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Future Forum's junior research fellow, Heng Molika, was published in Kiripost on August 7, 2024. Check out the original article HERE, and read it below!
In 2022, more Cambodian women were diagnosed with cancer, with 10,624 cases compared to 9,171 in men. According to the Global Cancer Observatory, in 2022, breast cancer was the number one cancer for all ages of Cambodian women, with 2,116 new cases (19.9 percent), followed by cervical cancer at 1,274 cases (12 percent).
The estimated mortality rates for cervical cancer in Cambodia is high at least in part because the Cambodian population lacks understanding and information about both detection and prevention.
Based on a study in 2018 on the knowledge, attitudes and practices toward cervical cancer prevention among women in Kampong Speu Province, it was found that among 440 respondents, women aged 20 to 69, 74 percent had heard about cervical cancer and only 34 percent of these women had heard about the Papanicolaou (Pap) Smear test.
Shockingly, only seven percent of these women had ever been screened for cervical cancer with a Pap smear test, and only one percent had been vaccinated against human papillomavirus (HPV), the sexually transmitted infection that is strongly linked to the development of cervical cancer.
It is also important to note that Cambodia’s public health challenges associated with cervical cancer go beyond access to information about the vaccine and screening. Based on the 2022 secondary analysis on cervical cancer screening, financial constraint is one of the two main factors, along with low education, hindering women from accessing these forms of healthcare.
Women with wealthy backgrounds were more likely to have had screenings for cervical cancer. One explanation could be that women with better financial status are more likely to be able to afford screenings as well as other preventative care services, while women with lower socio-economic situations may not be able to.
In addition to insufficient information and affordability, some Cambodian women feel uncomfortable having their private parts checked. Because of embarrassment, many Cambodian women avoid regular preventive pelvic and breast examinations. They present for care only when a problem arises and only to a female healthcare provider.
Insufficient knowledge on cervical cancer and limited access to its prevention have stopped Cambodian women from having cervical screening and HPV vaccination, which are the best ways to protect women from this deadly cancer. Although there has been progress in the distribution of the HPV vaccine, there is still work to be done in order to minimise cervical cancer rates in Cambodia.
While waiting for an external partner to help and support the delivery of cervical cancer vaccines and screening, the government should ramp up efforts to disseminate information about cervical cancer and the importance of obtaining these primary prevention measures.
Cambodia’s update on HPV vaccine and screening intake
Cervical cancer is an eminently preventable disease. The disease is strongly linked to a specific type of HPV, which is an STD that affects all sexually active populations. There are 12 high-risk types of HPV that can cause cancer, but the amazing news is that there are three types of HPV vaccines on the market: Gardasil 9, Gardasil 4 and Cervarix, which protect against high-risk strains of HPV, and therefore reduce a person’s risk of contracting cervical cancer.
In its 2020 Global Strategy, the World Health Organisation (WHO) introduced the HPV vaccine as a primary prevention for cervical cancer and the HPV screening test as a secondary prevention. The HPV vaccination has been available and approved since 2006 in the US and in 2009, WHO first issued a position paper recognising the HPV vaccine.
According to the WHO’s 2020 Global Strategy to accelerate the elimination of cervical cancer incidence, the organisation set targets for each country which aims to ensure that 90 percent of girls are fully vaccinated with the HPV vaccine by the age of 15, and 70 percent of women are screened with a high-performance test by 35-years-old.
In Cambodia, on October 5, 2023, the Ministry of Health (MoH) announced the introduction of the one-dose HPV vaccine for nine-year-old girls into the national immunisation schedule to support the prevention of cervical cancer.
MoH, in collaboration with the Ministry of Education, Youth, and Sport with support from Gavi, the Vaccine Alliance (Gavi), WHO, the United Nations Children’s Fund (UNICEF), and the Clinton Health Access Initiative (CHAI), offered HPV vaccines free of charge to all nine-year-old girls nationwide through regular school and community vaccination outreach sessions and year-round services at health centres.
According to Anirban Chatterjee, Deputy Representative of UNICEF Cambodia, almost all nine-year-old girls’ cohort of 2023 have now received the vaccine. Minister of Health Chheang Ra and Chatterjee stressed that in mid-2025 the ministry plans to provide inoculations to all girls up to 14-years-old.
The delivery of the HPV vaccine is aligned with the strategic objective in Cambodia's National Action Plan for Cervical Cancer Prevention and Control 2019-2023. Currently, with a request from the MoH, this cancer policy is under the International Atomic Energy Agency’s impact review for a recommendation to strengthen a new policy.
Regarding the HPV test, opportunistic screening is practised in Cambodia. This means the test only happens when someone requests that a doctor or health professional perform the test, unlike organised population-based screening, in which eligible women get an invitation or notification that they are due for a regularly scheduled test.
Because of the unavailability of a database system for health records, we do not have data on any progress and do not know how many women have been screened in Cambodia. Because of Cambodia’s reliance on opportunistic screening, it is all the more important that Cambodian women be aware of the availability of screening and the usefulness of requesting screening for themselves.
Increasing access to the HPV vaccine and screening uptake
Providing the HPV vaccine to nine-year-old girls is certainly a good start. According to IARC’s study, which contributed to the change of the WHO’s recommendation on HPV vaccination to one dose, stated that one dose can provide comparable efficacy and durability of protection as a two-dose regimen.
As Cambodia extends its activities in this area, one dose of the HPV vaccine should also be extended to girls older than nine. GAVI expressed its commitment to augmenting the National Immunisation Program in Cambodia, but there is no concrete plan to be discussed.
While we are waiting for an external partner’s support in expanding the free delivery of the HPV vaccine, the MoH should disseminate information on the importance and availability of the HPV vaccine to the public. The HPV vaccine can be given to girls starting at age nine and is strongly recommended for preteen girls (ages 9 to 12).
The HPV vaccine works best when given before possible exposure to HPV. Simply put, the key point is that the vaccine works best if a person can receive it before becoming sexually active. Sexually active adults who have not received the vaccine can still get the vaccine as it is not likely that those adults have been exposed to all of the types of HPV that it protects against, so the vaccine still may hold some value, even for women later in life.
Currently, in Cambodia, the HPV vaccine can be found at some private hospitals and at the Institut Pasteur du Cambodge. The price varies depending on the type of vaccine administered and where it is given.
Based on WHO’s recommendation, women who are 35-years-old and above should get an HPV screening test. Similar to the HPV vaccine, the information on the benefits, cost and screening availability must be circulated, making Cambodian women aware that getting a test done is an important, easy and normal thing to do, with or without symptoms.
The Cambodian government should make use of Facebook advertisements, campaigns, or in-person events to reach as many people as possible with this information. For instance, MoH should consider organising a talk show or quiz about cervical cancer and its prevention measures on its Facebook page to engage the public.
Along with this online strategy, posters about the HPV vaccine and screening should be presented in all provincial and district referral hospitals and health centres. General doctors should be able to answer some basic related information and refer women to gynaecologists, who could provide more detail on the prevention measures intake to women.
Earlier this year, Khmer-Soviet Friendship Hospital, with the help of internationally trained physicians, offered free cervical screening service from January 29 to February 1. MoH should take this opportunity to launch a campaign, link it with this event, to promote women’s awareness on the necessity of screening.
The campaign and free screening should also be extended and repeatedly organised in provinces. The outcome of women’s engagement and knowledge increasing should also be observed and followed up to understand the effectiveness of the campaign.
The MoH should also encourage private hospitals and clinics to include HPV screening tests in their female check-up health packages. This practice could raise women’s awareness that cervical screening is a part of annual health check-ups.
Another alternative is to introduce and encourage Cambodian women to use self-sampling for HPV testing. A study on 221 Cambodian women carried out in 2021 and 2022 shows that the instruction of self-sampling is easy to follow, and a majority of women were confident enough to perform self-sampling; still, when given the option between self-testing and being tested by a clinician they chose clinician-sampling as their preferred method.
HPV self-sampling is considered a new initiative in Cambodia. It is an affordable and powerful tool for populations with limited access to health care or limited access to cervical screening, and it could reduce barriers to cervical cancer screening. The price per test is rather low, at about $4.
The accuracy of specimens obtained by the patient has been confirmed by this study to have no statistically significant difference from those collected by a doctor. With the given benefits, it is crucial for the MoH to promote and encourage women to use this new method by considering offering a free test.
This action could help women gain trust in using the HPV self-sampling test, which also solves the problem of the embarrassment women face in getting their private parts checked by others.
The dissemination of information about the HPV vaccine and cervical cancer screening, including the benefits, cost, and the details of these procedures should be the first step taken to ensure Cambodian women’s sufficient knowledge of cervical cancer and the availability of prevention measures.
Another step is to make prevention measures, HPV screening, more convenient and accessible to women. The good news is that this disease can be easily prevented, and the more Cambodian girls and women we can vaccinate and screen, the healthier our country will be in the future.
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