Dr Ute Schilling is a gynaecologist with a specialisation in oncology who worked in Blantyre, Malawi, where more than 4,000 people are diagnosed with cervical cancer every year, but almost 3,000 people die from it every year describes five of the leading causes of Malawi's high cervical cancer mortality rate.
Have you been vaccinated against the human papillomavirus? Do you go for regular cancer screenings? Most women in my home country, Germany, will answer yes to these questions. 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 five years.
The situation is very different in Malawi, however, where I spent nine 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 gynaecologist specialising in oncology, I have mainly treated patients with other types of gynaecological cancer over the past five years, as cervical cancer is rather rare in Germany and is usually detected at a very early stage. Due to this difference, the daily work in Malawi was a great mental challenge.
Cervical Cancer while pregnant - a balancing act
The story of one patient particularly touched me. Let's call her Zola. Zola came to us 17 weeks pregnant with cervical cancer. It's 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 an 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 during the project, which is an enormous workload
It was very nice for this patient to not only be able to go home cured but also have a healthy child after all the hardships.Dr Ute Schilling
Doctors without Borders 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 a lot of trees on our site, and birdsong could be heard all day long. The air was fresh and clear. I could walk the ten minutes to the hospital every morning.
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 tumour. 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 was possible 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.
Despite all the difficulties, I enjoyed working in a very close-knit team. I was responsible for a lot of things myself. However, we were still in constant communication, whether at the weekly tumour conference, where we discussed the patients' treatment plans, or in discussions with colleagues from the palliative and psychosocial teams. The mutual support and good atmosphere made a big difference.
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 lives below the poverty line. Accordingly, the healthcare system is inadequate and has enormous gaps in provision. With regard to cervical cancer, the following points are particularly significant.
the HP virus triggers more than 95 per cent of all cases of cervical cancer. While around 50 per cent of all girls and almost 30 per cent of all boys over the age of 15 are vaccinated against HPV in Germany (which is also not a high vaccination rate), only between 12 and 14 per cent of girls in Malawi are fully vaccinated. This is due to both the lack of availability of the vaccine and the challenges of reaching poorer population groups.
As 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.
The early stages of cervical cancer do not usually cause any symptoms such as pain. Even irregular bleeding is not always suspicious of cancer, which means that it is not always investigated. A lack of education and also shame in relation to sexual health mean that many patients only come to us very late.
Insufficient treatment options: Until the beginning of this year, it was not possible to offer radiochemotherapy (a combination of radiotherapy and chemotherapy for inoperable findings) in Malawi. Only a small proportion of patients were sent to Kenya for this potentially life-saving treatment. (Link to the documentary)
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 I experienced in Malawi in just a few months were completely unfamiliar to me from my ten years of work here in Germany.
Treatment options
After examination and diagnosis, the treatment options were considered depending on age and stage. The main focus was on good palliative care for the older patients aged between 65 and 80. We tried to minimize 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.
Overall, I really enjoyed the assignment because my expertise was well suited to the requirements of the position, but I also learnt a lot. The appreciation of my work motivated me every day and I will always remember the gratitude of the patients, even if a cure was no longer possible. I would like to return to the project at some point to see how it has developed.
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