A cancer whose toll is quite unnecessary
BY ERICK KABENDERA, JUNE 6, 2009

Each year, about 8,000 new cases of cervical cancer are reported in Tanzania and about 6,000 die of the disease annually. Cervical cancer accounts for 60 percent of all female cancers in the country. Cervical cancer is in fact a largely preventable disease.

The trouble is it is difficult to prevent it in the country given the existing health system that doesn’t give priority to cancer. There is also a shortage of experts in diagnosing cervical precancer lesions. As a result, the disease continues to claim an otherwise unnecessary toll of human lives...

One Saturday morning last year, 30-year-old Marinasi Ntumo woke up to realise she was having an unusual discharge from her vagina.
Because she was not feeling any pain she decided it was nothing serious and continued with her planned work on her small garden in Kifura village, Kibondo district.
By one week later, the discharge had not only persisted it had also become so bad that she was forced to change underwear up to four times a day.

At that point, she decided to discuss the matter with her husband who advised her to go to the district hospital located more than 20 kilometres away for a checkup.
When she finally made it to the hospital, the doctor on duty did some tests and told her that he suspected she had cervical cancer.
“He cautioned me that his findings were not final,” says Ntumo, “but being told that I had cancer made my heart race fast than ever. I was scared.”
The doctor referred her to Bugando Medical Centre in Mwanza region for specialised diagnosis.
But getting to Mwanza was another headache for her because, as simple housewife, she could not afford the bus fare and her husband had little money on him.
“We decided to borrow money from relatives to enable me to go to the hospital and for maintenance there for a number of days,” says Ntumo.
When she reached the hospital in Mwanza, a doctor took a pap test and asked her to go back to the hospital three weeks later for her results.
She didn’t have relatives in Mwanza but she moved around the city looking for anybody she could find with ties to her village. She found someone with whom she stayed while waiting for her results.
“The doctor confirmed that I had cervical cancer and referred me to Ocean Road Cancer Institute in Dar es Salaam for specialised treatment,” says Ntumo.
The alarm bells
It was not the first time for Ntumo to hear about the disease. Her neighbour and a close friend of hers had died of the disease in her village a year before Ntumo was also diagnosed with it.
Ntumo’s friend had sought medical intervention when it was too late and when she was told at Bugando to travel to Dar es Salaam immediately, she had failed to raise the bus fare and had returned to her village where she died in pain and anguish days later.
“A lot of fluids were coming out of her private parts and she would cry throughout because of the terrible pain she felt and none of us could do anything to help her,” she says.
Ntumo could see her life ending in a similar way and she embarked on a passionate quest for financial help in a city in which she hardly knew anybody.
According to the World Health Organisation, cervical cancer is the second most common cancer among women worldwide with about 500,000 new patients diagnosed and 250,000 deaths every year.
The WHO says almost 80 percent of the cases occur in developing countries including Tanzania .
Dr Julius Mwaiselage of the Division of Cancer Prevention and Research at the Ocean Road Cancer Institute says cervical cancer ranks top among cancers affecting Tanzanian women.
It is found in about 75 percent of all women diagnosed with cancer and it affects 40 percent of all cases reporting for treatment at the institute.
“The disease is chronic and results from the changes of the normal cells to abnormal cells on the surface of the cervix.
If these changes are left untreated for a long time, they may develop to cervical cancer,” says Dr Mwaiselage.
There are different ways through which a woman could be exposed to cervical cancer, according to Dr Mwaiselage. Some of these are sexual intercourse, having multiple partners and the long-term use of oral contraceptives.
The long-term use of oral contraceptives causes hormonal changes that make it easy for cervix to get infected with the Human Papillomavirus (HPV) when a woman has unprotected sex.
“Most men are basically carriers of HPV but don’t get affected as much as women,” says Dr Mwaiselage.
An unnecessary toll
Each year, according to Dr Mwaiselage, about 8,000 new cases of cervical cancer are reported in Tanzania and about 6,000 die of the disease annually.
“Cervical cancer accounts for 60 percent of all female cancers. The policy of Tanzania is free treatment for cancer patients, this means that the government pays for their treatment,” he says.
Since treatment is offered for free, Ntumo didn’t need to pay for her chemotherapy and radiotherapy treatment which would otherwise have cost Sh100,000 and Sh1 million respectively.
The unusual vaginal discharge that Ntuma experienced, according to Dr Mwaiselage, was part of the symptoms of the disease though the signs vary from woman to woman.
As Ntumo went looking for bus fare, she wound up in a church in Mwanza whose members raised the money that eventually brought her to Dar es Salaam .
When she arrived in early April this year she was immediately put on radiotherapy.
“When I got here, I was told that I would go through radiotherapy for four weeks so I have seven doses to go before I finish my treatment,” she told me recently.
At the Ocean Road Cancer Institute, which is exclusively for cancer patients, the ward where Ntuma is admitted is congested and some of the patients sleep on the floor. Some of them have been at the hospital long enough to know almost all the nurses.
At lunchtime when patients come out of their rooms to meet visiting relatives and friends, the oval shaped shed, the size of two classrooms where they gather, is always packed.
Dr Mwaiselage says bed occupancy at the hospital stands at between 160 and 200 percent and the hospital has been asking patients with relatives in the city and who are not in a bad state to stay with those relatives as a means to reduce congestion.
“That is the short term solution but government will give us money to build another facility in the coming financial year,” says Dr Mwaiselage.
It is four months now since Ntuma last spoke with her husband and she fears that she might lose him to another woman.
In the period since her arrival, she has made friends with another patient, Zuhura Mwambiko, who is also admitted at the hospital with the same disease.
She lost her husband to another woman immediately after she started getting the watery discharge from her vagina.
Poor primary health care
When the water started coming out, the nurse at the village dispensary had suspected she had an STD.
“It was not possible to have sex with my husband because of the water so he decided to take me to my aunt where we had met five years earlier and promised that he would come back but he never came,” says Zuhura.
A few weeks later, a friend told her that her husband had married another woman, leaving her with her five-year-old son depending on her aunt at Majimaji village in Ruvuma where she was born.
Despite the STD medication she received from the dispensary, Zuhura did not get better and her aunt advised her to go to the witchdoctor, suspecting that she had been bewitched.
She did follow her aunt’s advice, but when she did not get better she abandoned their prescribed treatment.
By then, black odorous black blood had begun coming out continuously instead of water and she felt a lot of pain.
Preventable but alas!
“My situation was so bad that I asked my aunt to take me to Masasi district hospital but the hospital didn’t have a specialist to treat me,” says Zuhura. She was told to wait for almost a week until a specialist came from the regional hospital. She was diagnosed with a swelling in her cervix, which the doctor said had cancer strains.
Zuhura says she wept the whole day upon learning that she had cancer because she grew up hearing that cancer not treatable. “I thought it was the end of life because everyone in my village believed that cancer had no cure,” says Zuhura.
Like Ntuma, Zuhura didn’t have the money to travel to Dar es Salaam where she was referred for treatment and her husband had abandoned her.
Cervical cancer is in fact a largely preventable disease through vaccination and screening measures.
But Dr Mwaiselage says the problem in the country is that that it is difficult to prevent cancer and other non-communicable diseases in the country given the existing health system that doesn’t give priority to cancer.
But the Institute has set up a programme aiming to train health workers at regional and district hospitals to perform screening for cervical cancer, according to him.
The New England Journal of Medicine recently reported that a test for the human papillomavirus infection is better than the standard Pap smear at catching cervical cancer early.
The study of women aged 30 and above makes the case for changing cervical cancer screening practices, particularly in low-income countries, since the screening test for HPV would necessitate fewer doctor visits.
The most common screening method in Tanzania is pap screening but Dr Mwaiselage also complains of a shortage of experts in diagnosing cervical precancer lesions called cytologists.
“Thus Tanzania and other developing countries perform cervical cancer screening with the Visual Inspection Technique using Acetic Acid, which is a method used to spot cervical cancer before it grows to be severe,” he says.
WHO says cervical cancer is the leading cancer in all developing countries but ranks Tanzania and Zambia as countries with the highest incident of the disease.
As part of its efforts to help eradicate the disease, the UN organisation supports a cervical cancer screening programmes at selected hospitals in some African countries including Tanzania .
Dr Mwaiselage is aware of the programme and says that it aims at looking into the accessibility of cervical cancer screening programme. “The project ends in June 2009 and thereafter will be integrated in the normal services in the hospitals,” he says.
The Ocean road hospital is running an outreach cervical cancer screening programme since 2006, which Dr Mwaiselage says has been very successful but says setting up clinics in the regions has been slow due to lack of funding.
Possibly a future
“Only one of ten regions has not yet started the clinic. In addition,” says Dr Mwaiselage, “a total of 17,249 women have been screened and 1,715 have been found to have precancer lesions and have been treated with cryotherapy.”
Both Ntumo and Zuhura will be through with their treatment in a few days and are eagerly waiting to know what the verdict of their doctors will be a the end.
Ntumo says her vaginal discharge has now stopped while Zuhura says it is still coming out but not as bad as it was when she first reported to the hospital.
Dr Mwaiselage sees the stopping of the discharge as a good sign because it could mean that the patient has fully recovered or is on the way to recovery.
But before the two patients are discharged, another test will be done to find out if there are any cancer strains left.
“If the strains are not there, that would mean they have fully recovered but would only come back after three months for checkup to make sure everything is okay,” he says.