Cancer of any kind is a concern for all of us. In a developing country like Fiji, we rely heavily on available resources from government, public and private sectors, non-government organisations and our neighboring countries.

Cancer places a heavy burden on the person who has it and the people involved in its care, management and follow up plan.

Cervical cancer is the second common cancer in Fiji; breast cancer is the leading cause of cancer for women in Fiji in the last 10 years.

Key stats from HPV Information Center 2019 states that about 124 new cervical cancer cases are diagnosed annually in Fiji (estimates for 2018).

Cervical cancer is the second most common female cancer in women aged 15 to 44 years in Fiji. So, what can we do in the fight against cervical cancer?

In Fiji, one of the strategies to reducing morbidity and mortality from cervical cancer is to perform pap smear screening on a regular basis.

Unfortunately, pap smear in Fiji is performed on an opportunistic basis only. Fiji has not been able to perform regular Pap smear screening program like most developing countries due to various reasons.

 

Papanicolau (Pap) Smear Test

In 1940s, Conventional Pap smear test was the standard method for screening for cervical cancer.

Retrospective data have shown that screening with a Pap test reduces the incidence of cervical cancer by 60-90 per cent and the death rate by 90 per cent.

Then in 1996, ThinPrep Pap test was introduced which further increased screening success.

The ThinPrep Papanicolau test was approved in 1996 by the US Food and Drug Administration (FDA) as an alternative to the traditional conventional smear.

Test samples for the ThinPrep Pap test are collected the same way as those for the conventional Pap test. However, the specimen is placed in a preservative solution rather than on a slide.

The ThinPrep, liquid-based cervical cytology was developed to improve sensitivity by providing a monolayer of cells to the cytologist for review. Henceforth improving diagnostic reliability of Papanicolau (Pap) smears.

Conventional Pap smears can have false-negative and false-positive results because of inadequate sampling and slide preparation, and errors in laboratory detection and interpretation.

However, liquid-based cytology rinses cervical cells in preservatives so that blood and other potentially obscuring material can be separated.

It also allows for additional testing of the sample, such as for human papillomavirus (HPV).

The comparative accuracy of each technique has been studied extensively and has yielded conflicting results; recent systematic reviews reported that there is no convincing evidence to recommend one technique over the other.

So when performed correctly, conventional Pap smears and liquid-based cytology is equivalent for detecting cervical abnormalities.

Liquid-based cytology often results in fewer unsatisfactory specimens and allows for HPV testing on the same sample.

Choice of screening test also depends on the cytology laboratory in which the samples are processed; although liquid-based cytology is more expensive, its ease of use allows laboratories to process slides more quickly and efficiently.

For these reasons, liquid-based cytology has virtually replaced conventional Pap smears in the US.

ThinPrep’s high sensitivity and viral typing may be advantageous in some cases. In settings where annual follow-up is unreliable or impractical, the ThinPrep’s high sensitivity will definitely be advantageous.

ThinPrep Pap test result if normal results in recommendation for repeat screening in five years.

Today, accurate Pap testing is even more critical in light of extended Pap testing intervals.

A negative HPV test can keep patients from follow-up appointments for years, while a false negative HPV result can give cervical disease a chance to advance undetected.

Because of better specimen adequacy, ThinPrep cervical cytology appears to significantly reduce the occurrence of ASC/AGC compared with conventional Pap smears.

The public and private health facilities in Fiji are using ThinPrep Pap test for cervical cancer screening. No longer are we using conventional Pap test in view of reasons mentioned above. Currently the ThinPrep Pap test with HPV screening is locally available at private practice only.

This test is sent to Oceania Hospitals PTE Ltd laboratory which facilitates it to be sent to Laverty Pathology Laboratory in Sydney, Australia. Results are received within six weeks. Any woman with abnormal Pap smear result is referred for gynecologist consult.

Oceania Hospitals PTE LTD laboratory has been receiving on an average 60 ThinPrep Pap tests specimens, out of which an average of 20-30 per cent are positive for HPV infections.

 

Policy on Screening

for Cervical Cancer

1. All women who have been sexually active need to be covered by Pap smear screening;
2. The first screening should take place within two years of the first sexual intercourse, and the second about one year later;
3. Thereafter, repeat Pap smears should be carried out every three years for women with no symptoms or clinical appearance suggestive of cervical pathology;
4. Pap smears may cease at the age of 70 for women who have had two normal Pap smears within the past five years;
5. Pap smears may cease for any woman who undergoes total hysterectomy for any reason other than cervical pathology, provided that the cervix was histologically normal;
6. Any woman who had hysterectomy, but the indication and/or histology cannot be ascertained, should have two Pap smears from vaginal vault at an interval of one year, and if both are negative may cease;
7. Pap smears should be taken “opportunistically” in women who have not definitely had normal smear within the past two years; e.g. in Antenatal Clinics, Family Planning Clinics, on admission to medical or surgical wards;
8. Taking a Pap smear is a mandatory part of any gynecological examination in any woman not definitely screened within the past three years; and
9. None of the above rules out taking a Pap smear at any time when the doctor or patient considers it desirable on clinical grounds or to provide reassurance.

Note: For number three above; it is for conventional pap smear test every three years without HPV screening: ThinPrep pap smear tests every five years with HPV screening if low risk.

 

Conclusion

In Fiji, it can be counted as a blessing that we are able to screen for cervical cancer in our island nation.

So, using ThinPrep Pap smear test is up to the individual’s choice, availability and financial capacity as well as the providing facility’s infrastructure.

Families, friends, employment sectors and our society as a whole should support our women:

q Firstly, increasing awareness on cervical cancer screening;

q Secondly, to provide emotional, physical and financial support when going for Pap smear test, getting the result whether it is negative or positive for HPV; and

q Thirdly, to give support encouragement to go to gynae specialist for relevant treatment and follow-ups accordingly.

Let’s join efforts in reducing deaths from cervical cancer through ThinPrep Pap smear screening and go for female health checks at your nearest health facility.

This will support Fiji’s achievement of one its Millennium Development Goals of universal access to sexual and reproductive health services to improve women’s health.

 

 

n Dr Mabel Fong is a general practitioner at Oceania Hospitals. The views expressed are the author’s and does not necessarily reflect the views of this newspaper.