The Indian Cancer Society recently released a Position Paper to address the gap in cervical cancer. It covers issues of awareness about this cancer, primary screening, treatment and aftercare.
In the midst of COVID 19 emergency sweeping the globe, WHO called for the elimination of Cervical cancer, giving a formula & deadline. It was surely a wakeup call to governments of all Member States to sit up and take note of the dismal state of concern for women’s health in their respective countries. In India, there were 1,22,844 cervical cancer cases in 2012 and 67,477 deaths from the disease and in 2020 the corresponding number was 1,23,907 and 77,348. The numbers tell that nothing much has changed over the years.
Cervical Cancer is a slow growing cancer that is completely preventable, and curable when detected early. Early symptoms are slight and may be missed and hence, there is a urgent need for preventive care. The cancer can take up to 10 years to manifest fully. There are many risk factors that make cervical cancer so common, the most significant one is the “Human Papilloma Virus (HPV)”. It has been around for a long time; long enough to mutate into multiple strains and affects over 90% of men and women. It is sexually transmitted, but not counted as a serious hazard. It does not require penetrative sex, skin to skin contact and heavy petting also does the work.
When young people are vaccinated before age of puberty, the vaccination is most effective. It is still very effective upto age 15 years, thereafter, more doses are required to ensure protection. However, vaccination alone is not a magic bullet, sexually active men and women can reinfect each other. Hence, below are some ways how women can prevent themselves from cervical cancer and get cured, in case they are diagnosed.
Regular screening: One of the most effective ways to control cervical cancer is regular screening, which enables primary prevention. Early screening, with Pap smears or HPV DNA tests, identify precancerous changes in the cervix, and can be detected before they progress to cancer, which again allows time for intervention. Cervical cancer, with its long precancerous stage, presents an opportunity for prevention by eliminating these early changes. Historically, the PAP Test and Visual Inspection with Acetic acid (VIA) test were primary prevention methods, but with the understanding that HPV is a leading cause, testing vaginal secretions for HPV DNA and vaccination now offer more robust approaches to primary prevention. The global WHO strategy encourages a minimum of two lifetime screens with a high-performance HPV test at age 35 and again by age 45 years.
Vaccination is a recently introduced intervention for primary prevention, which has yet to take off in India, due to cost constraints and acceptance issues around the vaccination of girls and later boys in the pre pubertal of age group 9-14. The rationale for vaccinating girls at this age is that they should be protected before their first sexual encounter with the virus. Ideally, awareness of the vaccine and its efficacy should precede the roll out of the vaccine. This is where well crafted, non-threatening messaging, aimed at parents, and teachers, schools, paediatricians and family practitioners would help to sensitize urban and rural populations to this preventive intervention.
Visual inspection with acetic acid (VIA) is a quick test method, with results in lesser turnaround time. It is a naked eye examination of the uterine cervix after application of 5% acetic acid and interpreting the result after one minute. This is a simple and inexpensive test with moderate sensitivity and specificity for screening of precancerous cervical lesions and early invasive cancer. The result of the VIA test is immediately available. It does not require any laboratory support. Capacity building for VIA along with access to the screened individuals and treatment approach is limited.
Chairperson
Indian Cancer Society, Delhi.
Public health issues are intricately connected to issues like availability of privacy in toilets, water, clean menstrual protection and most of all, an awareness of this vital organ. Lack of information and understanding among men, yes men, and women leads to neglect, shame and commodification of women. This cancer affects not merely the individual, but also the family, as it often takes the lives of women in prime years of their lives, leaving dependent children, aging parents and bewildered husbands.
Despite the high prevalence of cervical cancer in India, there is a notable absence of a nationwide government-sponsored public health policy for screening or early diagnosis. NFHS-5 data reveals a mere 1.9% of women (2.2% urban, 1.7% rural) in India have undergone cervical cancer screening. Disparities exist, with higher screening rates among urban women in Mizoram, Himachal Pradesh, Kerala, and Maharashtra, while paradoxically, rural women in Andhra Pradesh, Bihar, Jammu and Kashmir, Telangana, and West Bengal show higher participation. Regions like Nagaland, Ladakh, and Gujarat exhibit close to insignificant cervical cancer screening rates.
Additionally, detection of individuals with high-risk HPV, pre-cancer, or early cancerous lesions is only the beginning of the prevention pathway. All screened women who have been detected positive must be directed to a Centre where they will be counselled, examined and be treated appropriately. If this important step is missed, the entire population of “Screening Exercise” is at risk. There is no greater tragedy than a woman who tests positive in a screening program and develops full-blown cancer through neglect of this vital step.
