Sharav Otgontsetseg, 37, from Ulaanbaatar’s Songino-Khairkhan district in Mongolia considers herself very lucky.
Mother of two, Otgontsetseg recently underwent surgery for cervical cancer at the country’s National Cancer Centre, after a routine Pap smear tested positive.
Since 2012, cervical cancer screening has been made available for free through family clinics throughout Mongolia for women aged 30 to 60 - thanks to a project supported by the U.S. Millennium Challenge Corporation (MCC).
Cervical cancer is caused by the human papilloma virus and is treatable when detected early. According to an article published in the Asia Pacific Journal on Cancer Prevention, cervical cancer is one of the most common cancers among women in Mongolia accounting for 17% of cases and 8% of deaths from cancer in 2011. This is predicted to rise in the coming years to almost 1 in 5 cancers among women by 2016. Data from the National Cancer Centre indicates that cervical cancer is the fifth most common cancer in Mongolia overall.
Institutionalizing cervical cancer screening in primary health care
In 2013, over 70 000 women from the target age group underwent cervical cancer screening at the primary health care level nationwide. With support from the MCC, nurses and cytologists were trained to administer and interpret Pap smears. To facilitate diagnosis, provincial, or aimag, and district-level clinics were also equipped with microscopes with cameras. In cases where the results were inconclusive, a system was put in place where samples could be sent to the National Cancer Centre in the capital for verification.
WHO has provided support in terms of building capacity among local oncologists in the use of ICD-10 for coding and diagnosis, improving cancer registries in Mongolia and strengthening the competence of cytologists by organizing training with an expert from the academe.
The new screening system recommends that all women within the target age range undergo a Pap smear every three years. Eligible women are initially notified by post or text message inviting them to visit the family clinics to undergo screening. Samples are then collected and sent to the aimag clinics where a cytologist examines them and interprets. Each of these secondary health care institutions is ideally staffed by one cytologist.
Unfortunately, despite the tremendous promise and impact of the project, it has been faced with several challenges in recent months. Of note is the lack of trained cytologists to interpret the samples collected delaying results. This is further compounded by the fact that some of the cytologists who underwent training have since resigned leaving many posts unfilled.
“When people do not get their test results in a timely manner it turns them off,” says Gotov Uyanga, the Director of the National Centre of Pathology and a lead trainer of the MCC project. “Unfortunately out of the 32 cytologists we trained, about half are no longer working in that capacity.”
She suggests that interpretation of the samples be centralized in the National Centre of Pathology to ensure the quality and consistency of the diagnosis. “One needs a lot of practice to detect 5-10 pathological cells among 50 000 healthy cells,” says Uyanga, herself a pathologist by profession. A lack of practice coupled by the absence of regular quality checks may lead to incorrect diagnosis.
The women themselves must also be encouraged to undergo screening. Since the beginning of 2014, 56 000 women have undergone screening under the programme, a significant drop from the year before.
“Only 28% of all women who are eligible to be screened for cervical cancer this year were actually screened,” says Tudev Undarmaa, a Cancer Epidemiologist at the National Cancer Centre’s Department of Public Health, Research and Training. “We need to conduct a study to understand why there is relatively low pick-up.” She surmises that this is due to a combination of factors such as a lack of financing support (the MCC project has ended), insufficient information campaigns and a lack of personnel.
Saving lives through screening
“Cervical cancer is a pressing issue but perfectly preventable,” according to Dr Soe Nyunt-U, WHO Representative in Mongolia. “The worrisome spread of sexually transmitted infections, including the human papilloma virus, underscores the importance of screening measures to detect dangerous consequences such as cervical cancer.”
Despite these challenges cervical cancer screening has shown promise in detecting cases and promoting appropriate treatment. For example, of the 90 women who tested positive in the Songino-Khairkhan district, 15 were diagnosed with cancer and subsequently referred to the National Cancer Centre. The others who tested positive underwent coagulation treatment at the district hospital. For her part, Sharav Otgontsetseg is thankful that she underwent the screening and shares her story openly with friends encouraging them to undergo cervical cancer screening themselves. “I’d like to encourage all women – mothers and daughters – to undergo screening. Better to undergo screening now and get treated than to be sorry later on.”
With further improvements in the system and continued political commitment, cervical cancer screening may yet save the lives of many more women in Mongolia in the years to come.