Bid to cut cervical cancer cases
To most people living in towns or cities, a daily shower is taken for granted. But it is certainly a luxury farmer Li Fengxiang has to do without.
"I can only bathe at home once every 10 days in winter because of the water shortage," says the 40-year-old mother of two, who lives in Xiangyuan County in North China's Shanxi Province. "In summer, I just cleanse my body with a damp towel about every another day."
Li's lack of washing eventually made her ill, and she caught a virus called HPV (human papilloma virus), which quietly deteriorates cells in the cervix and invades surrounding tissues. She ended up with a cancerous lesion in the cervix.
Fortunately, doctors say her case is still in the early stages and is curable. Li is now in Xiangyuan Women and Children's Hospital with 20 other patients suffering from the same complaint. They are waiting for a Leep (Loop electrosurgical excision procedure) excision by oncologists from Beijing.
Cervical cancer is easy to prevent and to cure if caught early enough, but ineffective screening mechanisms mean the disease has become quite widespread in parts of Shanxi on the arid Loess Plateau, where 10 times more women die of cervical cancer than the average in China as a whole.
Next to breast cancer, cervical cancer is the second most lethal cancer to women worldwide, affecting 466,000 women a year, with more than 100,000 cases occurring in China. More than 70 per cent of them are found among rural women like Li Fenxiang.
A five-year programme, which aims at curbing such disease, has been possible thanks to help from the Bill Gates Foundation.
Some of the causes of cervical cancer have been identified as persistent HPV infection and lifestyle.
"HPV is found in almost all cases of the disease," says Qiao Youlin, who is in charge of the project and also director for the Department of Cancer Epidemiology at the Chinese Academy of Medical Sciences in Beijing.
HPV is sexually transmitted, and Qiao said women who have a high number of sexual partners, begun to have sex at an early age, or whose partners have had contracted any STD (sexually transmitted disease), are at a higher risk.
"Bad hygiene and habits can increase the chances of HPV infection," he says. "And bad nutrition weakens the immune system's ability to resist the infection."
Unhealthy living conditions have placed numerous rural women at risk. Cui Lanhua, a 36-year-old cervical cancer victim in Xiangyuan County's Jijiagou Village, has already had to have a hysterectomy.
She couldn't remember if she had ever had a thorough shower or bath.
"I would go to a public bath in town, 10 kilometres away, if only I could afford it," she said. Her family of four live on a small plot of corn field and share one washing bucket. The public bath costs 40 cents (about 5 US cents) each. But she says she simply doesn't have that 40 cents.
"She is very young to have a hysterectomy," says Zhang Wenhua, a noted gynaecologist from Beijing Cancer Hospital. "By the time we gave her HPV and cytological tests in 2003, her HPV was already serious, and pathological results indicated she had developed invasive cancer, or cancer at a late stage."
Cui could have nipped the disease in the bud if she had been able to get regular gynaecological check-ups. But Cui does not have access to the rural co-operative healthcare system that so far only a small number of farmers are covered by. There was no way she would be detected early, which saves 99 per cent of patients, according to Qiao.
Effective screening needed
The vast majority of cervical cancer victims are rural women, who have never been smear tested, says Zhang Wenhua, a member of the project for cancer early detection and treatment. With money from the Bill Gates fund, she and her colleagues in Beijing regularly come to give check-ups to Xiangyuan's 120,000 women, 95 per cent of whom are farmers.
The smear test, invented in 1941, is the world's most common screening method and has reduced the incidence rate by 90 per cent worldwide. But in some areas of rural China, the rate is climbing, in contrast to the country average, which has reduced by 69 per cent in the past two decades.
Latest figures released by the Cancer Institute suggest that in Yangcheng of Shanxi, 36 out of every 100,000 women die, 10 times the country average, against the world's average rate of 8 out of every 100,000.
"The figure is daunting," says Qiao, adding that the smear, despite its success, is difficult to promote in developing countries. "It requires a fair amount of money to establish a high-standard cytologic testing system and well-trained cytologists, who can accurately identify the cells scraped from the cervix."
He believes the smear is more workable in developed countries, such as the United States, where 50 per cent of women have smears at least once every five years, while 85 per cent have it at least once in their lives. Ninety-five per cent of women in developing countries never have smear tests.
"That's because in developing countries, most of the limited medical funding is spent on disease treatment instead of prevention. As a result, developing countries account for 80 per cent of the total number of the world's cases."
Smear test results in developing countries are often unreliable, with poor techniques of obtaining the samples and analyzing them.
The ThinPrep and AutoCyte Prep methods were introduced in 1998 in Shanxi, and since then accuracy is reported to have improved significantly.
Now that HPV has been proved to be a primary risk factor leading to pre-cancerous lesions, the two methods have been shown to be the most effective in catching the symptoms. "The first important thing we are doing is training doctors and medical technicians in doing HPV screening among women aged 35-54," said Qiao.
So far, oncologists and gynaecologists from 20 provinces have been trained. "It's necessary training. China is big and populous but has limited sources. The training has a cascade effect. After I am trained, I will go back and train more medics at county level," says Li Jie, director of the oncology & gynaecology section at Hunan People's Hospital. "If a rural woman gets cervical cancer it normally means her family will run into debt. Prevention is always more economic and effective than cure."
In the meantime, two national pilot demonstration centres for cervical cancer prevention in Shanxi are to be set up, one at county level, the other at city level, according to Qiao.
It isn't just rural women who are coming down with the cancer.
Many urban women are also contracting HPV. Qiao cites late Hong Kong pop diva Anita Mui, saying economic power doesn't necessarily guarantee awareness of the cancer. Dubbed "Madonna of Asia," Mui died of cervical cancer at the age of 39 last year.
The demo centres will look at how to manage checks and treatment according to different economic situations. They will decide which screening methods are the most effective in certain areas and how to spread the prevention message across the country.
"The most effective way to keep cervical cancer at bay is to improve screening, which lets us more accurately predict who is at risk," Qiao says.