April 25, 2010 - By Ruthann Richter
Gynecologist Paul Blumenthal (right), is helping to build a program in Ethiopia to improve screening of cervical cancer. Adnew Shumet (left) is the program’s director. Also involved is a chief resident (center) at Ababa medical school.
During a recent trip to Ethiopia, Stanford gynecologist Paul Blumenthal, MD, MPH, was stunned to learn that 60 percent of the patients referred to the country’s only cancer center were women with cervical cancer.
“I’ve never been to a country where they told me 60 percent of the total number of cancer referrals were for cervical cancer,” said Blumenthal, who has traveled the world organizing prevention programs to spare women from the disease. “I was incredulous.”
Virtually all of the women were at an advanced stage of cancer — a virtual death sentence in a nation where infrastructure is so sparse that there is only one radiotherapy machine for cancer treatment, said Blumenthal, a professor of obstetrics and gynecology and director of the recently initiated Stanford Program for International Reproductive Education and Services, or SPIRES.
Blumenthal and colleagues from SPIRES are now working to change that prognosis for Ethiopian women through a new collaboration with the Ethiopian Ministry of Health and Pathfinder International, a Boston-based nonprofit. The project is funded by the federal Centers for Disease Control through the U.S. President’s Emergency Fund for AIDS Relief. Through the five-year project, Blumenthal will provide technical and clinical expertise, helping train doctors and nurses at five major medical centers and in outlying clinics in the East African country in the use of a simple, low-tech approach for detecting and treating cervical cancer.
“Our objective is to prevent cervical cancer from ever occurring by doing this simple screening, uncovering pre-cancers that could develop into cancers,” Blumenthal said. “We’re really hoping to make a difference for the women of Ethiopia.” He will provide necessary technical oversight for the program, while Pathfinder International will provide day-to-day management. That’s just the kind of role envisioned for SPIRES, he said.
Ultimately, the hope is that the new cervical cancer vaccine could become available in Ethiopia. However, it is not only costly, but needs refrigeration and requires that patients make three clinic visits, obstacles that could be hard to overcome in this resource-poor country, Blumenthal said.
In the meantime, the cervical screening technique, which he helped pioneer, involves the application of acetic acid — ordinary household vinegar — to the surface of the cervix. If there are any pre-cancerous lesions present, these will show up as opaque raised white patches, easily visible to the practitioner. The lesions can be treated on the spot by using cryotherapy to freeze the tissue, effectively killing the pre-malignant cells. Both the screening and treatment can be done in a single visit, sparing women the time and expense of a return trip to the clinic, Blumenthal said.
Blumenthal helped develop the approach in the early 1990s with other colleagues who were searching for an effective, low-tech alternative to the Pap smear, the widely used screening tool that has significantly reduced cervical cancer incidence and mortality in the West. Through a grant from the Bill & Melinda Gates Foundation, Blumenthal and his colleagues were able to pilot the approach in several countries, including Thailand and Ghana.
Two women leave the clinic, located about three hours from Addis Ababa.
“It’s been shown in multiple settings that it works,” he said of the approach, which is being used now throughout the developing world, where cervical cancer is a major public health problem.
In Ethiopia, the incidence of cervical cancer is relatively high because of the high prevalence of HIV, which affects more than 500,000 women in Ethiopia. The cause of cervical cancer is the human papilloma virus, a sexually transmitted infection. Women who are HIV-positive can’t effectively fight off HPV and are more likely to become infected and progress to full-blown cervical cancer, Blumenthal said.
An estimated 7,600 women in Ethiopia are diagnosed with cervical cancer each year, and 6,000 die of the disease, according to Pathfinder estimates, which officials believe are probably significantly lower than the actual number of cases.
Blumenthal said there is no cervical cancer-screening program in place in the country, so most women are diagnosed at an advanced stage, when there is no hope of recovery. Women in the early stages of the disease have no symptoms, so wouldn’t suspect any illness, he said. Because cervical cancers may develop over a period of 10 to 20 years, early detection and treatment is critical. The cancer is curable if caught at an early stage, and preventable if the pre-cancerous state is discovered, which is the real aim of the prevention program, he said. A single screening at age 35 can reduce a woman’s lifetime risk of cervical cancer by 25 percent, according to Pathfinder.
The screening test initially will be offered to women at HIV clinics, though Blumenthal said he hopes all Ethiopian women will be able to access the program. He and his colleagues aim to screen and treat at least 5,000 women and provide information on cervical cancer prevention to at least 20,000 more.
Blumenthal said he expects they will uncover many more cancers that were not previously detected. So he is planning to work with physicians in Ethiopia to help improve their skills in managing the disease, which is typically treated through hysterectomy and/or use of radiation therapy.
This project is typical of the kind of work SPIRES intends to pursue, according to Blumenthal. Another project focuses on providing technical oversight to family planning programs in 14 countries across Africa, Asia and Central America. Overall, the SPIRES program seeks to advance women’s health in low-resource areas by providing women with safe and effective reproductive health care and services.
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