regression. The OR of cervical cancer was reduced among women who had ever had a smear (OR = 0.3, 95% CI: 0.3-0.4). The OR declined with increasing number of smears to 0.2 for >/=>3 smears (trend P = 0.0003). Among women who had a smear <5 years previously the OR was 0.3, but even if the smear was taken >/=15 years previously the women remained at reduced risk (OR = 0.5). The data suggest that even limited Pap smear screening reduces the risk of cervical cancer. Should a screening programme be successfully implemented, the incidence of cervical cancer might be reduced by as much as 70%.

The incidence of cervical cancer in South Africa (SA) remains high, and the current screening programme has had limited success. New approaches to prevention and screening tactics are needed. To investigate acceptance of school-based human papillomavirus (HPV) vaccination, as well as the information provided, methods of obtaining consent and assent, and completion rates achieved. Information on cervical cancer and HPV vaccination was provided to 19 primary schools in Western Cape and Gauteng provinces participating in the study. Girls with parental consent and child assent were vaccinated during school hours at their schools. A total of 3 465 girls were invited to receive HPV vaccine, of whom 2 046 provided written parental consent as well as child assent. At least one dose of vaccine was delivered to 2 030 girls (99.2% of the consented cohort), while a total of 1 782 girls received all three doses. Sufficient vaccination was achieved in 91.6% of the vaccinated cohort. Of all invited girls, 56.9% in Gauteng and 50.7% in the Western Cape were sufficiently vaccinated. This implementation project demonstrated that HPV vaccination is practical and safe in SA schools. Political and community acceptance was good, and positive attitudes towards vaccination were encountered. During the study, which mimicked a governmental vaccine roll-out programme, high completion rates were achieved in spite of several challenges encountered.

Incidence and mortality of cervical cancer in South Africa is still very high and 4-6% of women present with FIGO stage IVB disease. However, the management of oligometastatic cervical cancer is no...