Saturday, June 25, 2022
Yesterday, in my clinic, I saw a 27 year old woman who was very anxious. She had travelled over 100km to see me, after having a chat with a nurse who had tried to allay her anxiety. The nurse recommended that she comes to see us.
The lady, who has no child, had gone for cervical precancer screening with HPV DNA testing. She was positive for high risk HPV (type 45), which predisposes her to cervical cancer. Pap smear (on a liquid-based sample) had been done. The result was Negative for Intraepithelial Lesion or Malignancy (NILM). She went to a private hospital to see a Specialist Obstetrician Gynaecologist. The specialist did not perform colposcopy (or Visual Inspection with Acetic acid) but booked her for ‘cold knife conisation’ – a procedure to take a cone of the cervix away in theatre, under anaesthesia.
In our clinic yesterday, one of our nurses performed colposcopy with the mobile colposcope, the Enhanced Visual Assessment (EVA) system. I was present, because I was very interested. Our nurses generally work independently, following our algorithms, but with a quality assurance process in place. Colposcopy was adequate. Transformation zone type 1. No lesion was seen on the cervix. The lady was reassured. She will come for review in a year to repeat the HPV DNA test.
As a colleague (a Ghanaian colposcopist in the UK) put it, having a cold knife conisation in a situation like this is like killing an ant with a sledgehammer. I have seen many of these cases including medical doctors offering a hysterectomy for Cervical Intraepithelial Neoplasia (CIN I or II).
Over a decade ago, I saw a big problem approaching. With one round of screening with HPV DNA testing having been found superior to cytology (pap smear) and Visual Inspection with Acetic acid (VIA) in preventing cervical cancer, it was clear that the world was going to move towards HPV testing in cervical precancer screening. I predicted that HPV testing was increasingly going to be simple, and at a point be as simple as performing a pregnancy test, with women doing this themselves. I still believe in this. As a ‘prophet of doom,’ my prediction continued that ‘In future, the problem will not be the testing, but the follow up and management of high risk HPV positives. It is necessary to train health workers to manage screen positives and precancer otherwise we are going to create chaos and anxiety.’
This is where we are. The Covid-19 pandemic had its positives. Many institutions in low resource settings including Ghana acquired PCR machines for Covid testing. Now these machines are being used for other tests including HPV DNA testing. Many laboratories are cashing in on running the tests. We are getting many women who test positive for high risk HPV. There are few health workers who can properly triage the screen positives and treat those with cervical precancer.
I have mentioned this in many of my pieces over the last couple of years. If cervical cancer (the second cancer killer in women in Ghana after breast cancer) is a real problem, our education system must produce graduates trained to address this. Unfortunately our nurses, midwives, physician assistants and medical doctors (including Specialist Obstetrician Gynaecologists) come out of training not equipped to address this practically. We have to look again at our curricula.
The Cervical Cancer Prevention and Training Centre (CCPTC) in Catholic Hospital, Battor has been training health workers in (practical) cervical cancer prevention skills for 5 years. More nurses and midwives are attending the training programme than medical doctors. If the medical schools in Ghana and the Ghana College of Physicians and Surgeons do not sit up to ensure that enough medical doctors are equipped with practical skills to prevent cervical cancer, nurses, midwives and physician assistants will fill this role and lead in this field. Haven’t we seen this in other other areas already? The last strike action by Nurse Anaesthetists (sorry Certified Registered Anaesthetists) who are working in many places across the country without doctor anaesthetists should be a lesson to all of us.
Dr. Kofi Effah is a gynaecologist and head of the Cervical Cancer Prevention and Training Centre in Catholic Hospital, Battor in the North Tongu District of the Volta Region of Ghana.