An Integrated approach of cervical cancer and Schistosomiasis treatment and care present opportunities towards elimination

By Esther Nakkazi

Initiating an integrated approach for cervical cancer and Female Genital Schistosomiasis (FGS) for affected women and girls presents an opportunity towards the World Health Organization (WHO) elimination target over the next decade.

The WHO targets to eliminate transmission of cervical cancer by 2030 and its policy brief on deworming adolescent girls and women of reproductive age aims to control schistosomiasis in the same time frame. 

Dr Tedros Adhanom Ghebreyesus, Director-General, WHO, has stated that “FGS is a silent and neglected epidemic, affecting the same people who carry a disproportionate global burden of HIV and cervical cancer”.

Now, scientists say there is an increased probability to achieve the WHO target by 2030 if an integrated approach for FGS and cervical cancer into routine sexual and reproductive health care services where affected women and girls most likely seek prevention, treatment and care is implemented.

“We want to support, develop and implement worldwide evidence based initiatives to improve on three spheres; first HPV and cervical cancer prevention. 

Secondly, FGS diagnosis and patient information and thirdly, quality of treatment which has to be tailored to the needs through research and policy initiatives,” says Eyrun Flörecke Kjetland a professor at Oslo University Hospital.

Scientists led by Dr Julie Jacobson, a global health leader who serves as Managing Partner for the global health non-profit Bridges to Development published in January in the Nature Reproductive Health Journal  says the skills necessary for FGS management is a critical step to prepare for proper diagnosis and treatment of women and girls in sub-Saharan Africa by trained health professionals. 

The suggested competencies can now serve as the foundation to create educative tools and curricula to better train health care workers on the prevention, diagnosis, and management of FGS, says the research.

Kjetland says right now there is an enormous thrust in the cervical cancer community to push forward to eliminate it is an opportunity for FGS to piggyback as the little sister in the system on a disease (FGS) that is life threatening with less much less funding, much less push. “It’s an excellent opportunity to try to wedge our way in and join with the big systems program.”

FGS is a chronic disease caused by parasitic worms, schistosomes, transmitted by contact with infested fresh water. An estimated 56 million women may have FGS in Africa, but almost none are diagnosed or treated. 

FGS like cervical cancer can be life threatening and life altering. They are both dangerous conditions for sexual reproductive health in endemic areas. They both cause physical pain and discomfort to women who also have to contend with stigma and isolation.

FGS as a common gynaecological lesion could be confused to be cancer or an STI. “When we looked at the implications of FGS on HPV and HIV, we found an association between the high risk of HPV which causes cancer and the FGS lesions,” says Kjetland.

“To me the most dangerous situation would be that you are misdiagnosing something as cervical cancer when it is genital schistosomiasis, removing parts of the cervix, unnecessarily creating problems for the women, fertility wise and vice versa as well,” says Kjetland.

As the overlap of the incidence of cervical cancer and the prevalence of schistosomiasis presents itself in Africa, coupling the two diseases using an integrated approach through opportunities in screening, early treatment and awareness creation would maximise cost effectiveness from limited resources available, says Teresa Norris a sexual health specialist and HPV expert, the founder and president of HPV global action.

Scientists also have an opportunity through a screening method that can be used for both diseases, the Automated Visual Evaluation (AVE), a deep learning computer application.

A typical country programme would first target HPV and cervical cancer prevention by combining screening simultaneously girls aged nine to 14 and then screening and treatment for women 25 to 45 years, scientists say.

“We would first of all do screening for cervical cancer lesions using AVE while simultaneously screening for FGS lesions using this same tool and then providing treatment,” said Norris.

Secondly, the program can look at the country wide HPV vaccination programs that run through GAVI while simultaneously providing Praziquantel through GAVI to supplement the mass Drug Administration programs. Many GAVI countries also have an objective of eliminating Schistosomiasis transmission.

The scientists say they need to consider the country’s specific resources, needs and attitudes to ensure this will work.“This will give us an opportunity to be mapping for FGS and cervical cancer via a pilot project proof of concept studies in Africa in several places,” says Norris. “These initiatives in individual countries will be able to assess the accessibility and feasibility and then we can move towards scaling it up for population control in many African countries.”

Both diseases also require early treatment for better outcomes. “The diagnosis and management strategies for the two need to be hand in hand. For the young girls we know that this can be prevented if you treat it early, so they don’t have to walk into their first sexual intercourses with damaged genitals,” says Kjetland.

Cervical cancer and FGS also need more awareness creation among populations, academics and professionals. But more work is required for FGS which is hardly known. “Currently, no women are diagnosed with FGS or informed that they have this disease and FGS is not mentioned in any prevention programs,” says Kjetland.

“To many of us, learning about the prominence of FGS is new for us and then also further to that is adding that opportunity to have a deworming strategy in a lot of our projects is something that’s new in our in our community,” says Norris.

Sierra Leone has managed to make remarkable progress to control Schistosomiasis. “And the most important lesson I think we’ve learned over the last 10 years certainly is the power of integration,”says Mary Hodges, Adjunct professor, Njala University, Sierra Leone.

“Transitioning from mass campaigns for preschoolers into an integrated service delivery that included family planning for their caregivers, was a real success. And going forward, I would recommend that further integration channels for adolescents, women of reproductive age, should take a careful look at the opportunities to ride on,” says Hodges.