Hope for cervical cancer patients

“My stage three cervical cancer test results came back on my 38th birthday in July last year, I can never forget that day,” Catherine Clare Khainza says.

The mother of three who was born and brought up in Mbale, Uganda is a trained teacher but works in the banking sector.

It all began in January of that year when she went into labour and the doctors opted to do a C-section.

“I was expecting my third-born, and it went well. After being discharged, I started bleeding but there was no pain. I thought it was due to the C-section and ignored it while hoping it would stop at some point,” she says.

“The bleeding was persistent and because our country had been placed under a total lockdown due to the Covid-19 pandemic, I could not go to hospital. I had to wait until the restrictions had been lifted, then I went to my gynaecologist, we did tests and found it was cervical cancer.

“After breaking the sad news, she says her gynaecologist strongly recommended she seeks specialised treatment at Aga Khan University Hospital (AKUH) in Nairobi. He gave me other options, including India at first, but with a global ban on international travel and a surge of infections over there, travelling outside the continent was off the table.

“ I think from his experience with such cases, he believed that my chances to beat this comfortably were much higher outside Uganda,” Ms Khainza discloses.

Speaking to Healthy Nation, Dr Khadija Warfa, a gynaecologic oncologist at AKUH explained that cervical cancer affects the neck of the womb.

Abnormal cells

“It is the growth of abnormal cells in the lining of the cervix. Worldwide, this disease ranks as the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women, yet it is a preventable disease.

“Cervical cancer ranks second behind breast cancer in low-income countries. According to WHO (World Health Organization), 33 per 100,000 women in Kenya have cervical cancer and 22 per 100,000 die from the disease,” she said.

According to the expert, all women are at risk of cervical cancer, which occurs most often in women over the age of 30.

The human papillomavirus (HPV) is the main cause of cervical cancer and is a common virus that is passed from one person to another during sex. Most sexually active people will have HPV at some point in their lives, but few women will get cervical cancer.

Other factors that can increase the risk of cervical cancer are sex at an early age, multiple sexual partners, sexually transmitted diseases, HIV and cigarette smoking.

“Precancerous conditions of the cervix are changes to cervical cells that make them more likely to develop into cancer. If left untreated, it may take 10 years or more for precancerous conditions of the cervix to turn into cervical cancer. These changes are seen on screening tests conducted by your doctor,” Dr Warfa says.

It is no wonder then that Ms Khainza encourages women to do regular body checkups and pap smear tests. And Dr Warfa agrees with her.

“Cervical cancer and pre-cancer lesions can be detected through a pap smear test. For this test, your doctor/nurse looks inside the vagina using a device called a speculum. He or she will then use a small brush to collect cells from the cervix that will be examined in the laboratory,” says the doctor.

Depending on your age, the doctor says, a HPV test may be conducted. Alternative tests done in low resource settings include visual inspection with acetic Acid or Lugols iodine (VILI).

“A screening test is not painful and provides information that can be lifesaving. The government of Kenya regularly conducts nationwide campaigns to encourage screening for cervical cancer. Women between the ages of 25 to 64 are advised to have pap smears every three years. However, HIV positive women are urged to undergo the procedure every year,” says Dr Warfa.

The widespread use of cervical screening programmes has dramatically reduced rates of cervical cancer in the developing world.

Dr Warfa notes that early cervical cancer shows no symptoms and therefore screening is of utmost importance.

“The most common symptoms at presentation are irregular or heavy vaginal bleeding or bleeding after sexual activity. Some women present a vaginal discharge that may be watery, mucoid or foul smelling.

“Advanced disease may present with pelvic or lower back pain, bowel or urinary symptoms such as pressure-related complaints, vaginal passage of urine or stool are uncommon and suggest advanced disease,” notes Dr Warfa.

In asymptomatic women, she says, cervical cancer may be discovered as a result through screening or if a visible lesion is discovered upon pelvic examination.

Ms Khainza’s treatment began as soon as she landed in Nairobi a few weeks after her tests. According to Dr Warfa, once cervical cancer is diagnosed, the next step is to determine the stage.

 “Staging is a system used to describe the spread of a cancer. Cervical cancer is staged based on the results of physical examination and imaging studies,” says Dr Warfa.

There are several options for treatment of early-stage cervical cancer. Decisions about treatment depend on the stage of the cancer, age and health.

“The most common treatment for early-stage cervical cancer is radical hysterectomy (removal of uterus, cervix and other parts).

“The alternative is radiation therapy, which is usually given in combination with chemotherapy,” Dr Warfa says.

Treatment

Dr Angela Waweru, a consultant radiation oncologist, and the radiotherapy section head in the department of haematology-oncology at AKUH told Healthy Nation that fear and misconception have caused many patients to either delay or worse still decline radiotherapy, which is a critical treatment method in the fight against cancer.

“By delaying care, patients’ may compromise their health and survival outcomes. Let me share some frequently asked questions about radiotherapy that should hopefully clear any doubts and dispel myths that may be influencing some patients to delay their care,” she says.

Radiotherapy is the treatment of cancer (and a few non-cancerous conditions) using high energy X-rays.

It may be given on its own or as is often the case, alongside other treatments such as surgery or chemotherapy.

Radiotherapy treatments for most cancers is delivered from outside the body by machines called linear accelerators (LINACS).

 When receiving the treatment, you do not feel anything and it does not make you radioactive, it is perfectly safe for you to be with other people including children and pregnant women throughout your treatment period.

Everyone’s’ treatment is different and planned individually. It is usually given as a series of outpatient appointments over five days a week, and the length of treatment can vary from a single treatment to a course lasting seven weeks or more.

The tissues of our bodies are made up of tiny building blocks called cells. The radiotherapy causes damage to cancer cells in the treated area.

Although normal cells are also affected, they can repair themselves and are able to recover and so the damage is mainly temporary.

Radiotherapy is a local treatment, which means only the area treated is affected. This treatment can have benefits at any stage of cancer.

For cancers that are detected early, the aim of treatment is cure, either with radiotherapy alone or in addition to another main treatment.

For example, you may have surgery to remove a tumour and may also be given a course of radiotherapy afterwards to kill any cancer cells that may have remained after surgery. Unless treated, these cells may cause a tumour recurrence at a later time.

In some cases, radiotherapy is done before surgery to reduce the size of the tumour and make it easier to remove while in other instances, radiotherapy and chemotherapy are used as a combination.

If a cure is not achievable (usually due to delayed diagnosis), it is often possible to limit the growth or spread of the cancer with radiotherapy.

Many patients with advanced cancer have benefited from this form of treatment, with reduction of symptoms such as pain and bleeding.

Side-effects

The treatment has some side-effects that can either be short-term or long-term, and it is important to know that these vary widely depending on the area being treated.

Some general short-term side effects include tiredness and sore skin in the treatment area. These will usually improve a few weeks after treatment.

 Long-term side effects take months or even years to develop and can occur in any normal tissues that have been exposed to radiation.

Careful treatment planning helps avoid long-term side effects. Patients are therefore encouraged to have a discussion about the expected side effects of their treatment and how they will be managed with their doctors.

Recurrence

Unfortunately, despite treatments such as radiotherapy, sometimes cancers come back, often as metastatic disease, that is outside the original (primary) location.

Cancers that are diagnosed at a more advanced stage are more likely to recur after treatment than those diagnosed at an early stage

Recurrence is a devastating diagnosis for a patient who was previously successfully treated; it is important to know that recurrence does not mean that the initial treatment was incorrect or unsuccessful.

 Some cancers are more likely to come back than others.

Scientific research has made great strides in understanding how recurrent cancers can be managed and a growing number of treatment options are now available.

While responding to a question from Healthy Nation on incidences whereby some people have alleged that they “got burnt” while undergoing radiotherapy, the Dr Waweru clarifies that “While it is true that a skin reaction, termed as radiation dermatitis, is one of the commonest side effects of treatment, technological advances incorporating modern radiation machines with new delivery systems and more powerful computers and software such as those available at AKUH have reduced the incidence and severity of dermatitis.”

 In addition, she says, having specialists adept at managing these and other side effects associated with the individuals treatment is paramount in taking a patient through radiation therapy.

Advanced technology

Recent notable technological advances in radiology include improved target delineation, which is a critical first step in planning radiation treatments.

“The extent of the tumour is defined; complimentary images from MRI to PET-CT scans are increasingly incorporated into the treatment planning process, allowing for increased safety in delivering the radiation dose while minimising exposure of uninvolved normal tissue to radiation,” Dr Waweru explains.

The radiotherapy specialist further discloses that other advances in treatment planning and delivery are devising radiation treatments that closely conform to the tumour, with the delivery of modulated radiation beams known as intensity modulated radiation therapy (IMRT).

Further refinements have led to improved conformity and reduced treatment times such as with volumetric modulated arc therapy (VMAT) and Image Guided Radiotherapy (IGRT) where imaging is used during radiation therapy to improve precision and accuracy of treatment.

She said that in recent years, there has been substantial interest in regimens involving a relatively large dose of radiation being delivered in highly conformal techniques, known as stereotactic body radiation therapy (SBRT) or stereotactic ablative radiotherapy (SABR) adding that these approaches are not appropriate for all clinical scenarios. The size of the lesion requiring treatment and its proximity to critical normal tissues with high sensitivity to radiation have to be carefully considered.

“Some of these forms of advanced radiotherapy are available locally and others like SBRT are planned for the near future. Where a patient requires treatment other than what is locally available, referral mechanisms exist for international treatments.

“These and future technological advances ultimately serve to reduce the toxicity of radiotherapy, whilst escalating the doses of radiotherapy which in many cases has led to improvements in disease control,” Dr Waweru observes.

Cost

Ms Khainza is nothing but thankful to the team that attended to her.

Her entire battle with cervical cancer cost her Sh1, 217,530.

“I spent Sh4,400 per session as consultation fee for eight sessions. My abdomen and pelvis MRI cost Sh62,500, laboratory tests were at Sh15,000 each on five different occasions. The CT simulation and planning cost Sh8,000 and radiotherapy, which I did 25 times, was at Sh9,500 per session. For chemotherapy they charged me Sh35,000 per session for five session,” she discloses.

“The doctors, the support staff and everyone else who handled me did an exceptional job, especially considering the fact that I did not know anyone in Nairobi. To those battling this disease, as much as the doctors are doing their part, keep your faith because this is a storm that will come to pass.

“To beat this disease I had to remind myself of every promise in the bible as well as keeping a positive attitude because as a mother I have my kids to think about, how much they need me, and it kept me going. Then there were all those who kept checking in on me and encouraging me,” says Ms Khainza.

“This was a test on my faith and my spiritual leaders came in handy. In fact in the bible, Proverbs 18:14 says that the spirit of a man will sustain his infirmity but a wounded spirit, who can bear? This means that all we need to do is to sustain our spirit, it has to be so grounded even when a disease comes.

“The doctors also gave me examples of some people who are even among the staff at the hospital who have beaten the disease and told me I could do it as long as I am in the right hands constantly listening to and following their guidance and advice,” she says.

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