South African Statistics: Cervical Cancer & Screenings

Concept Note By Kat Simon

A little bit of context…

·      Historically speaking, the cervical cancer burden has remained a challenge that has roots in traditionally inadequate systematic screening programmes, as well as compounded challenges with late diagnosis, and socio-economic inequalities. Previously, screenings were not easily accessible and there was even less awareness around the concept of regular and ongoing screening. Although the policy of South Africa introduced a cervical screening policy in 2000 that entitles women to three free smears per lifetime, by 2008 national coverage was estimated at only 13%, with provincial variations ranging from 2% to 45%. In the Western Cape Province (which includes Cape Town), lifetime screening coverage was approximately 54% in 2010, but only a minority of women received the recommended three smears.

·      Just over a decade ago, the Isa Modibbo et al study found that common reasons for not adhering to screening, included no symptoms, lack of time and fear (results and process). Among a sample of 456 educated black African women (mean age 42 years, 82% with tertiary education) attending tertiary institutions in Cape Town in 2013–2014, 78% reported ever having had a Pap smear, but only 36% were up-to-date with screening according to national guidelines.

· If we look further back, we can see that a lack of understanding preventative measures and perhaps even the treatment of cervical cancer, directly implicated the uptake of cervical screenings (or lack thereof). For instance, in the 1970’s and 1980’s, South Africa’s Department of Health recommended a PAP smear only if anything looked or seemed irregular during an examination. A decade later, a more regimented structure was put into place for women, but this was largely futile due to a general lack of knowledge around cervical cancer, preventative strategies and female health.

·      The 1990’s were no better, with a delayed implementation of a formal national screening programme, and so screening adherence remained occasional and was generally employed for women embarking on family planning/ prenatal services. The National Cancer Control Policy was launched in 1999/2000, when the National Department of Health finally implemented a policy offering three free Pap smears per lifetime to asymptomatic women aged 30 years and older at 10-year intervals.

What we know…

·      Currently, South Africa’s data reflects that cervical cancer is the second most commonly occurring cancer amongst women, and black African women have the highest risk of developing this disease.

·      Most studies have focused on disadvantaged women in the greater Cape Town region, and have concluded that there is a lack of knowledge about screening as a key structural barrier to treatment. Other structural barriers were: time, age at which free screening is available, and health education. The psychosocial barriers that were identified included: fear of the screening procedure and of the stigmatisation in attending screening.

·      An additional psychological barrier, fear, has been prevalent in former studies; including insufficient information from primary care providers, negative community opinions relating to the procedure, and fear of having an HIV test at the same time.

·      There could also be non-intellectual factors such as, apprehension, shame, apparent low personal risk and lack of time.

What is worrying…

·      Considering that the women within this demographic should be undergoing a co-test or HPV test every five years, or a PAP test every three years, (high risk individuals get tested annually or every six months, on recommendation of their specialist), the percentage of adherence should be greater than the 20% that some urban cohorts have exposed.

·      Some of the most important factors in South African studies, included socio-demographic factors like education level, income, lack of medical aid, and access being primary barriers. An important factor to distinguish and clarify, is that of ‘lack of knowledge’ and ‘lack of awareness’. Lack of knowledge speaks to women having limited or no knowledge about PAP smears or female preventative care. Lack of awareness speaks to a deeper level of understanding in terms of personal risk, frequency requirements and the importance of preventative interventions, as opposed to waiting until there is an abnormality or concern.

·      If we examine uptake rates in the urban Cape Town region, among women over 30 is ~35-66% and up to 68% with a tertiary education. Regular screenings (adherence to the recommendations), drop to ~20-50%. While higher education definitely does result in better uptake rates, there seem to be barriers even in this demographic that are consistently preventing adherence. While 45-60% of women from previous studies feared the screening and / or results (psychological barrier), there still seem to be access barriers, which the lower incomes groups experienced, as well as a lack of awareness of preventative strategies, despite the education level.

·      Screenings at public facilities - who/ which public clinics or hospitals offer these free PAP smears? How do members of the public book a screening when public facilities are often at saturation point? Are they geographically difficult to access or perhaps are the waiting lists so extensive that the women are going beyond the recommended wait or age prescription between screenings? These are just some of the possible barriers that are preventing uptake of these government-based screenings.

Action is Required…

·      Currently, the government supports the World Health Organisation’s (WHO) Global Strategy for eradication and is guided by the Cervical Cancer Prevention and Control Policy (updated 2021). In 2020, the WHO launched a global strategy to accelerate the elimination of cervical cancer as a public health problem. Regarding secondary prevention, the strategy aims to screen 70% of women and treat 90% of women with pre-cancer by 2030.

·      The focus is to shift screening methods to high-risk Human Papillomavirus (hrHPV) testing.

·      There is also a national drive for HPV vaccination and treatment. South Africa successfully vaccinated 405, 299 female pupils during February/ March 2024.

·       Many South African women do not adhere to recommended regular cervical screening, and some have not been for any at all. As one of the key preventative strategies in cervical cancer, it is imperative that we understand why women are avoiding going for testing, as well as why they are not going as regularly as prescribed.