So treatable and yet so deadly: Gynaecologist reports on cervical cancer in Malawi

Have you been vaccinated against the human papillomavirus? Do you go for regular cancer screenings? Most women in Germany will answer yes to these questions. And the great thing is that if you or your relatives are diagnosed with cervical cancer in Germany, your chances of recovery and survival are good: of the 4,400 people diagnosed with this type of cancer here every year, 90 per cent are still alive after 5 years.

The situation is very different in Malawi, however, where I spent 9 months on assignment as a cancer specialist. Here, too, more than 4,000 people are diagnosed with cervical cancer every year, but almost 3,000 people die from it every year. This means that Malawi has the second highest mortality rate for cervical cancer after Eswatini. As a gynecologist specialising in oncology, I have mainly treated patients with other types of gynecological cancer over the past five years, as cervical cancer is rather rare in Germany and is usually detected at a very early stage. The daily work in Malawi was a great mental challenge due to this difference.

Cervical cancer while pregnant - a balancing act 

I was particularly touched by the story of one patient, let's call her Zola. Zola came to us 17 weeks pregnant with cervical cancer. Not an easy situation, because in such a case you can't operate without terminating the pregnancy. Zola then decided to continue the pregnancy and undergo chemotherapy, despite possible side effects for the child. Without any therapy, the carcinoma would have continued to grow during the pregnancy and would have worsened her prognosis.

She then received chemotherapy every three weeks until shortly before the due date and the child was delivered by planned caesarean section. At the same time, the uterus, its suspensory structures, fallopian tubes and pelvic lymph nodes were completely removed. Although this is the standard procedure for cervical carcinoma, it is a very extensive operation with many potential risks and requires a high level of technical expertise. My two Malawian colleagues perform this operation up to eight times a week, which is an enormous workload. 

I was very pleased that everything went according to plan: fortunately, Zola did not go into premature labour so the operation could be carried out. After two days on the neonatal ward, the baby was able to return to its mother. It was very nice that Zola was not only able to go home cured, but also with a healthy child after all the hardships.

60 per cent incurable 

MSF has treated more than 4,750 patients with cervical cancer in Blantyre since the project opened its doors in 2018. The city lies 1,000 meters above sea level, surrounded by mountains. Although 800,000 people live there, it often felt like we were in the countryside. There were lots of trees on our site and birdsong could be heard all day long, the air was fresh and clear. 

Most of our patients came to my consultation at a very advanced stage. I mainly treated women who came for an examination because of suspected cervical carcinomas or, in rare cases, vulvar or ovarian carcinomas (ovarian cancer). Their screening results had already been conspicuous in previous examinations. We were effectively the second step in the diagnostic procedure. We took samples and used ultrasound to determine the stage of the tumor. We then found out whether the cancer was still operable, whether the patients needed chemotherapy or whether a cure was no longer possible. In 60% of the patients we examined, unfortunately only palliative treatment and no cure was possible - that was extremely depressing. 

Enjoying my work - despite all the difficulties 

Time and again, I had to give very young women, some of them single mothers, very poor diagnoses and prognoses. That wasn't always easy to bear. I therefore tried to maintain a certain distance, which was helped by the fact that I always worked in a team and usually had a Malawian nurse at my side to translate. This meant that I was able to initiate individualised therapy from a medical perspective without being completely overwhelmed by the difficult fates. 

The problem lies in the system

The reasons for the dramatic situation in Malawi are complex. The country in south-east Africa is considered poor: according to the World Bank, more than 70 per cent of the population live below the poverty line. Accordingly, the healthcare system is inadequate and has enormous gaps in provision. With regards to cervical cancer, the following points are particularly significant:

• Poor vaccination rate: the HP virus triggers more than 95 per cent of all cases of cervical cancer. Only 12 to 14 per cent of girls in Malawi are vaccinated against HPV. This is due to both the lack of vaccine availability and the challenges of reaching poorer population groups.
• Hardly any screening: there is hardly any screening in the public healthcare system in Malawi and many patients only have very limited access to good quality healthcare services. There is a lack of appropriate early diagnosis options; in some cases, women were treated incorrectly for months before they came to us.
• Hardly any early symptoms: the early stages of cervical cancer do not usually show any symptoms, which means that it is not always investigated. A lack of education and also shame in relation to sexual health mean that many patients come to us very late.
• Insufficient treatment options: until the beginning of this year, it was not possible to offer radio chemotherapy in Malawi. Only a small proportion of patients were sent to Kenya for this potentially life-saving treatment. 
• HIV is a huge risk factor: people living with HIV are six times more likely to develop cervical cancer due to their compromised immune system and Malawi has one of the highest HIV rates in the world.

All of this has serious consequences: on a normal day, I have seen around 15 patients - of which a good twelve had carcinoma. The severity and density of the cases that I saw in just a few months was completely unfamiliar to me from my previous ten years of work in Germany.

Treating cervical cancer in Blantyre, Malawi

Depending on age and stage, the treatment options were considered after examination and diagnosis. For the older patients aged between 65 and 80, the main focus was on good palliative care. We tried to minimise their pain during their remaining time. 

It was different with the younger patients: I was always very relieved when a patient came to us at a stage that was still operable. If the operation could then be performed successfully and the pathology results confirmed our previous assessment, no follow-up treatment was necessary. The patient was discharged with a good prognosis. 

How are MSF treating cervical cancer in Malawi?

Since 2018, MSF has run a cervical cancer project in Malawi focused on providing effective and high impact care to prevent and treat cervical cancer. The program includes screening, consultations, specialised surgery and palliative care for advanced-stage patients. Radiation therapy, considered to be the first-line treatment for cervical cancer, is currently unavailable in Malawi, though two radiotherapy projects (non-MSF) are ongoing and aim to be operational by 2024. MSF has therefore set up a temporary referral system for certain cervical cancer patients, sending them to Kenya for radiotherapy. The documentary recounts the journeys of the patients through the treatment process and their trip to Kenya for radiotherapy.