Cervical cancer is among the top five causes of death among women between the ages of 45 and 59 in the developing world. For South African women, cervical cancer is the most common type of cancer, accounting for about a quarter of all cancer-related deaths.

The Philani Cervical Cancer Prevention Project in South Africa is now working to meet a need that has never before been addressed effectively - screening to prevent cervical cancer.

The Philani project is located in Site C of Khayelitsha, a settlement outside Cape Town. Unemployment in Khayelitsha is about 60%, and the population, estimated at close to one million, is highly mobile. Residents often move between Khayelitsha and the more rural Transkei, which was a homeland (an area reserved for blacks only) under apartheid.

AVSC International, as one of the project's five collaborators, is providing technical and management assistance.

Comparing Screening Methods

Though cervical cancer screening measures were initiated in South Africa as early as 1970, these efforts were never effectively implemented.

In 1993, a research study from Johannesburg outlined the characteristics of a successful screening program. The study indicated that, at a minimum, such a program must reach women at the highest risk (those between 30 and 50 years of age) with effective educational messages, must screen these women at least once, and must provide appropriate treatment to those who need it.

The Philani project, a demonstration study for a larger cervical cancer prevention project, is working to meet these criteria.

The project is comparing the use of Pap (Papanicolaou) smears and four other screening modalities in a low-resource situation in order to develop protocols for similar programs.

Now in its second year, the Philani project has enrolled 1,600 previously unscreened women over the age of 35.

The Mobile Clinic

The Philani project uses a mobile clinic parked outside an outpatient treatment center that houses clinics for family planning, tuberculosis, sexually transmitted infections, and maternal and child health.

The clinic's staff is headed by Dr. Lynette Denny, a gynecological oncologist. Other staff members include Dr. Liliana Risi, a primary health care doctor responsible for the project's day-to-day coordination, as well as a nurse who does screening and three other staff members.

Women enrolled in the project are given cervical cancer education and Pap smears along with each of the other four screening methods. After screening, the women are asked to return for their results within two to seven days. Those identified as having an abnormality are then seen immediately for follow-up.

Follow-up and Treatment

For the follow-up examination, Denny uses a colposcope, an instrument that provides magnification to allow direct observation of cervical cells.

If a significant abnormality is detected, Denny performs a procedure under local anesthesia to remove the abnormal area of the cervix, thereby preventing the later development of cervical cancer. The procedure (called LEEP excision) lasts about 30 seconds and is virtually painless.

Lessons Learned

One of the study's primary objectives is to assess the acceptability of immediate diagnosis and treatment of cervical abnormalities.

The important lesson learned from previous programs is that women frequently do not return for the results, sometimes because of poor client education and information and sometimes because they do not feel that they have a health problem that requires treatment by a physician.

A central challenge the project faces is in locating women who are identified as needing further treatment but who do not return for the results of the screening. Because of the transient nature of the population, tracking requires time, diligence, and persistence.

At present, the return rate for women who have a problem identified by screening and require colposcopy is 80%.

The number of women who return voluntarily for follow-up is continuously increasing due to the staff's attention to providing community education about cervical screening.

Preliminary Results

About 9% of clients to the clinic were shown to have abnormalities of the cervix that had the potential to progress to a malignancy. These are precisely the clients that cervical screening is designed to detect, since the women cannot feel these abnormalities, and they are not visible to the naked eye.

The screening has identified eight cases of cervical cancer in Khayelitsha - about a 0.5% incidence. However, Denny explained that this does not reflect a true incidence of the disease. "Four of these are women who came in for screening only because they were symptomatic," she said. "The other four women were not symptomatic, and their cancers, all detected at a very early stage, were discovered because they were screened."

Reaching Out to the Community

The clinic staff see client education as a key aspect of community empowerment. In addition to training in clinical and administrative procedures, Denny has provided client-education training for each member of her staff.

Clients are also told about the link between cervical cancer and sexually transmitted infections (STIs), particularly human papilloma virus, which causes nearly all cases of cervical cancer.

The STI incidence in Khayelitsha is extremely high; about 30% of the population is affected at some point in their lives. The incidence of AIDS is not known, but six women from the study have been diagnosed with HIV infection.

Innovative Programs

Along with posters and other conventional methods, client education has taken more innovative forms.

The project recently initiated a "health day" with the theme, "Empowering Women Through Knowledge." About 250 women and children participated in raffles, contests, plays, singing, and poetry.

Prizes were given to women who demonstrated that they applied health care education to their everyday lives. For example, clothing vouchers were awarded in a raffle that asked women, "Why do we do Pap smears?"

Working Together

The project team has worked with the African National Congress, the local state hospital services, and the community's health forum, first to get permission to proceed with the study, and second to give feedback on the results.

As Denny explained, Americans and Europeans have come to the area before to set up huge research projects that create a need in the community. Then, once the research is over, the project ends, and with it, the service. "Consequently," she says, "the people feel exploited because they have never really understood the research and had no feedback on the results. I think research has to be more than aim, objective, execution - especially clinical research that involves people."

Leah Kennedy is a freelance writer for AVSC International.