Malawi: Managing cervical cancer in a country with limited treatment options

'A day at Blantyre cervical cancer referral hospital'

A woman participates in group support sessions for cervical cancer patients set up by MSF at the Queen's Elizabeth Central Hospital in Blantyre, Malawi.

A woman participates in group support sessions for cervical cancer patients set up by MSF at the Queen's Elizabeth Central Hospital in Blantyre, Malawi.

Queen's Elizabeth Central Hospital is the referral hospital for thousands of people in southern Malawi. MSF initiated a cervical cancer project in Malawi in 2018. In 2019, facilities were built at the hospital to create and enhance capacity to cope with upcoming treatment demands.

Here a patient leafs through a leaflet prepared by MSF that includes information about the disease and chemotherapy. The sessions are also attended by caregivers, women who are usually part of the family and who accompany the patients throughout the process.

This place is called Ward 4B and is managed by the Malawi Ministry of Health. It currently has 50 chairs where cancer patients, no matter what type of cancer, receive chemotherapy. Normally cervical cancer patients who receive the treatment stay in the hospital for 2 or 3 days.

The high number of women dropping out of cancer treatment prompted MSF to seek strategies to get them to complete their treatment.

In January 2021, patient support groups were created, a space where women can share their personal experiences of the disease.

During the sessions, emphasis is placed on therapeutic education, patients are given information about the side effects of chemotherapy, they discuss the diet to follow during treatment and even share different rehabilitation exercises they can do at home.

Martha Kambewa is 42 years old and was also a cervical cancer patient at Queen's Elizabeth Central Hospital in Blantyre, southern Malawi.

After going through five chemotherapy sessions and a hysterectomy where her uterus was removed, the cancer subsided and Martha became a peer-patient, a patient-referral. Her job is to talk to women about their experience in order to convince them to complete their treatment despite the difficulties of the process. Martha began this work on her own until MSF hired her on a part-time basis.

Kumbukani Kaliwo, social worker, conducts a group session with the husbands.

Although they are not very frequent due to lack of interest and the fact that many of them have to go to work, they are having a positive effect on the participants. Justin Moses, at the center, says that sharing his personal experience and seeing other husbands go through the same thing has made him learn about the importance of staying by his wife's side.

After undergoing chemotherapy, many women suffer from body weakness, pain, diarrhea, vomiting and even hair loss. These are the side effects of treatment. Aware of this, MSF dedicates part of the session time to nutritional education.

Here, sitting in a circle, the women discuss and learn about the different foods they should eat. Meat, vegetables, carbohydrates, proteins...To support them, the NGO Give Directly, along with MSF, provides them with financial assistance through transfers to the cell phones they give them. The initiative is called 'Cash for Health' and so far has 141 women enrolled, although its goal is to reach 680. There is an initial transfer of 180 euros and a monthly transfer of between 40 and 60 euros for a year.

Aliyanesa during a patient support group session.

Gynecologist George Chilinda performs a biopsy on a patient suspected of cervical cancer.

Aliyanesa during a patient support group session.

Gynecologist George Chilinda performs a biopsy on a patient suspected of cervical cancer.

Cervical cancer is easily preventable through the human papillomavirus (HPV) vaccine. Yet, this was not included in their national vaccination schedule until 2019. Here, in the country where this cancer kills the most women worldwide, a global shortage of the HPV vaccine meant that in 2019 only just over 30% of the doses needed to immunize the country's 357,397 9-year-old girls arrived.

Before I started treatment I was in a lot of pain and couldn't eat or sleep at night. Since I have started I feel much better.
says Aliyanesa Nkunye during a chemotherapy session at Queen's Elizabeth Central Hospital

In 2021, of the 98 patients who underwent a biopsy with MSF, 67 (68.4%) had a final diagnosis of cancer. The average age of the women was 55 years.

Cervical cancer accounts for 37 per cent of new cancers in women in Malawi. Since 2018, MSF has been working to reduce the incidence of cervical cancer and bring down deaths from the disease in the districts of Blantyre and Chiradzulu. MSF head of mission Marion Péchayre explains how.  

Why did MSF turn its attention to cancer patients?  

“MSF’s interest in cancer is the result of a combination of factors. In low-income countries, epidemiological projections suggest a decline in infectious diseases and a simultaneous rise in chronic diseases such as cancer. The lack of resources and the late stages at which cancers are diagnosed in sub-Saharan Africa, for example, suggest that they will eventually claim more victims than infectious diseases, as they do currently in high-income countries. The World Health Organization (WHO) estimates that cancer mortality will double in Africa by 2040.

In Malawi, where we have been providing HIV/AIDS care for many years, we found that a lot of our patients had cervical cancer too. Women with HIV are six times more likely to get cervical cancer than women without HIV. This led us to carry out a comprehensive assessment of the cervical cancer problem in Malawi, which has the second highest prevalence and mortality rates in the world. In 2020, 4,145 new cases of cervical cancer were detected and 2,905 women died. Access to anti-cancer drugs is highly variable, radiotherapy is non-existent, and surgery is poorly developed. We are interested in supporting vaccinations to protect against cervical cancer where possible, as well as extending screening programmes and developing treatment solutions.”

How do you treat cancer in the absence of radio therapy?

“Radiation therapy is normally the first-line treatment for cervical cancer, but it is not currently available in Malawi. Over the past two years, MSF has developed a model of care that combines chemotherapy and surgery. After three to six cycles of chemotherapy, tumours have shrunk and can be operated on, saving patients’ lives. We don’t yet have the data to assess the two-year survival rate, but the treatment shows satisfactory results and can be expected to provide a life expectancy fairly close to that of treatment with radiotherapy.

In resource-limited countries, this type of treatment could be considered as a serious alternative to radiotherapy, as long as there are well-trained surgeons. This is why we have paid particular attention to training the surgeons who perform advanced surgical procedures such as hysterectomies, where the uterus is partially or totally removed.

Each month in our project, surgeons perform an average of 14 hysterectomies, and 40 surgeries in total. As a result, these surgeons have become highly specialised and have acquired a higher level of competence in the field of onco-gynaecological surgery than their counterparts in Europe, where this surgery is rare. In addition, the quality of treatment is ensured by multidisciplinary work, involving anatomopathologists, oncologists, surgeons and supportive care teams, who provide social and psychological support, physiotherapy or palliative care.

There is another category of patient whose cervical cancer is detected at a more advanced stage. For these women, we arrange and finance referrals to Kenya so that they can have radiotherapy there. But these referrals require significant support and resources and patients cannot benefit from them on a large scale. But by the end of 2023, we should have access to radiotherapy in Malawi, which will make it much easier to arrange treatment for women with advanced cervical cancer.”  

What is the role of vaccinations?

“Vaccinations are crucial because cervical cancer is easily preventable. It is one of the few cancers associated with a virus, the human papillomavirus (HPV), and there is an effective vaccine against some HPVs. The other way to protect against cancer is screening, which is both a means of prevention and the first phase of treatment, as pre-cancerous lesions can be treated at this stage. The HPV vaccine is made available through international mechanisms such as GAVI, but routine vaccination in health centres does not easily reach the target population in Malawi, i.e. girls aged 9 to 13. They don’t come to health centres as they don’t generally get sick, so they have to be vaccinated either at school or in the villages, for those who don’t go to school. Such systematic prevention programmes in schools and communities require additional resources. We will continue supporting these vaccination programmes, in partnership with the Malawian Ministry of Health, as we did in January, when we vaccinated 17,000 adolescent girls in the Phalombe district.”