Nathalia Debora Sidabutar, SKM, M.I.Kom
Penata Kependudukan dan KB Ahli Muda
BKKBN Representative Office, South Sulawesi Province
Keywords: Cervical cancer, delaying age at first marriage, Pap test/VIA
With the high rate of illnesses in this modern day and time, anyone from all age groups is at risk of suffering from some types of diseases that may affect any part of the human body. The convenience that the modern lifestyle offers has been discussed as one of the risk factors, while lifestyle has been recognized as an important determinant to an individual’s overall quality of life and health. Someone with a positive and healthy lifestyle is more likely to also enjoy quality living. Conversely, an individual with an unhealthy lifestyle is more likely to encounter illnesses, both communicable and non-communicable.
Cancer is the name of a collection of diseases that are caused by cells that abnormally grow and develop into cancerous cells4. There are multiple types of cancer, named for the organs or tissues where the cancer starts. While cancer is not transmissible from person to person, cancerous cells invade the surrounding tissues or even spread further from their origin. At the early stages, a person with cancer may be asymptomatic and he or she may not be aware of the presence of these malignant cells; when symptoms occur, however, it usually indicates that the disease has advanced4.
Among women, cervical cancer is the second of ten most common types of cancer that affects women and has become a global threat2. In Indonesia, as many as 348,809 cases of cervical cancer were reported in 2016. According to a 2018 report of the Global Cancer Observatory, Indonesia has 32,469 cases of cervical cancer per year with the number of deaths reaching 18,279 people5. With this number, Indonesia has become the country with the second highest cervical cancer cases in the world. In terms of age, women between 30 to 50 years old are typically more at risk to cervical cancer, although the disease takes around seven to ten years before it becomes invasive. Preventive measures are therefore crucial in order to lower the rate of illness due to cervical cancer.
Law Number 52 of 2009 concerning Population and Family Development stipulates the mandate of the National Population and Family Planning Board (BKKBN). According to the law, to realize a well-balanced and healthy population, BKKBN has the competence to design family planning policy to, among others, help couples or married couples to take wise decisions and to fulfill reproductive rights responsibly. BKKBN also has the competence to educate couples on the ideal age at marriage and age to bear children, on reproductive health, birth spacing, and the overall measures to safeguard the health and lower the mortality rate of women, infants, and children.
In the following section, I shall discuss the role of BKKBN in the prevention of cervical cancer.
Cervical cancer is a cancer arising from the cervix, or the lowermost part of the uterus. The cancer is caused by the human papillomavirus or HPV3. The rates of incidence of and mortality due to cervical cancer in Indonesia are the second highest after breast cancer. According to the World Health Organization (WHO), Indonesia has the largest number of cervical cancer patients in the world. The results of the 2013 Basic Health Research show that cervical cancer and breast cancer are two diseases with the highest prevalence in Indonesia10, with 0.8‰ prevalence rate for cervical cancer and 0.5 ‰ prevalence rate of cervical cancer10. Meanwhile, the 2010 data of Hospital Information System found 5,349 (12.8%) cases of inpatient treatment due to cervical cancer and 12,014 (28.7%) cases of inpatient treatment due to breast cancer6.
- Risk Factors of Cervical Cancer
Despite extraordinary advances in medicine, the genuine cause of cervical cancer remains a question mark, with many factors that could contribute to the disease. However, research has found that by minimizing the risk factors, the risk of women to develop this life-threatening disease may be lowered by 40 percent4.
The following are some of the main risk factors of cervical cancer:
- Early Marriage
Marriage at a young age may lead to reproductive issues; the younger a person enters into a marriage the reproductive time horizon is also extended. There may also be reproductive complications with serious risks to a mother and child. In her research, Ike Ate Yuviska (2015) found that early marriage among girls younger than 16 years old may be linked to cervical cancer. According to Azis (2006), girls who are married before the age of 16 are ten to 12 times more at risk of developing cervical cancer compared to women who are married at the age of above 20 years old. At the tender ages of the adolescence period, the uterus of a female is exceedingly sensitive, and the cervix is more susceptible to carcinogenic stimulus because of the active squamous metaplasia that may stimulate the growth of cancer cells in the cervix. It is important to understand that before the age of 18 a female’s cervix anatomy is not yet fully developed.
According to Acting Director on Reproductive Health of BKKBN drg. Widwiono, while cervical cancer may take ten to 15 years to develop and may not immediately affect girls who are sexually active before 18 years old, sex at an early age has been linked to a higher risk of developing this type of cancer due the adolescents’ cervix condition that makes susceptible to HPV9. In the same note, the Head of BKKBN DR (H.C), dr. Hasto Wardoyo, Sp.OG(K) also shared about other risks associated with child marriages through the Instagram account of @bkkbnofficial: potential cervical tear that causes bleeding, increased risk of pre-eclampsia indicated by high blood pressure and swelling in the legs and feet, seizures during delivery, even death. The evidence underlines the importance for women and girls to carefully plan the timing of marriage. In the case of cervical cancer, 85 percent of the cases are caused by sexual contacts and direct or indirect contacts with HPV-infected mediums9. Women also need to be alert of possible non-sexual HPV transmission; according to internist Kristoforus Hendra Djaya, HPV may also be found in surfaces such as desks and toilet seats and may survive for up to three days8. HPV may be immediately transmitted upon contact. A person with weakened immune system that comes into contact with a large amount of the virus may be more susceptible to HPV that later develops into cervical cancer.
- Women Aged 35-50 Years Old
Other than child marriages, a research conducted by Ike (2015) also found that older age is also a risk factor of cervical cancer. Aging organs will slowly lose function, and this occurs not in just certain organs, but the overall human body. For this reason, as people age, they are more at risk of being ill or developing infection. Women at 35-55 years old are two to three times more likely to develop cervical cancer.
Some common initial symptoms of cervical cancer include blood spots between or following periods; bleeding after intercourse, pelvic examination or after menopause; watery, brown, or bloody vaginal discharge with foul smell; pelvic pain; pain when urinating or during intercourse, and blood spots in urine3. The diseases may take seven to ten years to develop into an invasive cancer, which is why most patients are only diagnosed at a later age.
In addition to the age factor, having multiple sexual partners also increases the risk of contracting HPV. In this case, a woman’s cervix will be exposed to semen with different pH levels, which may stimulate abnormal cell growth. The risk of cervical cancer is ten times greater in women that have six or more sexual partners6.
2.2 The Role of BKKBN in Preventing Cervical Cancer
Indonesia is at the cusp of the demographic dividend 2025-2035 and looks forward to celebrating a century of independence in 2045, the year that is already entitled the “Golden Indonesia”. In both of these significant periods of history, young families will be playing a crucial role for the nation. Women are the pillar of families and have vital roles. As the pillar, women need to be physically and mentally healthy. These aspects are inextricable. Therefore, strong, healthy women are the prerequisite of healthy and happy families. Without them, we may never realize healthy families. As families represent the smallest unit of a country, all women and girls in Indonesia must be protected physically and mentally. Healthy women will also bear healthy, productive, and well-rounded next generation.
Law Number 52 of 2009 on Population and Family Development mandates BKKBN to realize a balanced population growth and healthy families. Exercising this mandate, BKKBN has designed a family planning policy to, among others, help couples or married couples to take wise decisions and to fulfill reproductive rights responsibly. BKKBN educate couples on the ideal age at marriage and age to bear children, on reproductive health, birth spacing, and the overall measures to safeguard the health and lower the mortality rate of women, infants, and children.
BKKBN’s program that aims to delay age at first marriage is important to be promoted to adolescents. They need to be aware and understand that family formation needs to be planned, taking into account different aspects of family life, personal readiness in terms of physical, mental, and emotional maturity as well as education, social, and economic competencies; and the knowledge about the number of births and birth spacing. According to BKKBN, the ideal age at first marriage is 25 years old for men and 21 years old for women.
In reality, married couples may be younger than the recommended age. In this case, they need to be encouraged to delay the first pregnancy until they reach a more mature age. Delaying marriage will allow the couple time to be mentally and physically ready for childrearing, while delaying pregnancy may prevent the mother from experiencing at-risk pregnancy and fatality.
Cervical cancer has been recognized as a serious threat to women. We often hear about the great merit of disease prevention rather than treatment. In Indonesia, a movement called the Prevention and Early Detection of Cancer in Indonesian Women was carried out for five years in the whole archipelago. The movement was launched by Indonesia’s first lady on April 21, 201 at Nanggulan Primary Health Facility (Puskesmas) in Kulonprogo Regency of the Special Regional Province of Yogyakarta4. The movement consists of a series of promotive, preventive, early detection, and treatment activities. The goal was to increase public awareness and engagement in the efforts to control the risk factors of cancer and cancer early detection to lower the prevalence and mortality rate associated with cancer4.
Preventive Efforts of Cervical Cancer:
- Leading a healthy lifestyle, abbreviated into CERDIK4 in Indonesian, which stands for regular check-up, no smoking, do physical activities, do healthy diet, get sufficient rest time, manage stress well.
For women and girls, the first preventive step is to keep the reproductive organs clean. Women and girls need to learn the ways to do this properly, including the healthy way to keep vaginal hygiene, avoid towel sharing, and avoid lending personal items such as underwear or other objects that may facilitate fomite transmission of HPV. In terms of food, always choose food that are rich in antioxidants, carotenoid, flavonoid, and folic acid such as fruits and vegetables that will help the body to build immunity to fight viruses, including HPV.
- Regular screening of HPV to detect virus presence or precancerous lesions using Pap test or VIA (Visual Inspection with Acetic Acid). This is especially important for women who are sexually active, particularly in the 30 to 50 years old age group.
BKKBN has also produced materials for reproductive health education that cover a wide range of topics from the basic knowledge of reproductive health and reproductive rights, prevention of reproductive diseases including gynecologic cancer, and infertility management. The materials are made into books, posters, leaflets, and short videos uploaded to BKKBN’s official social media channels. By disseminating the materials, BKKBN ensures that the public can easily access credible information about reproductive health and disease prevention to protect their families.
BKKBN also administers FP service that is integrated with Pap test/VIA screening. This program is highly beneficial in the prevention efforts of cervical cancer. By participating in a screening process, women may learn earlier of the condition of their reproductive health that is associated to the use of contraceptives based on screening results. Unfortunately, the FP program attached to cervical cancer screening is currently limited to long-acting reversible contraceptives (LARC), leaving acceptors of short-acting contraception methods uncovered by screening. Endang (2016), in her research in Yayasan Kanker Wisnuwardhana in Surabaya, suggested a correlation between the type of contraceptives used and the duration of hormonal contraceptive consumption with cervical cancer. Birth control pills are indicated to increase the risk of cervical cancer, especially in women and girls who are found HPV positive. Evidence has shown that the use of oral contraceptives (birth control pills) for at least five years correlates with an increased risk of cervical cancer. It is also plausible, therefore, that this risk is also higher in other hormonal contraceptives. Moreover, the use of hormonal contraceptives for a duration of one year may change cervix condition. Women who use hormonal contraceptives are advised to regularly undertake Pap test/IVA screening or shift to non-hormonal contraceptives (condom, IUD, or male and female sterilization).
IUD, or intrauterine device, offered under the BKKBN’s FP program is a T-shaped device. To prepare for IUD insertion into the uterus, the cervix will be lined up with the uterus. If inflammation/infection is found in the cervix, the acceptor will be recommended for treatment to allow the cervix cells to recover and/or for the acceptor to be inoculated before IUD insertion can continue. It is best for a prospective acceptor of either hormonal or non-hormonal IUD to undertake a preliminary screening.
World Cancer Day that falls every February 4 adopted the “I Am and I Will” as the theme of its three-year campaign in 2019. The theme denotes a personal commitment to act. We all need to have a commitment to prevent cervical cancer, starting from small steps such as maintaining reproductive hygiene, educating our adolescents and teaching them about the importance of planning for the timing of marriage, and regularly undertaking Pap test/VIA. These actions will not only keep us healthy but will also make sure that our future generations are borne by healthy women. Together, we can witness Indonesia unlocking its demographic dividend in 2025-2035 because planning is ‘cool’.
Cervical cancer may be prevented by:
- Delaying age at first marriage to the ideal age of 21 years old for women and 25 years old for men. Age delay may prevent maternal and infant mortality and allow young people to be ready mentally, emotionally, and physically; to gain education, and to be socially and economically competent to ensure that the future generation is borne from healthy mothers.
- Regular Pap test/VIA for women above 35 years old, especially those who use hormonal contraceptives, and avoid having multiple sex partners.
Recommendations to BKKBN:
- To expand FP services that are integrated with Pap test/VIA to provide access for all FP acceptors to cervical cancer screening prior and after the use of contraceptives.
- To campaign 21 & 25 years old as ages at first marriage and promote the importance of regular reproductive health examination.
- Bramanuditya, Amrisinta, 2018, Hubungan Antara Pernikahan Usia Muda Dengan Kejadian Kanker Serviks di RSUP Dr. Sardjito Yogyakarta, Poltekes Yogyakarta
- Buda, Setyowati, Endang, 2016, Jenis Kontrasepsi Hormonal dan Lama Pemakaian Kontrasepsi Hormonal Dengan kejadian Kanker Serviks, Akbid Griya Husada, Surabaya
- https://www.alodokter.com/gejala-kanker-serviks-stadium-awal-dan-pencegahannya, Gejala Kanker Serviks Stadium Awal dan Pencegahannya accessed on 8 February 2021
- https://yayasankankerindonesia.org/tentang-kanker, Tentang Kanker accessed on 8 February 2021
- https://lifestyle.okezone.com/read/2019/04/20/481/2045895/kasus-kanker-serviks-indonesia-terbanyak-kedua-di-dunia Kasus Kanker Serviks di Indonesia Terbanyak Kedua Di Dunia, accessed on 8 February 2021
- https://www.p2ptm.kemkes.go.id/artikel-sehat/deteksi-dini-kanker-serviks-dengan-iva accessed on 8 February 2021
- https://www.liputan6.com/health/read/4458935/angka-kejadian-dan-kematian-akibat-kanker-serviks-menduduki-peringkat-kedua-di-indonesia, Angka Kejadian dan kematian akibat kanker serviks menduduki peringkat kedua di Indonesia accessed on 9 February 2021
- https://sains.kompas.com/read/2018/04/20/161653623/kanker-serviks-tak-selalu-akibat-seks-bebas-hapus-stigma-itu?page=all, Kanker Serviks Tak Selalu akibat seks bebas, Hapus Stigma itu accessed on 26 January 2021
- https://www.jawapos.com/kesehatan/27/11/2019/mengapa-perempuan-menikah-usia-dini-lebih-rentan-kena-kanker-serviks/, Mengapa Perempuan Menikah Usia Dini Lebih Rentan Kena Kanker Serviks accessed on 27 January 2021
- Kemenkes RI, 2015, Pusat Data dan Informasi Kementrian Kesehatan RI, Jakarta
- Yuviska, Ike, et.al, 2015, Analis faktor Terjadinya Kanker Serviks Di Rumah Sakit Umum Daerah Dr. H. Abdul Moeloek Provinsi Lampung, Jurnal Kesehatan Holistik, Lampung