Cervical cancer or Cervicitis?

In Bangladesh, the Government, NGOs and other health clinics undertake numerous activities to deal with various health care issues. It is essential that we carry out thorough research and cost-benefit analysis to ensure that the money spent is used in programme which ought to be high in the priority list. In a resource strained country such as ours it is imperative that this is so done to ensure that valuable financial and other resources are not wasted. In the process of doing due diligence for a project or a programme opportunity cost must have to be taken into consideration.

I was part of a team which arranged the Socio-Scientific Conference on Cancer in March 2008 under the guidance of legendary cancer specialist Late Prof. ABMF Karim.  Nobel Laureate Prof Muhammad Yunus was the chief guest of the conference. As a follow up activity of the conference, the organisers of the programme decided to take on two initiatives:

a)  Conduct a Pilot Human Papilloma Virus (HPV) Vaccination Programme.
b)  Arrange Continuing Education Programme for the young Oncologists of Bangladesh by sending them to renowned cancer centres such as Massachusetts General Hospital (MGH), New York University Hospital, TATA Memorial Hospital, and few other hospitals from Europe, Australia and USA.

Few months before the cancer conference, Dr. James Cusack of MGH asked me if we can conduct a Pilot HPV vaccination programme in Bangladesh. My response was if we can get the funds we might be able to do it. Fortunately Grameen Phone came forward to fund the initiative and in December 2008, 50 young girls from a slum received HPV vaccine. It took almost a year for Late Prof ABMF Karim and his team to complete all the necessary regulatory formalities for conducting the Pilot HPV Vaccination Programme. Through this programme, Bangladesh probably became the first developing country in the world to conduct a HPV vaccination programme.  However, we also realised that a massive HPV vaccination cannot be conducted without the funding from the donor agencies.  I, along with Bimalangshu Dey (Oncologist from MGH) and Judy Foster (Nurse Practitioner from MGH) went to Prof Muhammad Yunus hoping he would agree to approach the International Donor Agencies to conduct a massive HPV vaccination program in Bangladesh. Considering the cost of the vaccine ($250 to $300 at the time) Prof Muhammad Yunus asked us whether we are sure that cervical cancer is widespread in Bangladesh as claimed by many. We told him there is no scientific data available to conclusively say that cervical cancer is widespread in Bangladesh but it is the leading cause of death among poor women affected by cancer. Next, with the help of Dr. Mizanur Rahman Shelley of Centre for Development Research, Bangladesh (CDRB) we went to see Sir Fazle Hassan Abed of BRAC. After listening to us, Sir Fazle Hassan Abed said at $250 per HPV vaccine, cost is very expensive, he would rather consider early diagnosis and treatment of the disease because BRAC has 8 million Micro Finance borrowers (mostly women), hundreds of health workers and around 50 health clinics. It was agreed in that meeting that Bimalangshu Dey and his colleagues from MGH would send him a protocol on how to screen and treat cervical cancer through a low cost technique. Dr. Maswoodur Rahman Prince of CDRB took Bimalangshu Dey and all his colleagues from MGH on a day long field trip to visit BRAC's Microfinance Program and its Health Clinic. Everyone was expecting a quick response from the US team to implement a cervical cancer screening and treatment project initially with BRAC and later on with all the major NGOs.

It was probably in December 2008, at least six months after the meeting with Sir Fazle Hassan Abed, I contacted Bimalangshu Dey and reminded him that he was supposed to inform Sir Fazle Hassan Abed on how to screen and treat cervical cancer using a low cost technique. In response Bimalangshu Dey said he would have to contact his Gynecology-Oncology colleague Dr A K Goodman as this was not his subject. I requested him to talk with his colleague at the earliest.

In March 2009 we formed A K Khan Healthcare Trust. The vision of the Trust was to build a Hospital and Nursing College in Chitttagong. Around this time I also got an opportunity to travel with Prof Muhammad Yunus to Washington to attend World Health Congress. At this conference I saw a very interesting presentation by a company called Click Diagnostic. This company was using mobile phone to send images from a remote place in Africa to a Doctor in a Hospital thousands of miles away. One of the images was a picture of a Cervix. I arranged a meeting between Click Diagnostic and Bimalangshu Dey in Boston hoping this might give him some clue on how to screen and treat cervical cancer using a low cost technique. We saw a nice presentation from Dr A K Goodman on cervical cancer but nothing on how to screen and treat the disease through a low cost technique in a poor country like Bangladesh.

During the trip to USA in honour of Prof. Muhammad Yunus, Harvard School of Public Health arranged a dinner meeting, I was very fortunate that I was able to attend the event. In my table sitting next me was a famous Professor from Harvard School of Public Health, Dr. Richard Cash. When I informed him about our work in Bangladesh he immediately told me _"you are wasting your time. Bangladesh has low prevalence of HIV, therefore you will not see high percentage of cervical cancer cases because it is caused by a HIV like virus HPV". Prof Richard Cash has been visiting Bangladesh since 1960s, he is also a faculty of BRAC School of Public Health and is keenly familiar with the challenges of our healthcare system. After my discussion with Dr Richard Cash I was torn between honouring a commitment versus wasting time and precious resources. Within a few days of the Program at Harvard all of us (Prof. Muhammad Yunus and his team) returned to Bangladesh and my regular activities in Bangladesh resumed.

I was against the idea of involving A K Khan Healthcare Trust in cervical cancer related outreach work because in my opinion it would have drained resources and diverted focus from the core projects of the Trust which were establishing hospital and nursing college in Chittagong.  Moreover, a newly established Trust comprising only of a few people was simply not ready to launch multiple side projects at the same time.  Outreach Programs related to cancer should be undertaken by cancer hospitals and in our case if our hospital was ready we could have utilized the resources of the hospital for operating multiple outreach programs.  Personally though, I was also mindful of the fact that we have to respond to Sir Fazle Hassan Abed.  Since I was not getting any help from Bimalangshu Dey or his colleagues from MGH on how to setup a low cost clinic for screening and treating cervical cancer and I was under constant pressure from the US side and the Trustees of the Trust to launch the outreach clinic, I approached Prof Sultana Razia Begum, the Chairman of Obstetrics and Gynecology Department of Bangabandhu Sheikh Mujib Medical University (BSMMU) for assistance.  She shared with me how United Nationals Population Fund (UNFPA) was running a nationwide cervical cancer screening program in Bangladesh using a technique known as VIA or Visual Inspection Using Acetic Acid.  Prof. Sultana Razia Begum agreed to help us should we decide to go ahead with the program.  She also gave me a list of equipment which are used to screen and treat cervical cancer at the Bangabandhu Sheikh Mujib Medical University.  Her contribution was crucial for designing and implementing our Outreach Clinic but due to health reasons she wanted her involvement to be limited to six months.  By this time Trust had decided (against my recommendation) to go ahead with the Outreach Program.  Once the decision was made to launch an Outreach Program I gave my full support to execute the project.

In 2009 the movie Slum Dog Millionaire became quite famous all over the world; it had an impact on me as well. Taking cue from the movie, I chose Korail slum, the largest slum in Bangladesh with around 200,000 inhabitants, to setup a clinic.  I approached my biomedical engineering friends in the USA to help us select equipment for the clinic. I sent the final list of equipment to Dr A K Goodman of MGH and she approved the list. We decided to purchase a Welch Allyn Video Colposcope and Valley Lab Force-2 Electrical Surgical Unit from USA. I did some customization of the equipment so that the images from the Colposcope could be accessed from a remote location if needed. A local Oncologist helped Prof. Sultana Razia Begum prepare a protocol for the work at the clinic.  Eventually the clinical work at the clinic started from 2010 under the supervision of Prof. Sultana Razia Begum. The basic difference between our program and UNFPA's programme was that UNFPA is screening women for cervical cancer whereas we wanted to offer a one-stop service for both screening and treating the disease. During her next visit to Bangladesh, Dr. A K Goodman trained a few young gynaecologists who were involved with the program on how to screen (using VIA) and treat CIN/CIS states of cervical cancer (using Loop Electrosurgical Excision Procedure).  She screened around 30 women in two days and identified 6 patients to be in the CIN state of cervical cancer.  She recommended invasive procedure Loop Electrosurgical Excision Procedure (LEEP) for all of them.  However, biopsy reports of these 6 cases from Delta Cancer Hospital performed by distinguished Pathologist Prof Syed Mukarram Ali, stated that these 6 patients had chronic cervicitis. To date I do not know whether Dr A K Goodman's diagnosis was accurate. My request to investigate the matter was rebuffed by Bimalangshu Dey claiming "this is a highly technical matter, non-technical people should not interfere with clinical work". I found this statement perplexing as the statement was coming from a doctor who is practicing in USA where the highest ethical standards were supposed to be maintained.  I have no doubt Dr A K Goodman is an excellent clinician and her contribution towards Bangladesh is remarkable. If her diagnosis had any error it was most probably due to the fact that she is more familiar with the pathological screening procedure (Pap Smear) which is used in USA rather than VIA to screen for Cervical Cancer. Pap Smear takes fluid sample for giving report whereas VIA is done through naked eye. Unless a doctor is using VIA all the time it might be difficult for him/her to be accurate through this technique. The bottom-line is proper transparency and accountability must be in place for all clinicians regardless of where they are coming from and who are their target patient. Internet has enabled people to ask the right questions, information is available and accessible to everyone; therefore it is no longer possible to hide behind technical jargons.

In order to improve the quality of work and activity of the clinic at the slum, in 2011 we recruited three full time relatively young doctors. Under the supervision of Prof T A Chowdhury, a renowned Gynaecologist of Bangladesh, these doctors rewrote the protocol on how to screen and treat cervical cancer and cervicitis. Compared to screening around 25 to 30 patients per week in the previous months, clinic was now screening around 80 to 90 patients per week. At Taka 500,000 per month operational expense for the Outreach Clinic, at patient flow rate of 30 patients per week, screening cost for each patient stands at around Taka 4,000 per person and at patient flow rate of 80 patients per week screening cost stands at around Taka 1,500 per person. Through process reengineering output of the clinic drastically improved. During the next 12 months the new team screened around 3000 women from Korail slum and only 3 of them were clinically confirmed to have cervical cancer, but quite many had cervicitis and they were treated by giving antibiotics. In case of chronic cervicitis, if antibiotic did not work, patients were sent for CryoTherapy.

If only 0.1% or let us for the arguments sake assume 1% of the women are either in the CIN/CIS state or cancerous state of Cervical Cancer, isn't it more appropriate to give emphasis on preventing and curing cervicitis rather than cervical cancer? Through health awareness and promoting better hygiene practices health problems such as cervical cancer and cervicitis can be prevented. A question might arise why people are seeing relatively high number of cervical cancer cases at the cancer hospitals of Bangladesh? It might be because doctors are referring those patients to the cancer hospitals who already have been diagnosed with cervical cancer. Compared to the total population of the country the percentage of cervical cancer cases seems to be quite small.  My current organization Good HEAL Trust has established a clinic at Korail slum where we are trying to provide comprehensive healthcare service to the underprivileged people.  Once a week we screen women for cervical cancer and other common cancer.  Between March 2013 and November 2013 we have not yet found any cervical cancer patient. Good HEAL Trust is also running targeted health awareness campaign at the slum because prevention is much better and cost effective approach than treating a disease. One of the health awareness programs targets adolescent girls to teach them how to prevent cervical cancer and cervicitis.
In conclusion I would say in a resource strained country we have to be careful how we are utilizing our funds. We cannot afford to be whimsical. We should not start a program which we cannot sustain in the long run. Even though we might have perfected a model on how to effectively and ethically screen and treat cervical cancer and cervicitis through a one-stop low cost approach, if we do the cost benefit analysis it would have been better if the project was undertaken by a cancer hospital. The Marginal Cost to run health camps or Outreach Programs for an existing Hospital would have been significantly lower compared to the program we ran with a monthly Operational Expense of around Taka 500,000. I remember attending a meeting with Prof ASM Ruhal Huq along with Bimalangshu Dey and his colleagues from MGH and few others from A K Khan Healthcare Trust.  In the meeting when Bimalangshu Dey informed Prof Huq that MGH is cooperating with A K Khan Healthcare Trust at Korail slum for cervical cancer screening and treatment, Prof Huq pointedly told Bimalangshu Dey that cervical cancer is not in the health priority list of Bangladesh. The work at the slum is insignificant. A small clinic at a slum might help publish a research paper but it will not have any real impact in the country. He further added if Bimalangshu Dey is really interested to have an impact he should provide resources to equip government clinics all over the country and train its personnel to screen and treat cervical cancer.  I could not agree more.  As UNFPA is already active with the program, the best approach for screening and treating cervical cancer would be to take UNFPA's help and complement its program rather than establishing a parallel program.  The data collected from a large and well-coordinated program which the NGOs should also participate will shed light on how to prevent or treat both cervical cancer and cervicitis.

Recommendations:

It is a well-documented fact that in India HIV virus has spread primarily through the truck drivers.  If we want to make sure that Bangladesh continues to maintain low percentage of HIV cases, we have to give a booklet to every migrant worker on Sexually Transmitted Diseases when they come for health checkup before leaving Bangladesh, we have to curb on floating prostitution particularly in the areas frequented by foreigners, and if Bangladesh decides to give transit facility to India we must not allow the Indian truck drivers to drive through Bangladesh.

Cervical Cancer takes a long time to progress and Bangladesh most probably has low prevalence of the disease. Therefore, in a low-cost approach, if a girl or a woman comes to a health center with common symptoms, after completing VIA she can be given antibiotic assuming she might have Cervicitis.  The cost of VIA is only couple of hundred Taka and cost of antibiotic is also not expensive.  After completing antibiotic if the patient is not fully cured, Pap-Smear test should be performed.  Usually Pap Smear cost is around Taka 1,500.  If the Pap Smear test comes out positive patient is either in the Pre-Cancerous State of Cervical Cancer or in the Cancerous State of Cervical Cancer.  If the clinician is not sure of the status of the disease biopsy needs to be performed on the patient.  If the clinician is sure the patient is in the CIN/CIS state of Cervical Cancer, the affected cells should be removed through invasive procedure LEEP.  If Pap-Smear test comes out negative the patient should receive Cryo-Therapy for curing Cervicitis.  If the number of women affected with cervical cancer is small, patients requiring LEEP will be small as well.  Bangladesh has only a handful of trained Gynecology-Oncology clinicians who are comfortable with the clinical procedure LEEP.  Most of these clinicians are working in Dhaka.  Therefore following the Hub (Referral Hospitals) and Spoke (Screening Centers) model patients today can receive necessary treatment for Cervicitis, CIN/CIS states of Cervical Cancer and Cancerous State of Cervical Cancer at an affordable cost.

As I had said earlier our clinicians are well trained in VIA, Pap-Smear and Cryo-Therapy but only a handful of them have the training on how to perform LEEP.  In the long run the number of clinicians capable of performing LEEP has to be increased.  Bangladesh College of Physicians and Surgeons (BCPS), has a training center for the practicing doctors in Mohakhali, Dhaka.  This training center can be used to train the clinicians on how to perform LEEP.  It might cost only Taka 2,500,000 to equip the center with the necessary equipment (Electrical Surgical Unit, Colposcope, Blue Coated Speculum and Manikin) to setup a lab for the hands on training.  A two-weeks training might be sufficient for a clinician to acquire the skills for performing LEEP.
It would be a mistake if I end this article without mentioning the names of Late Prof. Muhammad Ibrahim, Late Prof. ABMF Karim and Prof. Brig (retd) Abdul Malik.  These three remarkable individuals established Diabetic Association of Bangladesh, National Institute of Cancer Research Hospital and National Heart Foundation which are not only providing health care to the millions but also producing trained clinicians for other hospitals.  If we want to get into Public Service and wish to follow their footsteps, we should have a clear conscience and be transparent.  We have to control the temptation to use the contacts and access gained through people's goodwill and trust for personal profiteering.

Reference: Holowaty P, Miller AB, Rohan T, et al. Natural history of dysplasia of the uterine cervix. J Natl Cancer Inst. 1999;91(3):252-8.

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Tanvir Raquib is the Executive Director of Good HEAL Trust.