Experience of South Africa

Courtesy of FIGO

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Dr. Lynette Denny: “Mr. Chairman, ladies and gentlemen, good-morning.  I’m going to be presenting to you some of the South African experience of managing gynecological cancer.  I was only asked to do this talk about ten days ago as I’m replacing someone who couldn’t make it but let’s hope that it will be informative.  

Cervical cancer is a relatively rare disease in the developed world with age standardized incidence rates of like 4-12 per 100,000 women reported compared to 50-67 per 100,000 in those countries with cancer registries, this is a huge difference.  In South Africa, it’s an extremely unequal country particularly due to the legacies of colonialism and apartheid which means that most white South Africans have a quality of life equivalent to those who live in the developed world compared to most black South Africans who are extremely poor, and this difference is reflected in the different incidences of cervical cancer.  For instance, white women in South Africa have an age-standardized incidence rate of 12 per 100,000 with a lifetime risk of 1 in 83 of developing the disease, and it’s estimated that over 90% of white South African women have been screened.  By contrast, the age-standardized incidence rate among black women is around 35-39 per 100,000 and it’s probably much higher with a lifetime risk of developing this disease of 1 in 26, and it was recently estimated in a nationwide survey that less than 10% of black South African women have been screened.  

This graph shows you the age specific cervical cancer rates and, as you can see, for all ethnic groups in South Africa the rate is relatively low until about age 30 when there’s a rapid rise in incidence peaking in the 64-65 age group amongst black and so-called colored people who are people of mixed descent.  The line for white women remains fairly static throughout the age groups.  Now just to give you some example of what we go through in South Africa, I took some data from our computerized database from the Groot Schur Hospital Cape Town Experience between 1991-1995.  We saw 725 women with cervical cancer during this time with the mean age of 51 years and the majority of the cases as to be expected were squamous.  In addition, and very typical and very similar to Mike’s data, the vast majority of women were in the stage III-B, overall, over 70% of women presented with disease that had extended beyond the cervix.  In addition, not only did these women present late but they also presented with large tumors, with the vast majority of stage II and stage III tumors being more than 4 cm in diameter.  

Looking at the proportion of women in the different ethnic groups presenting, we see that white women tend to predominate in the early stage disease and black women, the poorer women, predominate in late stage disease.  We’ve selected out a group of 99 women with FIGO stage III-B tumors on whom we have five years of follow-up and who had complete radiotherapy, and what we’re trying to do with these women is to try to predict which III-B’s are worth attempting to treat with curative intent or whom we should palliate.  Of these 99 women, 75% had a tumor diameter of greater than 5 cm, 50% had bilateral extension to the pelvic sidewall, 73% had involvement of the vagina, and just under a quarter had hydronephrosis at the time of presentation.  Of these women with a minimum of 5 years follow-up, only 42% are alive with no disease, and 45% have died despite receiving radical radiation.  This shows the overall survival rates of the different stages of cervical cancer, and what we see is that for stage I-B like in other developing countries, the overall survival is around 70%, for II-B it’s about 56% at five years, and for III-B it’s a really low 25% that’s equivalent to women with ovarian cancer.  However, if we separate out those women who in fact completed their radical radiotherapy from all patients including defaulters represented by the green line, our five year survival rate for stage III-B increases to 38% which is a little bit better than 25.  Now our radiation oncologist describes the cobalt unit as the workhorse of radiotherapy units in developing countries.  These have largely been replaced by linear accelerators in the developed world.  Cobalt units are easier to maintain, they’re cheaper and in fact they’re less prone to breakdowns.  

At Groot Schur Hospital, we have three cobalt units and one linear accelerator.  It has been claimed that cobalt gives inferior results in the treatment of cervical cancer but from 1991-1995 we had 112 women who were treated with cobalt and we had 162 women treated with a linear accelerator.  This graph shows us that their five-year survival rates are in fact identical.  Although not demonstrated here, the crude complication rate of RTOG grade III and IV lacks morbidity is also similar between the two types of treatment.  In Cape Town on South Africa, amongst poor black women, obesity is extremely common.  It in fact represents a form of malnutrition due to diets very high in fat and carbohydrate; hence, a LINAC unit with its superiority penetrative abilities remains an essential component of a radiotherapy department in a developing country such as ours.  The availability of cobalt units facilitates the curative therapy of women of normal build and also the large number of women for whom we can only palliate, which shortens the waiting lists for the LINAC unit.  

There are a number of major issues around cervical cancer in developing countries.  The current policy in South Africa, which has been accepted by the government, is to provide three free smears in a lifetime at approximately ten-year intervals to women over the age of thirty years.  However, as is so commonly the case, the gap between policy and implementation remains huge and to date there’s been very little implementation of this policy.  In fact, the question arises whether it will ever be feasible to implement mass screening using cytology as a screening tool, and as some of you may have heard, we are currently investigating alternatives to cytology to see if this can make some kind of a difference.  Cervical cancer presents a major burden to radiotherapy departments in developing countries simply due to the large numbers of women requiring treatment.  There are many complex reasons for the late stage of presentation of women with cervical cancer which range from lack of knowledge and understanding among women to cultural barriers to poor access to healthcare services, and most disturbing of all, the poor quality care provided by many health services.  

The paucity of resources has resulted in some radiotherapy departments rationalizing whom to treat with curative intent.  For instance, in Durban women with large III-B tumors are given one pallet of fraction only and absolutely no attempt to treat these patients radically.  In addition, despite the evidence from five randomized trials are the efficacy of concomitant radiation, chemoradiation, and the treatment of cervical cancer, logistics and limited budgets have prevented us from fully adopting this therapeutic approach.  A major concern for us in the management of cervical cancer is the very high default rate from treatment.  For many of our black patients the shear logistics of daily visits to the hospital are often impossible to negotiate.  In addition, there is great suspicion about radiotherapy and a common view is that radiotherapy is a form of burning or as explained by one woman, like a felt fire after the grass has been burned, the green shoots like the cancer will re-grow immediately.  There’s also a common perception that it is the treatment not the disease that is killing these women.  

Finally, resources for palliative care are either extremely limited or non-existent in many poor countries such that even essential drugs such as morphine may not be available leaving large numbers of women to die undignified and painful deaths.  Just moving to vulval cancer briefly, we have a series of 46 women with stage III and IV advanced vulval cancer.  The mean age was 54 years with a mean tumor size of 8.4 but with a range of up to 20 cm in diameter.  We treat these patients up front with concomitant chemoradiation in an attempt to avoid mutilating surgery, and this is followed where possible by surgical resection of residual tumor after the chemoradiation.  Of these 46 women in this series, 20 have already died of disease, that’s 43%.  But if you look at it by responders, of those women who responded completely to chemoradiation and did not require further surgery, 61% have survived compared to those who partially responded to chemotherapy but were able to have post-chemoradiation surgery, 9% survived but those partial responders who could not have complete excision of the remaining lesion, none survived.  These results for the treatment of cervical cancer are far worse than reported in the developed world and most likely due to the advanced nature of the disease and presentation.  

I’m not going to talk much about ovarian cancer, we see about fifty cases per year, and we have a chemotherapy budget of just over $17,000.  What is interesting is that if we were to use Taxol as a treatment method for our patients our entire budget would be used to treat two women per year as opposed to the fifty that we treat per year with carboplatin and cyclophosphamide.  This in fact has raised an ethical dilemma for us knowing that we are giving probably an inferior treatment and the question is do we tell our patients that we’re doing this?  In fact, we took this to our Bioethics Committee, and if anyone’s interested, we can debate that in question time.  In addition, we treat about 6-8 cases of advanced choriocarcinoma per year, we use the WHO scoring system.  Most of our patients are treated with EMACO and it makes a fairly major dent into our chemotherapy budget.  We had two very interesting cases recently where both women presented with multiple metastases including brain metastases and both women were HIV positive which we discovered about three to four days after we had initiated chemotherapy for their choriocarcinoma.  In fact, both women went into complete remission but we were unable to give them antiretroviral therapy despite having spent tens and thousands of South African rands in curing these women from their cancer.  This poses yet another ethical dilemma.  

So in conclusion ladies and gentlemen, the management of gynecological malignancies in developing countries is significantly affected by factors outside of the health services.  In fact, South Africa for a developing country is probably one of the best resourced, and we’ve done hundreds of thousands of Pap smears in South Africa with no impact on cervical cancer incidence.  Our patients present to us with advanced often incurable disease and our limited human and material resources greatly influence how and who we treat with curative intent.  Women in poor countries tend to be dis-empowered and uninformed and consequently do not demand that resources and the political world be directed towards their specific health problems.  Finally, I believe that it is unlikely that gynecological cancers will receive priority allocation of resources while the competing health needs of maternal mortality, malaria, tuberculosis, and HIV remain so prevalent.  Thank you for your attention.”