In Nepal, Uterine and Cervical Cancers Increase; Awareness Remains Scarce

By Tara Bhattarai

KATHMANDU, NEPAL --"I will never forget the day the doctor advised to me remove my uterus," Bikramiya Chaudhary, 33, said meekly from bed number 53 of the surgical ward of Bharatpur Cancer Hospital in Kathmandu. "This [cancer] was something I had never heard about. I felt like I was falling from a steep hill," she recalls of learning of her diagnosis.

Chaudhary suffers from uterine and cervical cancers, the most common cancers in Nepal. Despite their prominence here, many women in Nepal, especially in rural areas, remain ignorant of the disease. According to Dr. Rajendra Baral, director of Bharatpur Cancer Hospital, says the problem is rapidly increasing. "Due to the lack of public awareness, when cancer patients reach the hospital, they are often already in the last stage [of the cancer] and it is difficult for us to save them."

In her hospital bed, she wore a dirty blouse and her hands and feet were pale. These days, Chaudhary is so fragile that she cannot sit without a support. As she received a saline water transfusion in her left hand, she pressed her lower abdomen with the other hand. She muttered aiya aiya, as she twisted and turned from pain. Her husband, Kari Mahato, sat by her side looking helpless. Her mother, Laxmi Chaudhary, cried as she fanned her daughter with the end of her sari.

Chaudhary's mother brought her daughter to the hospital four days ago when she began to experience acute pain in her lower abdomen. She was diagnosed with fourth stage uterine cancer and was admitted here.

But this is not the first time Chaudhary has been admitted to the Bharatpur Cancer Hospital. She was operated on here three years ago. In 2004 she was diagnosed uterine cancer in the third stage and her uterus was removed. Chaudhary, who is from Chainpur, in a central district in Nepal, had to travel 25 kilometers to reach the hospital, one of only two available cancer treatment facilities in the country.

"The doctors said that a tumor has developed in my uterus and it needed to be removed," Chaudhary said of her first operation. Though even after her uterus was removed, she says she did not understand the reason for it. She says it was not made clear to her that she had cancer.

According to her doctor, Jitendra Pariyar, it is common for women not to understand their medical conditions. "We tell the patient's guardian about the disease," Pariyar says. Though Chaudhary is an adult woman, it is common within the medical system in Nepal for doctors not to offer female patients detailed information about their conditions. Dr. Pariyar says doctors tell patients like Chaudhary, women, about their conditions only when they inquire.

Bhola Shivakoti, the member secretary of Cancer Service Society of Bharatpur Cancer Hospital says women are often forced to wait for their husbands or son or in-laws to make treatment decisions. "When a woman and a domestic animal fall sick at the same time, the first priority is given to the treatment of animals," Shivakoti said.

While doctors and international aid organizations say that uterine and cervical cancers are both under-treated and on the rise in Nepal, the national Health Ministry here does not keep or collect any official cancer statistics. Dr. Rajendra Baral, director of Bharatpur Cancer Hospital says, "Population based statistics on cancer are not available in Nepal. But we recently started keeping records based on hospital cases," he said. The cases registered from the country's two cancer hospitals show that the problem of cancer is increasing each day.

According to records obtained from Baral, between 2003 and 2005, 5,913 cancer patients were seen at Bharatpur Cancer Hospital. More than half of the patients treated at the facility, 3,347, were women. More than 1,200 of the female patients were seen for uterine, cervical, or ovarian cancers.

While there is no way to predict the number of women in Nepal who are currently suffering from cancer, one research study conducted last year helped doctors estimate the degree of the problem. Dr. Arati Shah of Bir Hospital in Kathmandu, tested 6,100 women between the ages of 25 to 60 in Bhaktapur, a central district of Nepal for uterine and ovarian cancers. The study showed that 2.5 percent of the women tested had cancer. According to Shah, as many as 8.5 percent of the women tested showed potential for cancer in the future. Experts say that there are likely thousands of women in Nepal who are suffering from cancer. But poverty, and a lack of awareness and health services will prevent most women from ever seeking treatment for their cancers.

In Kathmandu, a woman undergoes an operation to remove her uterus.

The World Health Organization (WHO) estimates, in Nepal, of every 100,000 people 120 people have cancer. On this basis, the WHO estimates that there are as many as 30,000 cancer patients in Nepal.

Dr. Baral says the increased levels of uterine and cervical cancer are the results of early marriages and intercourse, having many children, irregular eating habits, malnutrition, smoking, lack of proper hygiene and an upsurge in sexually transmitted diseases. "Many women get married at the age of 13 or 14 in Nepal and they rear many of children by the age of 30. The possibility of cancer is more in such women," Baral said.

According to a report published in 2004 by the United Nations Children's Fund, UNICEF, 40 percent of women in Nepal get married before they reach 14 years of age while 60 percent get married between the age of 15 and 19. The reproductive rate of Nepali women is 4.1 per person and 21 percent of women have children between the ages of 15 and 19. Though the government of Nepal has outlawed marriage before the age of 18, the practice is still common.

Chaudhary was a child bride. She was married at the age of 15 to Mahato, who was the same age, in 1989. She bore her first child at the age of 16 and she went on to have three more children over the next ten years.

Chaudhary says when she first developed severe pain in her lower abdomen and vagina she did not tell her husband for fear that he would leave her and marry another woman. She says she ignored the pain for four months but when it got worse she traveled the 25 kilometers by bus to Asha Medical Center, a private clinic in the Chitwan district.

"I took a loan of 400 rupees (about $5.70 USD) from a neighbor and got myself checked at the doctor," Chaudhary said. But doctors there were unable to diagnose her at the health center and they advised her to travel to the cancer hospital in Kathmandu. "As soon as I reached [the hospital], the doctors said [they needed] to remove my uterus." She added, "After the operation I felt better. But now I am again experiencing the same pain."

Chaudhary's physician Dr. Pariyar says, "When she came to the hospital three years ago, it was already late. Among the four stages of cancer, she is in the final stage and now we cannot do anything. She will not live long."

Chaudhary is currently undergoing chemotherapy, which is very rare in Nepal. Few facilities have the technology and the cost of the treatment is prohibitive for most patients, as a single dose costs as much as 8,000 rupees, or $115 USD. Pariyar says she is also taking medication to relieve her pain. Her treatment costs are now nearing 30,000 rupees, about $429 USD. Her family pays for her treatment with a loan that her mother took from local villagers.

In Kathmandu, doctors perform an operation to remove a young woman's uterus.

According to the former chief of Cancer Prevention, Control and Research Department of Bharatpur Cancer Hospital, Dr. Murari Man Shrestha, more women could be prescreened for cancer if they received the Pap Smear tests. However, Shrestha says that due to a shortage of specialists, resources and awareness, most women in Nepal never receive the test.

Advocate Dhungana says the government is creating awareness on epidemics like dysentery, leprosy and AIDS, but is not doing anything significant to prevent cases of uterine and cervical cancer. "Since all the sectors are male dominated, women are barred even the minimum information and awareness that they should get and due to this their lives are in danger," she said.

Meanwhile, Health Ministry officials say that they are aware of the problem. Arjun Bahadur Singh, chief of policy, planning and international cooperation division at Health Ministry of Nepal, says, "In the future, we are trying to create awareness, alert people about cancer and stop the disease in its starting phase."

For Chaudhary, after she finishes her chemotherapy treatment, she wants to return home. She says she will work hard to pay the loan that she took for the treatment and she wants to send her four children to school. Her husband says, "Doctors say we came to hospital very late but the hope that she will live will linger until her last breath."

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