Culture and its influence on an increase of cervical cancer cases in Angola

The word ‘cancer’ has a Greek origin. The surface of a solid tumor, with its vascularization in various directions, suggests a multi-legged crab. Cancer comprises a significant group of diseases characterized by unregulated cell growth. In cancer, the cells divide and grow wildly, forming ‘malignant tumors’.

Cervical cancer is the third most common type of cancer among women worldwide, with approximately 80% of cases occurring in developing countries. The highest incidence rates of this neoplasm are observed in South America, Africa, and South Asia.

It is estimated that more than 266,000 women die each year from cervical cancer, and 87% of these deaths occur in less developed regions around the world, notably in the WHO African Region. If nothing is done, the death toll will reach 416,000 by 2035. In Sub-Saharan Africa, 34.8 new cases of cervical cancer are diagnosed annually by 100,000 women, and 22.5 out of 100,000 women die from this disease.

The intraepithelial neoplasia (CIN), adenocarcinoma, and squamous (or squamous cell) carcinoma of the cervix share many risk factors. These include early onset of sex life, multiple sexual partners, promiscuity, history of sexually transmitted disease (such as Chlamydia trachomatis and herpes simplex virus), multiparity, immunosuppression, low socioeconomic status, prolonged oral contraceptive use, and previous history of dysplasia, and scaly areas of the vulva or vagina. In the case of squamous cell carcinoma, smoking is also a risk factor.

The main etiological factor of cervical cancer is HPV infection, whose DNA is detected in over 99% of cases. These viruses are transmitted primarily through sexual contact and approximately 20% of the sexually active population is infected. HPV is responsible for over 99.7% of cervical cancers, about 90% of the anal canal, 70% of vulva and vagina, 70% oropharynx, and 60% penis.

The HPV infection is widespread in the population. More than 50% of women with active sex lives acquire the virus at some point in their lives. Infection is a necessary but not sufficient condition for the development of the disease. When the infection becomes persistent, the time between initial infection and the development of invasive dysplasia/cancer is approximately 15 years, although faster courses have been described.

From infection to the development of invasive cancer, four stages are described:

According to data from the Global Cancer Observatory (2018),^[x] there was an increase in cases in Angola, in 2018.

Factors that influence increasing rates of cervical cancer in Angola: social-cultural factors: human papillomavirus (HPV), the necessary cause of cervical cancer, is endemic in Africa. Many of the factors that increase HPV acquisition and promote the oncogenic effect of the virus are also widespread in Angola. These include early marriage, polygamous marriages, and high parity.

Polygamy is accepted in many regions of Angola. In some cultures, very young girls, usually virgins, are given marriage to much older men, some with three or more wives. This practice can increase the likelihood of a girl getting an HPV infection at first sexual intercourse with her husband. Polygamy is reported to increase the risk of cervical cancer by two-fold, and the risk increases with the increasing number of wives. High parity, which is the norm in some cultures, is also a recognized and independent HPV-related cofactor for the development of cervical cancer.

Socioeconomic factors: women around the world with low socioeconomic status have a higher risk of cervical cancer. Cervical cancer is often referred to as a disease of poverty and poor women. Poverty is endemic in Sub-Saharan Africa. A recent study in Mali, West Africa, showed that within a population widely infected with HPV, poor social conditions, high parity, and poor hygiene were the primary co-factors for cervical cancer, in Angola is not different. Poverty, in its many ramifications, is also a significant barrier to the prevention and treatment of this disease.

Biological factors: poor nutritional status and infections, P. malariae, HIV, and tuberculosis are causing many people to be immunologically compromised. Reproductive tract infections are also endemic. Recent studies associate sexually transmitted infections (STIs) other than HPV with cervical cancer.

Cultural, ethnic, and linguistic taboos have a major influence on the increase in cervical cancer cases in Angola. In some regions of Angola, there is a disbelief in Western medicine, medical means, and procedures (in vaccines).

Non-adherence to gynecology consultation, reduced availability of HPV vaccine, and the belief that vaccines make women sterile are cited as critical conditions for the increase in cases.

Illiteracy, low academic level, lack of information, and sex education are proving to be a sine quo condition for the high prevalence of cases. Early age in the first coitus is one of the risk factors for the onset of the disease, in Angola sexual activity generally starts at 13-15 years.

Although polygamy is not constitutionally approved, it is practiced in all regions of Angola; there is an example of a man known worldwide for having 49 women and 160 children in the province of Namibe, southern Angola.

Multiparity is considered a normal phenomenon and prostitution is common in all spheres and regions of the country.

As long as the high numbers of low-educated, lowincome women with peer-to-peer partners, and low-discernment in Western medicine, prevail the numbers will be difficult to reverse.