High in the Andes Mountains of Peru, women have perfected the art of multitasking—knitting while keeping a watchful eye over playing children, spoon-feeding infants while selling food, or carrying heavy loads through the fields while herding cows.
But one thing women here have trouble doing is seeking out preventative health care for themselves. When it comes to cervical cancer, this barrier can mean the difference between catching precancerous cells early enough to treat, and developing advanced cancer.
Across Peru, cervical cancer kills more women each year than AIDS, complications of child birth or any other form of cancer. One in every 4,000 Peruvian women dies from the disease each year, more than breast cancer and lung cancer combined.
While that rate dwarfs the United States, where cervical cancer doesn’t rank in the top ten causes of cancer deaths, Peru’s experience is not uncommon in Latin America. Cervical cancer rates in the region are among the highest in the world, second only to Southern Africa in a World Health Organization analysis released in February.
“[The rates] in Latin America are higher because cervical cancer is strictly related to the socioeconomic level, the development level of the country,” said Carlos Santos, a gynecological oncologist who directs the education department at Peru’s national cancer institute, Instituto Nacional De Enfermedades Neoplasicas.
Like other resource-restricted nations, Peru has struggled to make screening consistently available. Most women rarely—if ever– receive pap tests, the most widely used test for identifying the presence of pre-cancerous cells in the cervix.
New action on the issue is desperately needed, says Carmen Mayurí Moró, a gynecologist who works for the Peru health ministry sexual and reproductive health team.
“In the last six years, very little has been done,” Mayuri says. Pap tests are supposed to be available at health centers throughout the country, she says, but equipment and personnel trained to read the tests are not available everywhere.
Simply put, “there are not enough funds,” she says.
Between 1997 and 2001 the country did have a program that provided free screening, and during that period, the percentage of women who were tested went up from 5 percent to 30 percent, Mayuri said. Since the program ended, data has not been reliably collected, but she suspects the rate of women screened has fallen again, well below 30 percent.
While women are encouraged to get pap tests at points when they enter health services, such as for prenatal care, women are often discouraged by the test because it can take weeks to get results back, and some never return to learn the results.
Looking to the future
To address these issues, Peru is planning to reboot its efforts, and move in a new direction, said Santos.
Health experts want to use a pilot project run by the Pan American Health Organization as a model. The TATI project, completed in 2004, tested the use of a technique called visual inspection with acetic acid, or VIA, in a rural, low-resource area of Peru.
After applying acetic acid during a pelvic exam, a midwife or trained worker visually checks for abnormal tissue, which will turn white temporarily when exposed to vinegar.
It’s cheaper and faster than a pap test, said Luciani Silvana, PAHO’s advisor on cancer prevention and control.
“It can be done by a trained nurse or midwife or general physician, it doesn’t require a highly skilled gynecologist,” Silvana said. “In terms of test performance it performs equal to or better than the pap test in detecting precancerous lesions.”
The other advantage, said Santos, is that with the immediate results, a woman could be treated that day with cryotherapy for precancerous lesions.
“Sometimes it is very difficult for women to reach a health post, sometimes they have to travel along the river for many hours,” he said.
“So it’s critical in these lower resource settings and in this geography to establish a pattern of fast management [of the disease].”
The pilot project achieved a 35 percent coverage rate for screening, far below its goal of 80 percent, but an improvement from the status quo nonetheless. Some of the problems involving Peru’s testing coverage also can’t be changed by access and ease of testing alone.
Slowly changing attitudes
Giovanna Morote Huaytalia, an obstetrician in the small rural town of Vilcashuaman in the Ayacucho region of Peru, explained that traditionally men resisted their wives getting gynecological exams.
“They joke ‘we don’t even look between their legs, why should you?'” she said, and the resistance is even greater if the doctor is male.
That attitude has been changing slowly in her community, Montes said, because the health center encourages couples to be educated together about the risks of cervical cancer.
Santos said women’s resistance to the physical examination makes other possibilities for remote testing, such as self sampling that is then mailed in to be tested, particularly appealing in Peru. But he hopes that willingness will also increase when swift treatment options are attached to testing, so that women will see the clear benefit of having an exam.
Latin America fights back
There is no date set for Peru’s new program and doctors involved in its research are still trying to build the political will to fund the project, which does not have a price tag attached to it yet.
But there is good evidence from other Latin American countries that have taken on the high cervical cancer mortality rates that improvement is possible.
Chile, which has poured money into making pap testing free and available, with the necessarily technological infrastructure and paired treatment, has seen a 40 percent reduction in mortality since beginning the push in the 1990s, Silvana said.
“[Pap test programs] are working well in Chile and Costa Rica where they have invested a great amount of resources…but in countries that have not been able to make those great investments and reduce mortality there has to be an alternative method.”
She and Santos say for the time being, VIA is a good option but they are both anxiously awaiting the advent of cheaper human papilloma virus testing technology, which is a closer predictor of precancerous cells.
“It is the most sensitive, and also the negative predictive value is so high that it is possible if a women has a negative HPV test it is possible not to repeat the test in the next five to ten years, so it’s cost effective,” Santos said.
“So we are trying to prepare now to pave the way in order to implement those screening methodologies, to be ready for the future.”