Fighting cervical cancer with hand-held device

When Mercy Wanjiru was queueing outside a makeshift clinic in Nairobi's low-income Kayole neighbourhood, a positive cervical cancer test was the least of her worries.

"I had never experienced symptoms, not even an unusual discharge to signal abnormalities in my cervix. I'd actually brought a friend for the cancer screening and as I waited for her, I decided to do it," she says.

In the tent clinic, a sheet hanging to provide some privacy, a nurse took a cotton swab and rubbed vinegar on her cervix. She looked at Ms Wanjiru's tests, then she called a doctor, to confirm the whitish lesions in her cervix.

"They told me that they had found three abnormal cells in my cervix. I was in shock. I wondered how long I had to live, fearing that my two-year-old son would grow up without a mother," the 25-year-old says.

For Kenyan women, a positive cervical cancer test is usually unsettling.

The lack of awareness that abnormal cells, also known as pre-cancer lesions, are easily cured and cervical cancer prevented, the long treatment delays in public hospitals, and the shortage of specialists and medical equipment mean that thousands of women feel lost after a positive diagnosis.

But Ms Wanjiru counts herself lucky.

Using thermo-coagulation, a relatively new technology in Kenya, which burns abnormal cells in the cervix in minutes, doctors gave her a new lease of life.

"The treatment took minutes. It was done in the same makeshift clinic where the screening was done, that I didn't have to be referred to the congested public hospitals," she says.

Thermo-coagulation is seen as a game-changer in taming new cervical cancer cases in Kenya, which have risen to 5,250 annually, according to the World Health Organisation (WHO).

Dr Nicholas Kisilu of Ampath Oncology Institute in Eldoret says thermo-coagulation is best positioned to slow down cervical cancer rates, as patients are screened and treated immediately.

"This technology will tremendously reduce the late-stage cervical cancer patients that we see due to delayed treatment," he says.

One advantage of thermo-coagulation is that the device is portable.

"It is a hand-held device that can be carried anywhere. It is easy to use that one does not need a gynaecologist as nurses can easily and safely use it to treat precancerous lesions," he says.

However, its usage is still low. Africa Cancer Foundation (ACF), a Kenyan charity, is among the few organisations that are using thermo-coagulators in free medical camps.

"We have treated 30 women in Kisumu, Nairobi, West Pokot, Nyandarua, and Makueni since February last year," says Wairimu Mwaura who is in charge of ACF Programmes.

Ms Mwaura says having a thermo-coagulator in the free medical camps ensures all patients are treated after diagnosis.

Previously, some women would return to distant areas where they live or work after the screening, making it hard to trace them if their tests turn positive.

Research shows that in most low-income countries, up to 80 percent of women diagnosed with pre-cancer lesions never receive treatment.

At present, the standard treatment of most precancerous lesions is gas-based cryotherapy, which involves freezing a section of the cervix to destroy abnormal cells, which then shed off after weeks.

However, most times public hospitals run out of gas, or some procure gas that contains impurities, making it ineffective in treating the cervical lesions.

Other treatment methods are expensive and difficult to reach women living in areas underserved by specialised doctors.

For instance, the loop electrosurgical excision procedure (LEEP) treatment, which involves scraping off the diseased tissue using a wire loop, is unavailable in many hospitals due to a lack of experts.

"With thermo-coagulation, you treat the patient immediately after diagnosis. The device is simple to use and easily portable to the remotest of places as long as the batteries are charged. The treatment method requires no anaesthesia, and is administered within a very short treatment cycle, less than a minute, hence many patients can be treated in a day," said Ms Mwaura.

Dr Kisilu adds that thermo-coagulation is also cost-effective compared to cryotherapy.

"Cryotherapy requires gas cylinders and refilling costs. The gas cylinders are also bulky to keep," he says.

Thermo-coagulation uses heat to destroy tissue in the cervix. A speculum and acetic acid are inserted through the vagina to define the lesion in the cervix.

"A probe is introduced through the speculum and focused on the lesion for 20 to 30 seconds. This is repeated until the whole lesion is covered. The probe is removed and a doctor checks for any signs of bleeding and then removes the speculum," says Dr Kisilu.

SHAME, CULTURE

Even with the availability of the technology in free medical camps, the turnout for gynaecological check-ups is still low due to shame and culture. For instance, in the eight years that ACF has been doing free screenings and treatment in various counties, only 20,000 women aged between 25 and 49 have been screened.

"About 10 percent were found to have precancerous lesions or advanced cancer," says Ms Mwaura.

Because rural areas lack high-quality laboratories, ACF uses a cheap vinegar method to screen for cervical cancer. They set up tents and an exam table, where a health worker takes a cotton swab, brushes vinegar on a woman's cervix and precancerous spots turn white.

Even for those who can afford regular Pap smears or human papillomavirus (HPV) tests, the turnout is still low.

According to Pathologist Lancet Kenya, one of the biggest laboratories in the region, they do about 10,000 Pap smears and 1,000 HPV tests every year.

Of those tested, about 17 percent are found to have high-risk HPV, which causes cervical cancer.

"High-risk HPV is more prevalent in younger women in their early 40s," said Dr Ahmed Kalebi, the chief consultant pathologist and CEO of Pathologist Lancet Kenya, during a Kenya Obstetrical and Gynaecological Society conference in Diani on the Kenyan coast.

HUSBAND PERMISSION

Another challenge is gender power relations in Kenya, which clouds screening and treatment of cancers of the reproductive organs.

Most women are hesitant to go for pelvic exams and if found with abnormalities, they can only be treated if their husbands consent, yet the burden of cancer is heavier on women than men.

Women lead in cancer deaths with 18,772 dying from the different types compared to 14,215 men yearly, representing 56 percent of the total deaths, according to WHO.

Cervical cancer is the leading cancer killer in women in Kenya, with an estimated 3,286 deaths each year.

"Some women decline treatment, fearing that their husbands will refuse to abstain from sex afterward. After treatment of precancerous lesions of the cervix with thermo-coagulation, a woman is told to abstain from sex for 30 days," Ms Mwaura said, adding that some patients are also in denial when they are told of the diagnosis and walk away, never to return for treatment.

Before Ms Wanjiru was treated using thermo-coagulation, she was asked to come with her husband.

"He had to give consent because I couldn't have gone ahead with the treatment then he refuses to abstain from sex for a month. He didn't know much about the treatment but when he heard that the abnormal cells could multiply or turn into cervical cancer, he agreed quickly. The chances of beating cancer especially if you aren't rich like me is very low," says the mother-of-one.

Myths that thermo-coagulation causes infertility or it will not rid the cervix of the lesions also inhibit the take-up.

"It has very few risks. It is associated with premature deliveries in pregnant women but this is extremely rare," Dr Kisilu said, adding that after treatment, a patient should do follow-up tests after six months to one year.

SIDE EFFECTS

Six months after the thermo-coagulation treatment, Ms Wanjiru went back for screening.

"I was doubtful. I didn't believe the treatment had cleared the lesions. I did three Pap Smears in three different clinics. My cervix was clean," she says.

The 'see-and-treat' approach is important to people like Ms Wanjiru, who braids hair for a living. On a good day, she earns Sh500. With no regular monthly income, she has no time to wait at the jammed public hospitals, and she cannot afford a private doctor or medical insurance.

The prospects that this low-cost technology could save the lives of thousands of poor women excites Dr Kisilu, but only if the device which costs about Sh250,000 is available in more hospitals and health workers are trained in how to use it.

PAINLESS TREATMENT

However, what worries Ms Wanjiru is the number of young women who know little about early cervical cancer screening and those who do are skeptical about pelvic check-ups.

"The treatment was painless, just a backache that disappeared after I took painkillers. I went back to plaiting people's hair after a day and resumed my normal chores, including fetching water from a nearby borehole and carrying it up the stairs to my house," she says.