(Focus- Philippines)
As January is Cervical Cancer Awareness Month, so, decodeMR brings you our discussion with Dr. Cecilia Llave, an esteemed Gynecologic Oncologist from the Philippines, wherein she explained the importance of cervical cancer screening and HPV vaccination.
Dr. Cecilia Llave is a Technical Adviser of the SUCCESS project, Jhpiego, Philippines, affiliate of Johns Hopkins University and Research Affiliate Professor in Institute of Child Health and Human Development, National Institute of Health, University of the Philippines, Manila, Philippines
We have a memorandum of agreement with the Department of Health, which states that Jhpiego with experts of France and UICC will work together for the start-up of the HPV DNA test.
As we all know, cervical cancer can be prevented by vaccination. So, is there a mandate for an active cervical cancer screening program in the Philippines?
Dr. Cecilia: In the Philippines, we have a cervical cancer prevention and control program, but it is not yet well organized. We are yet to have it as a nationally organized program. But I think it will come in the next few years because we have just now finalized the National Integrated Cancer Control app (which was approved two years ago), and the Universal Health Care program. Both programs are now finalizing their IRR and finalizing or consolidating all the programs that we have, so, that we will really have a Cervical Cancer Elimination program.
Historically, we started in the year 1970s with the PAP smear test as a screening tool for the country. We just had 12% of our women community who had been screened, which is a very small number. So, our goal was to increase this percentage. Based on the national research done by the University of the Philippines’ Epidemiologic Center, the Department of Health issued an administrative order in the year 2005 which stated that the primary screening tool for the local governments' health centers will be VIA, though the PAP smear test will not stop.
The VIA was initially started with the programs for service delivery by Jhpiego, an international, non-profit health organization affiliated with Johns Hopkins University. I was then the chair of the Cancer Institute of the University of the Philippines, and the head of the Jhpiego team was our resident in the university. During this time, in 2005, I was invited to speak about the Philippines' status of the cervical cancer program. Following this conference, within two years, we started to plan for the implementation of service delivery of a single visit approach using visual inspection acetic acid or vinegar linked to treatment using cryotherapy.
We started with three pilot sites in the country. And now we have a total of about 35 sites, and by the year 2013 to 2017, we endorsed this approach to the Department of Health. So, this is where we are now. In July of 2021, the WHO presented the updated guideline, and this time WHO wanted different nations all over the world to shift to the high screening tool, which is HPV DNA testing. This is a molecular test and is kind of expensive.
In our country, VIA is free for women of 25 to 55 years of age because the local government receives funds for it. Yes, but then the PAP smear is not free. The WHO wants to shift to DNA testing. In our country, we have DNA testing only for private hospitals, and those costs 6,000 pesos, which is so expensive for an average Filipinos, as the average daily wage is only 500 pesos.
The pandemic has adversely affected the vaccination drive as the schools were closed for a long time. The program shifted from school-based vaccination to community vaccination, and therefore, the number of vaccinations decreased to 50%.
Doctor, please tell us more about the international collaboration that you are a part of.
Dr. Cecilia: We are just very lucky as we were chosen as one of the four countries all over the world for the service delivery and implementation research. So, what is SUCCESS? It means to Scale Up Cervical Cancer Elimination with Secondary preventive Strategies. This program is an aided program involving a consortium of experts from France, Jhpiego, the Union for International Control, and it is supported by the National Cancer Institute of the US, Japan, Brazil, and France.
We should have started this program by the end of 2019. But, because of the pandemic in 2020, there has been a delay. We already have a memorandum of agreement with the Department of Health, which states that Jhpiego with experts of France and UICC will work together for the start-up of the HPV DNA test. I'm just very lucky that I was taken in as a technical advisor for the Jhpiego implementation.
The collaboration will last until 2023. We're hoping that maybe this time the government will be able to really support this collaboration. The results that we will get from this collaboration should be used to formulate all the guidelines and policies.
So, in your opinion, how effective is the vaccination against HPV in preventing cervical cancer?
Dr. Cecilia: It is very helpful because vaccination will prevent the progression of the infection. We know that 99.7% of the time the cause of cervical cancer is the HPV virus. If you're able to vaccinate 9 to 14 years old girls, children, or adolescents before they become sexually active, then we will be able to cut back the progression of the infection and prevent from developing it into cancer.
So, what is the status of vaccination in the Philippines?
Dr. Cecilia: We started the vaccination drive in 2015 in which the government started enrolling public schools from 20 provinces for 9 to 14 years old girls. Then, from the next year, the program was expanded to 26 provinces, and by 2018 or 2019, it covered 54 provinces. Initially, we were giving it in three doses, but in 2015, it was found that we can give two doses for children of 9 to 14 years, and three doses if they are more than 15 years old.
The pandemic has adversely affected the vaccination drive as the schools were closed for a long time. The program shifted from school-based vaccination to community vaccination, and therefore, the number of vaccinations decreased to 50%.
If we talk about the healthcare landscape in the Philippines, what do you think are the barriers regarding the timely diagnosis of cervical cancer?
Dr. Cecilia: Well, number one is the lack of awareness among Filipino women that cervical cancer is a disease that can be prevented and treated if diagnosed early. They don't even know about the PAP smear and VIA tests. The woman should know that they should go to the health center and get checked.
The second barrier is our devolution system. The devolution means that the national government takes care of the regional centers, and the local health centers are devolved, as a result, there are always some coordination issues. Thus, the government should closely collaborate with local health centers to create an effective system.
And then, of course, the other barrier is finance, but it's a matter of leadership. You should know how to control your money or your budget. I think with the national cancer integrated app and the universal health bill, there will be a lot of improvement in terms of finances.
We have a national insurance system, called Philhealth. This is the one giving funds for cervical cancer screening, but it is not yet complete. I think they should be able to give a refund for the screening, the diagnosis, the pre-cancerous treatment, like cryotherapy or thermal ablation.
So, doctor, till now we discussed about the barriers, we talked about diagnostic tests like the PAP smear test. What are the other ways that can help in improving the diagnosis of cervical cancer?
Dr. Cecilia: I think the implementation research, which is ongoing with the SUCCESS program, has already awakened the government. It involves timely assessment of the status of this program like what needs to be done, what should be the priorities, what are the available resources, and which resources we lack. If we consolidate all these findings, then we can save a lot of money. In the end, it's very important that the screening, diagnosis, and treatment are all consolidated and prioritized in an organized manner.
Another thing is that different cancer societies are doing almost the same thing when they should not be doing it like that. It's like the Society of Gynecologic Oncology should focus on the treatment. The Society of Cervical Pathology and Colposcopy should focus on the diagnosis, and the Society of Ob-Gyn should focus on primary health care.
It's very important to move together as one, as a team, if you want to contribute towards cervical cancer prevention.
As you mentioned about the implementation that is going to be done by 2023, do you see any interesting trends with respect to cervical cancer diagnosis and treatment in the Philippines?
Dr. Cecilia: I think there is a very good chance that we will be shifting to high-end performing laboratory tests, like HPV DNA testing. In addition to this, the doctors, nurses, and midwives in the community would be equipped with the arms or with the tools that would stop cervical cancer early and these women would not progress to invasive or late-stage cancer. There is not so much you can do when it's too late. And you know, chemotherapy and surgery are expensive.
So, coming to the second last question, what would be your suggestion for our readers on how they can contribute towards cervical cancer prevention?
Dr. Cecilia: Well, the suggestion will be to move together as one. There are many champions, good people, and advocates, but they should move as one. Because if you have many leaders, and champions and they are not moving together, then nothing will be achieved. We are not going to maximize the resources and it will be a waste of time. Thus, it's very important to move together as one, as a team, and it's not only one person or a group of an organization, but it should be everyone in the country.
So, on the same line, what can everyone do towards cervical cancer prevention?
Dr. Cecilia: For example, if I'm just a simple woman who lives as a homemaker, now that I have already learned about cervical cancer screening, and undergone diagnosis tests, I can invite all my women relatives and friends - and try to convince them to go for screening. So, the most important for us women is to share the knowledge and to encourage other women so, that their lives can be saved. The word of mouth is very important.
Thank you very much Doctor for your time and for sharing with us your experience and thoughts.