So I'm Dr. Poonam Lama, I am Gynecologic Oncology graduated IGCS fellow and today I'll be presenting on cervical cancer situation in Nepal. I would like to thank my mentor, Professor Dr. Jitendra Pariasar for providing me with all data and the materials for this presentation. So to begin 2025 with a positive note, we know that the theme for this Cervical Cancer Awareness Month is the We Can Prevent the Cervical Cancer and the theme highlights a unified call to action and cervical cancer we know is of course the most common cancer among women globally and of the estimated 600,000 new cases which have been detected annually approximately 342,000 women die of cervical cancer each year. And when we look at the incidence of this mortality chart right here we can see the darkest color are the reason with the less of the resources, less of the services and these are the most disadvantaged countries which is clearly visible and there is a clear division of the have and have nots with 85% of cervical cancer cases and it is occurring in the lower middle income countries and here we can see this chart shows Nepal has the highest incidence of the cervical cancer incidence and the mortality among the ASEAN countries and the Australia has, Australia is far better and probably will be the first country to achieve the target of the WHO global action call to eliminate cervical cancer with the target of less than four cases per 100,000 women. So regarding the incidence here we can see most of the countries have reported the increased incidence of the cervical cancer burden being the breast cancer followed by the cervical cancer. So we know that the causative agent is the human papilloma virus and SBB 16 and 18 are the high risk causes of the cervical cancer, 16 for scomcil carcinoma and 18 for the adenocarcinoma. And in 1970s, Heralder Hossain through his research concluded that the patients infected with the SBB were at increased risk of developing the cervical cancer and in 2008 he was awarded Nobel Prize for this momentous work. So cervical cancer is undoubtedly a preventable disease because we already know what causes it, we know how to prevent it and we have proven interventions that is SBB vaccine. So no woman should die of cervical cancer due to a disease that is almost 100% preventable. So in 2018, WHO issued a global call to eliminate cervical cancer stating the threshold where all countries should achieve the threshold of less than four cases per 100,000 women and the strategy has identified three targets, three pillars to help to reach the goal by 2030, the first one being the vaccination, 90% of the girls should be vaccinated for SBB by the age of 15 and the second pillar being screening, 70% of the women should be screened at least twice by the age of 35 and again by the age of 45. And the third pillar being the treatment, that's 90% of the women with the disease that's the pre-invasive and invasive ones to receive the treatment and care which is a big challenge, especially for lower in middle income countries like ours. So for cervical cancer rates have been declining in developed countries, however, it is very disheartening to see in low middle income countries like Nepal where it continues being the leading cancer among the women and there are reported 2,300 new cases and 1,500 dead and we can see that half of the pie is actually taken up by this kind of the preventable, early detectable cervical cancers. So in Asiana-Oceania region, no country is below the global elimination target of less than four cases per 100,000 women and the reported rate of cervical cancer incidents in Nepal is 16.4 per 100,000 women which is nearly four times WHO target. So the studies done in Nepal have shown that 90% present with the advanced disease done in Nepal have shown that 90% present with the advanced disease. So the question arises that why this preventable cancer is being ranked as the most common cancer among Nepalese women. The particular risk being for the delayed diagnosis is due to the referral in the delay, medical source being the major first contact point of patients with healthcare providers and the symptom misinterpretations and almost 80% cases had no cervical examination in the initial consultation. So we should give at least one minute time to look at the cervix. So now coming to the three pillars, vaccination, screening and treatment and where do we stand. Discovered by Ian Fraser, SPV vaccine which was used in USA since 2006 and now it has been incorporated in national immunization program in more than 100 countries. We know that it's given to the age group of nine to 26 years, two doses below age 15 and three doses after age 15 and immunocompromised patients and as of 2020, less than 25% of the low income and less than 30% of the lower middle income countries had introduced the SPV vaccine into the national immunization schedule. However, more than 85% of the high income countries had done so. So the first attempt at the SPV vaccine in Nepal was done with Gardasil in the year 2008 with the assistance of the Australian Cervical Cancer Foundation and 1,000 school girls between age 10 to 26 from 17 schools were vaccinated and it was a successful vaccination campaign. In addition, collaboration with Gavi led to SPV vaccine demonstration project launched in two districts, Kaski and Chitwan district and this picture here shows the area that had been covered during the campaign. So here we can see in the map of Nepal, the campaign were laid in these areas of the country. The main motive being the participants to be involved should represent the plain area and the mid-hilly region of the country and it would represent the population, the target population of the country. So here this chart shows that the pilot study which was conducted in two districts, the Kaski and the Chitwan, the Kaski being the hilly area and Chitwan being the mid-hilly and the plain area of Nepal. The total 14,000 school-going girls were offered the vaccination and so the eligible girls were vaccinated. The coverage was more than 95% and adverse reaction was recorded in only 24 girls out of 14,000 girls and those were only minor ones, which is a very encouraging result. And here I would like to highlight that in contrast to Japan, the SPV vaccine uptake, which was up to 70%, the side effects were seen in almost... and then side effects were recorded. So government temporarily suspended to investigate the reason for the adverse effects. However, due to the huge media coverage, there was the negative news and the bombardment of negative news and it dropped to almost 2%. So this was also the presentation which was done by the ICC's president himself, Keiji Fujihara and Sayaka Ikeda and they had presented the changing trend of the vaccination in Japan and the effect, the negative impact was done by the huge media coverage on the adverse effects of the SPV vaccination. So when it comes to vaccination in Nepal, Nepal has done very well even in other vaccination program, which has now been incorporated into the national immunization program. That is why WHO and UNICEF has awarded Ministry of Health Nepal as immunization coverage is more than 90%. So we are very optimistic that the first pillar, that is the vaccination in cervical cancer elimination program will be successfully addressed. And we would like to share one very good news that we will be marking the February 4th, that is the World Cancer Day, with the initiation of the SPV vaccination nationwide and almost 1.7 million eligible girls will be vaccinated over a period of one month. The target population would be school-going girls, 10 to 14 years. And also the campaigns have been laid for the public to inquire about the centers for the SPV vaccination program, SPV vaccination services, where it would be available. And they have quoted the quota would be 1115 to make the inquiries for the general public. So cervical cancer burden in Nepal has not gone unnoticed by the government of Nepal. So the National Guideline for Cervical Cancer Screening and Prevention was developed in 2010. And to strengthen the second pillar, that is screening of cervical cancer elimination program, the guideline recommended the VIA every five years for women 30 to 60 years. And it has recommended a single visit approach where a visual inspection with aesthetic acid would be done and the positive cases would be treated with pharmacoglution and cryotherapy there and then at the same time. And now the recent updated guideline endorses the SPV DNA as a screening tool for cervical cancer, which would be both physician-collected and cell sampling. And as of 2019, the screening coverage is less than 10%. So we hope that with the ongoing effort, the screening coverage will improve. So these are the data which shows the cervical cancer screening available in the country. And the cervical cancer screening available in 11.7% of centers, VIA in 9% of the centers, and thermal ablation in 1.4% of the centers. And the ablative, the excisional procedures like LEAP available in only 1.1% of the centers as reported in the 2021 data. So here we can see the chart shows the low-income countries have the high burden of the disease, however, the less of the resources, the less of the treatment facilities, which is required for the cancer treatment. However, the high-income country has more than 90% of the access to the resources and low-income countries have less than 30%. So talking about the treatment, treatment that is a third pillar in the elimination program, there are only 10 dedicated cancer care hospitals in our country, and most of them are located in the central Nepal. And currently there are five radiation centers. And there's a five is the functioning, out of the five radiation centers, two public and three private, they're providing the radiation therapy services with two cobalt teletherapy and six Lignite machines. So Nepal at present is far below WHO recommendation of one megavoltage missing for a million people for a population of approximately 30 million. And there are currently approximately 40 certified onco-surgeons and approximately 30 gynecologic oncologists in the country. But we know that a successful trip from the diagnosis to treatment to operating room requires more than a scalpel and a handful of surgeons. So we need well-organized education, training, and human resources to develop an effective workplace for cervical cancer elimination initiative. And we have different fellowship program in the country. One being the IGCS fellowship program, which was started in the year 2019, based at Civil Service Hospital. And we have three graduates till now, and we have two in training. And the other fellowship program being conducted by the National Academy of Medical Sciences, which is done at the Parapurkar Medical Maternity Women's Hospital in Kathmandu. So cervical cancer prevention is linked to treatment. So the capacity building through the training and the courses is very important in achieving the goal. That is why the IGCS program and the fellowship program has helped us a lot. And we have been conducting several cervical cancer courses. And it began with the initiative of ASCO. And Professor Linus was one of the faculties, along with Professor Catherine and the Anderson team. So Nepal team has been conducting such courses, not only in Kathmandu, but even outside the valley. Outside the valley in Kaski, and as far as the far western area of our Nepal, Baki and Jumla. So here we can see the area of the cervical cancer courses that we have done in the country, the central part of our country. Here we have done in the Kathmandu, in the Lalitpur area. And then in the Kaski, there's the Pokhara. And as far as Baki and the Jumla area, which are the far western area of our country. So we have Gynecological Oncology Society of Nepal, GOSON, which is a professional group of gynecological oncologists, which is committed to work on the gynecological cancers. And since its formation in 2017, this organization has worked for the improvement in the field of early detection and the appropriate treatment of the gynecological malignancies. So for cervical cancer elimination, we need to double our efforts today, and we must ensure that all these three pillars are successfully implemented for the overall long-term goal. So on this note, I would like to end my presentation. Thank you.

cervical cancer

HPV vaccine

Nepal healthcare

screening coverage

treatment infrastructure