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Friday, February 08, 2008

Reproductive Health and Cancer

A.G. Romualdez Jr., M.D.
07 February 2007

In men, the only cancer of reproductive health significance is cancer of the prostate. The prostate is a gland the size of a small guava ("bubut") surrounding the urethra immediately after it exits the urinary bladder. Its function is to contribute secretions that contain nutrients for sperm cells as they are ejaculated to the outside. For men who are no longer sexually active, the prostate is a non-functional gland much like the appendix.

Unfortunately, the prostate is also the site of one of the most common cancers of males over the age of 40. In 2006, in the United States there were almost 220,000 new cases of prostate cancer with an estimated 27,000 deaths. During the last decade, the numbers of new cases detected have risen sharply with the introduction of a new blood test that detects a substance known as "prostate specific antigen" or PSA in the blood of men with prostate cancer.

For the majority of Filipino males, at about two thousand pesos, the test is largely unaffordable. Further, the economics, epidemiology and usual course of the disease makes publicly funded mass screening for PSA unsound from a cost-benefit standpoint.
For one thing, an elevated PSA is non-specific since other conditions such as urinary tract infection can cause such increases. Thus by itself, it does not establish a diagnosis and it must be followed by ultrasound guided needle biopsy and histological examination, a procedure that is even more expensive.

When the diagnosis is established, treatment options vary depending on the patient’s age. For men over the age of 65 with no other sign of prostate disease, the preferred option is "watchful waiting" – i.e., no intervention while monitoring PSA levels and other signs of prostate dysfunction. For younger men, the two main options are radical surgery or the less invasive radiotherapy modalities.
The good news is that prostate cancer generally runs a long and indolent course. This means that very often other pre-existing conditions of the elderly are the most likely causes of death in men who are over the age of 70.
Unfortunately for women, there are several cancers of reproductive health significance that are associated with the female reproductive system. The most common of these is breast cancer. The most important public health intervention for cancer of the breast is early detection and treatment. In all developed countries, mass screening by means of an x-ray procedure known as mammography is the standard method of early detection.

Unfortunately, poor countries like the Philippines have not made this screening available to the majority of their populations. The fact is that the low technology intervention of choice is a good program for breast self-examination. However, public health service providers must be truly committed to this education-intensive method of early detection for it to be truly beneficial to communities.

Cancer of the uterus, particularly that of the cervix (the outermost, exposed part of the uterus), is the second most common cancer in women especially in lower socio-economic groups. Early detection and treatment is also the most effective public health intervention. The old reliable Pap smear was deemed too expensive for poor countries, but with the advent of the acetic acid smear which serves as a first screen, it may be possible for public health providers to mount a major program of early detection.

In addition, there is now a new vaccine to prevent cancer of the cervix. Immunization against the human papilloma virus (HPV) is known to effectively protect against this cancer. There are two major barriers to implementing an HPV immunization program. The first is cost – which can be overcome with coordinated efforts between public health providers and the suppliers of the vaccines. The second barrier is much more difficult to overcome – puritanical religious zealots view programs to immunize young girls at puberty as inducements to sexual promiscuity.

The other common cancer of the reproductive tract is ovarian cancer. There is no accepted intervention designed for early detection and treatment of this cancer. Thus these are usually diagnosed during annual physical examinations (which should include a good pelvic examination) or when there are symptoms of pain or a mass.
While there is no specific public health intervention for early detection, there has recently been reported a possible preventive measure. Researchers at Oxford University in the United Kingdom have reported a study involving thousands of British women indicating that ovarian cancer could be prevented by the use of the new low progesterone birth control pills. In contrast to the anecdotal evidence usually cited by anti-birth control extremists who claim that pills may be harmful, the evidence of protection against ovarian cancer is solid enough for the editor of The Lancet to advocate the promotion of their use specifically to prevent ovarian cancer.