Cancer of the cervix – The view from Australia’s nearest neighbour

In November 2019, the authors were co-examiners for the University of Papua-New Guinea post-graduate exams in obstetrics and gynaecology in Port Moresby General Hospital (PMGH). One of the patients presented to candidates was Julie,* who had been referred to PMGH from Mendi Provincial Hospital in the Southern Highlands of Papua-New Guinea (PNG) with a diagnosis of Stage 1B2 cancer of the cervix. Julie was uncertain of her age but nursing staff put her in her early 30s. She had given birth to six children including one set of twins, one son who had been stillborn and one who had died in infancy from meningitis. She had never used contraception; her youngest child was about four years old. Julie, who was the third wife of a man who had a menial job in Mendi town, had no formal education. Julie presented to her local health centre with several months of vaginal bleeding and discharge; she had examination under anaesthetic and biopsy of a cervical lesion performed in the Mendi hospital in July 2019. The histology report did not reach the gynaecologist in Mendi until October 2019; he then had to locate Julie, and she had to find the money for the airfare to Moresby (about $500). She had no family travelling with her or in Moresby. She had not flown in an aeroplane before. By the time Julie was examined in PMGH her cancer had progressed to Stage 2B. Although she had initially been referred to PMGH for consideration for radical surgery, this was no longer possible. Nor was radiotherapy an option. There has been no radiotherapy at all available in PNG since the end of 2016. For cervical cancer treatment, there has been virtually no brachytherapy available since the early 1990s, for various logistical reasons. PNG has one of the highest incidences of cervical cancer in the world: about 30/100 000 women of reproductive age per annum – this translates to about 1000 new diagnoses of invasive cancer per year, and an estimated similar number of deaths annually.1 Yet in PNG there is no nation-wide screening program and no human papillomavirus (HPV) vaccination program. A 2018 PNG study of the use of vaginal inspection of the cervix using acetic acid (VIA), a low-cost strategy endorsed by the World Health Organization and used in several other low-resource settings, found an association with HPV 16 infection but not with other serotypes.2 Recent operational research by the Kirby Institute and the PNG Institute of Medical Research using battery-operated point-of-care gen-eXpert machines (which can provide results for HPV tests in less than an hour), provides hope for a viable screening program that could then offer immediate treatment with thermocoagulation to those women who test positive. Local research shows that this would be the most cost-effective way of screening (and treating positives) for cervical pre-cancer in PNG; however, the HPV test cassettes are expensive (US $10 each).3-5 To roll out a national screening program would require significant investment by the PNG government. Educational opportunities for girls and women in PNG are very limited. The Ministerial Task Force reporting to the government on improving maternal and newborn health in 2010 identified improving female education as being a key factor in improving maternal and newborn health. There has been little if any improvement in the provision of education for women and girls since 2010, and in some cases things have gone backwards. Indeed, because of the parlous state of PNG finances, found when the new government of James Marabe took over from Peter O’Neil in mid-2019, it has been announced that free primary education has been ceased. In PNG health workers are faced with cases like Julie’s every day, and long waits for histology results are the norm. At PMGH a woman is diagnosed or admitted with invasive cervical cancer almost every day, and only five percent of these women are deemed suitable for radical hysterectomy (ie stage 2A or less). Unfortunately, of the 20–25 Wertheim’s hysterectomies done every year, only about 50% survive five years. The low cure rate has a number of causes – but the bottom line is that these few radical surgeries, which take up a large amount of theatre time and other resources, have very little impact on the overall national case load of invasive cervical cancer; PNG needs radiotherapy. Providing radiotherapy in low- and middle-income countries (LMICs) is not simple. A cobalt unit (with brachytherapy using manual placement of caesium ovoids) was set up at Angau Hospital in Lae in 1972 by the Australian colonial administration. It provided good service and saved thousands of cancer patients’ lives between 1973 and 1991. Dr John Niblett was the first radiotherapist; he left to take up a position in Perth radiotherapy in 1987. From 1987 to 1991 the radiotherapy unit was run by Drs Craig Martin and Sareth Abeyakoon. As the cobalt source’s power ebbed away the number of patients who could be treated diminished until the unit was closed down in 1991. Between 1992 and 2001 there were huge efforts by doctors working in PNG to get the Lae radiotherapy unit functional again. The Health Minister between 2002 and 2007, Sir Peter Barter, was instrumental in getting a new cobalt source with the assistance of Canada; the Australian government flew it by military aircraft to Lae in 2005. However, a fully functional radiotherapy unit was not reinstituted, and between 2006 and 2016 when the radiotherapy unit closed again it was not possible to provide effective radiotherapy for cancer of the cervix. Although cervical cancer is the commonest women’s cancer in PNG, fewer than ten patients received brachytherapy between 2005 and 2016; understandably the overall treatment results (external beam only given to the majority of patients) were poor. Australia is right next door to PNG: the distance from Saibai and Boigu islands off the tip of Cape York to the PNG mainland is just 5 km. Twenty minutes in a tinnie. The world age-standardised incidence rate for cervical cancer in Australia and New Zealand (2018) is 6.0 cases per 100 000 women.1 The five-year survival rate from cervical cancer in Australia is 74%.6 Australia, New Zealand and other high-income countries are likely to see even further declines in the incidence and mortality of cervical cancer as they have effective primary prevention in the form of HPV vaccination, secondary prevention with HPV-based screening, and excellent accessible public services for the treatment of established cancer.7 Since 2016 PNG governments have made many promises about setting up cancer treatment centres, but so far none have eventuated. Meanwhile, PNG citizens who can afford it do travel overseas, but this represents a tiny minority of the case load. It was certainly not an option for Julie, and anyway overseas treatment should not ever be considered the national solution. For radiotherapy to be set up, PNG needs to finalise the legal framework with the International Atomic Energy Commission (IAEC) in Vienna, build the cancer treatment centres, employ overseas radiotherapists, and start training local radiotherapists and other support staff for the cancer centres. All the above requires a large amount of money, but also a health and political system that is coordinated and focused on the health needs of the country. Assistance from overseas is clearly needed, but the ethical, intelligent and practical leadership needs to come from PNG.

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