Dr. Mirium O. Laker-Oketta
Cancer screening is the hottest thing in town. Private clinics and pharmacies are promoting their brands by arranging free screening services. Recently, I gave in and went for free cervical cancer screening when a reputable clinic advertised it. I arrived at 8:00 am and by 10:00am, when the service commenced, one would have been excused for thinking it was the Beijing Women’s Conference of 1995 all over again. The place was thronged with women waiting for the free cervical cancer screening. I waiting patiently sipping the tea offered to us as part of the clinic’s public relations. At last, my name was called.
I did not reveal that I was a doctor. I settled on the screening couch but two minutes later, the young doctor said my cervix was fine and I could go. No explanation of the procedure just concluded. As I prepared to leave, I asked:
Did you do VIA? “No”, the young doctor replied. Are you testing for HPV? “No” he said, “I do not think that test is available in Uganda.” Are you doing a PaP smear? Again the answer was , “No”.
Then what exactly did you do? “Oh” he said, “You seem quite informed. Today we are just looking to see if there is anything suspicious for cervical cancer. The other tests you mentioned are expensive.”
I respond: You know very well that using the naked eye to visualise a cervix is of no use unless one already has obvious cervical disease. You need to be open with the multitude waiting for the screening and let them know that what you are doing today does not pass for cervical cancer screening.
Let them know that they can either choose to opt out or pay for a PaP smear. You can refer those who cannot afford your fees to public facilities where the service is free or substantially subsidized. I asked him to perform a PaP smear, he reminded me that it would be at a cost, which I okayed. I was already here so why not? These days, we are all either washing cars to send someone for cancer treatment in India, attending the funeral of a cancer victim, reading the news to hundreds stranded because the cancer treatment machine has broken down, receiving cancer treatment or recuperating from cancer.
Most of us are engaged with cancer in some way. This makes our population ripe fodder for screening. Screening for cancer and, indeed, any disease means looking for disease in people without any of the known signs of the disease. Although screening is touted everywhere, one must remember that there are costs associated with screening for cancer. The costs may be direct financial (screening and treatment costs), psychological e.g. finding of a cancer that would never cause diseases or death, getting a wrong diagnosis or finding a cancer that will have a bad outcome regardless of when it was discovered and regardless of treatment.
Some screening tests also lead to disease in the longer term e.g. through exposure to radiation or damages to the body during surgery in the event that screening discovers something that requires surgery for proper ascertainment. Sometimes, the costs of treatment either do not guarantee positive health outcomes or are so high that they destroy families financially. I have seen families sell all their valuable material possession and take children out of school to finance cancer treatment even when it is known that the treatment does not offer hope for cure.
Prostate cancer is an example where screening is associated with psychological costs, financial costs of further testing, and risk of damage from surgery. Many men have prostate cancer with no symptoms that remain contained and they live a full life, die natural death only to be found at post-mortem to have had cancer. If these men had been screened in life, however, they may have ended up with radical surgery with all the risks inherent to surgery per se and to surgery in the delicate area where the prostate gland sits.
Indeed, countries like the US, inspite of prostate cancer being their most common cancer, now strongly discourage routine screening. The PSA test that was initially promoted for screening often gives results that are almost impossible to interpret without cutting off part of the prostate gland for examination under the microscope. Some lung cancers also remain indolent in life and are found incidentally during post mortem. Finding them during routine screening would have a huge psychological impact on the patient and if they can afford it, they would subject themselves to unnecessary major surgery.
There are also costs to the individual’s family, the medical system, and larger economy, but, my word restriction cannot allow me to go into the details. Is all screening therefore useless? Absolutely not. There are cancers like cervical cancer, colon cancer, Kaposi’s sarcoma (one of the most common cancers in Africa), many forms of breast cancer to mention a few which if detected very early can cure completely. In these cases, one wants to strongly advocate for screening. Cervical cancer is now largely preventable through vaccination so the best approach is to get vaccinated against it, that not being feasible, women must have cervical cancer screening as frequently as prescribed by their doctors preferably using PaP smear and HPV testing and when not available, VIA. People aged 50 and over must have a colonoscopy, we should find out the cost and begin saving for it while we still have time. We should take advantage of screening that is technically free e.g. breast cancer monthly self-examination of the breast, Kaposi’s sarcoma self- or partner-assisted skin examination, testicular cancer: self-examination of testicles.
Before one decides to go for screening, they should ask themselves some hard questions: “If the test comes out positive, will it be enough to confirm the diagnosis or will I need further testing and if I do need further testing, can I get access to the tests?” “Will I know that the kind of cancer I have is one of those that require treatment or one of those that need no intervention and will not endanger my life?” “If treatment is available, is it accessible to me?” Would the treatment available cure the disease? Improve survival with a normal to reasonable quality of life? Would I afford the treatment?
In summary, it is best to stay away from avoidable known factors that increase one’s risk for cancer (read leadership March 2019) and to consider the costs (financial and beyond) of screening for individual cancers before screening.
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