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A BRIEF REPORT ON CERVICAL CANCER IN INDIA
Cervix
Cancer
I. Cervical Cancer
Cervical cancer starts in the cells on the surface of the cervix, the lower part of the uterus (womb) that opens at the top of
the vagina. Most cervical cancers are squamous cell carcinomas with adenocarcinomas that involve the glandular
epithelial cells, being the second most common type. Cervical cancer usually develops very slowly and starts as a
precancerous condition called dysplasia. This condition can be detected by a Pap smear and is 100% treatable. The early
stages of cervical cancer are completely asymptomatic and it can take years for precancerous changes to turn into
cervical cancer (NCBI, 2012).
Human papillomavirus (HPV) infection is a well-established cause of cervical cancer and there is growing evidence of
HPV being a relevant factor in other anogenital cancers (anus, vulva, vagina and penis) and head and neck cancers. HPV
infection is common among women but it usually goes away on its own. Persistent HPV infections, however, can cause
cellular abnormalities that sometimes develop into cervical cancer if not treated. High risk HPV genotypes includes HPV16, HPV-18, HPV 31, HPV 33, HPV 35, HPV 39, HPV 45, HPV 51, HPV 52, HPV 56, HPV 58, HPV 59, HPV 68, and HPV 69 out of
which 70% of cervical cancer are caused by HPV 16 and 18 worldwide. In India about 7.9% of women in the general
population are estimated to harbor cervical HPV infection at a given time and 82.5% of invasive cervical cancers are
attributed to HPVs 16 or 18 (WHO 2010).
II. Burden of Cervical Cancer
Cervical cancer is an important public health problem
in women in many developing countries. It is a major
cause of morbidity and mortality among women in
The Burden of Cervical Cancer in India
In 2004, cervical cancer was the third largest cause of
cancer mortality in India, and was associated with:
resource-poor settings. Majority of cancers in
developing countries like India are detected in late
stages, predominantly due to lack of awareness about
the condition, lack of availability of screening
§ 987,000 DALYs (disability adjusted life-years)
§ 88 DALYs per 100,000 women
§ 113 age-adjusted DALYs per 100,000 women
programs and prevention services (Diaz M et al, 2008).
In India, cervical cancer is the most common cancers
among women between 15 and 44 years of age,
followed by breast cancer. Current estimates report
the age adjusted incidence rate of cervical cancer per
year is 27.0 per 100,000 women with an age adjusted
mortality rate of 15.2 per 100,000 women (according
to the WHO/ICO 2010).
2
Fig. 1: States with a higher age adjusted incidence and mortality rate of cervical
cancer in India+
Bhopal
=18.94
Mizoram
Madhya Pradesh
Barshi Rural
=18.93 <1.4
Maharashtra
Barshi Expanded
=18.93 <1.4
= Incidence rate per 100,000 women
< Mortality rate per 100,000 women
Karnataka
Bangalore
=21.13
Aizwal District
=22.45 <6.4
Tamil Nadu
Chennai
=18.53 <3.0
+
ICMR, 2006-2008
3
Fig. 2: Age-specific incidence and mortality rate of cervical cancer in India+
Mortality rate per 100,000 women
Incidence rate per 100,000 women
100
Age-specific incidence and mortality rate of
cervical cancer per 100,000 women per year
90
80
70
60
50
40
30
20
10
0
0-14
15-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
Age group (years)
+
WHO, 2010
+
III. Risk factors associated with Cervical Cancer
Several risk factors increase the chance of developing cervical cancer. Most common risk factor for developing cervical
cancer is infection of HPV. There are some risk factors that may influence the progression of cervical cancer such as
leaving the HPV infection untreated and allowing it to persist for a long period of time, smoking cigarettes, weakened
immune system, multiple partners etc.
Human Papillomavirus
(HPV specially 16 &18)
Overweight or obese
Smoking
Family history of cervical
Weekend immune system (i.e. HIV)
Multiple partners
+
Hussain H et al, 2012; Dutta S et al, 2012; Franceschi S et al, 2003
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IV. Cervical Cancer Prevention
Prevention and control of cervical cancer requires primary
prevention with vaccination of high-risk patients, secondary
prevention with regular screening and treatment of pre-
Barriers to Screening Programs in India
§ Age- older women are less likely to undergo
screening
cancers, and availability of cancer treatment and palliative
§ Women who did not use contraception
care. (WHO/UNFPA, 2006) While epidemiological data is
§ Low education levels (> primary school)
useful and necessary to identify populations at high risk for
§ Reluctance to undergo testing in the absence of
cervical cancer, an understanding of the knowledge and
attitudes regarding HPV and cervical cancer prevention of
racial/ethnic groups are critical for the implementation of
symptoms
§ Costs
§ Anxiety and fear related to the testing procedure
and results
effective, targeted educational efforts. Inequities in cervical
§ Apprehension at sight of instruments
cancer screening, diagnosis and treatment and HPV
§ Long waiting time
vaccination may arise from a number of barriers including
access to healthcare, cultural beliefs and limited awareness.
To address the issue of limited vaccine uptake, it may be
beneficial to develop culturally-relevant interventions at the
individual and community levels. That coupled with an
increased educational program regarding HPV-related
cervical disease, transmission and risk, as well as vaccination
as a preventative measure, may help to diminish existing
disparities in cervical cancer incidence and mortality.
An awareness program initiated by the National Cancer
Health Promotion & Education
§ Cervical cancer is preventable
§ About the signs and symptoms of the disease
§ What they should do if signs and symptoms are
present
§ Regular screening is essential to detect the cancer
early and avoid disability and death from the
disease
improvement in the stage at diagnosis of cervical cancer
Recommendations to Increase
Participation in Screening
Programs in India
from 1988-89 to 1990-92, with a control site (no awareness
§ Sustained and focused public awareness
Registration Program at Barshi, a rural area in India, showed
program) showing no such improvement. The methodology
campaign
consisted of educating the general population about the
§ Health education activities
symptoms of the cancer, and encouraging women who had
§ Easy access to clinics for target women
such symptoms to undergo screening (Jayant et al, 2006).
§ Testing and treatment in the same session
Similar findings were reported by a study in a district in
Western India (Sankaranarayanan et al, 2001). These studies
demonstrate the importance of incorporating health
education in a national screening program.
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V. Screening Strategies
alternatives that are less expensive and can be
Despite the fact that more than 80% of cervical cancer
performed by paramedical staff in low resource settings
cases are in developing countries, only 5% of women in
(Sankaranarayanan et al, 2003; Goldie et al, 2005).
these countries have been ever tested for abnormalities
Although the sensitivity and specificity of VIA has been
of the cervix (WHO 2006). Cytology screening programs
found to vary considerably from study to study
have resulted in a marked decline of this disease in
(Sankaranarayanan et al, 2004), the general finding has
developed countries. However this method of screening
been that the sensitivity of VIA and VILI is comparable to
requires excessive use of resources in terms of
that of cytological screening, but its specificity is lower
laboratories, equipment, trained personnel, etc.
for detecting CIN2 or worse lesions (Sankaranarayanan
Furthermore, a large proportion of the Indian population
et al, 2004). Results from an Indian cluster randomized
resides in the rural areas where a very small percent of
control trial based in Tamil Nadu suggests that screening
women undergo cytology-based screening every year. In
using the VIA method substantially reduces the incidence
addition, the costs associated with these tests have
of, and mortality from, cervical cancer [incidence hazard
prevented cytology-based screening programs from
ratio of 0.75 (0.55–0.95) and mortality hazard ratio of
being effectively implemented in low-resource setting
0.65 (0.47–0.89)].(Sankaranarayanan et al, 2007)
countries.
Another screening method is HPV DNA testing, which
The difficulties in organizing cytology screening in
although expensive, can be cost-effective in the long run,
developing countries have prompted the assessment of
as it has higher sensitivity than cytological screening, can
alternative methods which may be more suitable and
detect CIN lesions at an earlier stage than cytology.
readily implemented in developing countries (Table 1).
Sankaranarayanan et al (2009) found that a single round
Visual inspection-based screening tests (VIA) and visual
of HPV DNA testing in a rural setting in India to result in a
inspection post application of Lugol's iodine (VILI) are a
decrease in incidence of, and death from, advanced
couple of screening tests that have been used in low-
cervical cancer.
resource settings, including in India (Sankaranarayanan et
al, 2004). These methods have many advantages: they are
less expensive than cytology based screening, easy to
administer and train appropriate health care workers,
Table 1: Sensitivity and specificity of
screening tests used to detect cervical
cancer+
and provides real-time results. Thereby, enabling those
eligible for treatment can receive treatment of the
Parameters
precancerous lesions using cryotherapy or loop
electrosurgical excision procedure (LEEP) on the same day
and in the same health facility. This "single visit see and
after diagnosis, hence stemming the problem of women
Sensitivity
78.7%
76.9%
93.8%
80.9%
Specificity
94.8%
89.3%
98.6%
94.6%
99%
99.1%
99.2%
-
NPV
treat" method ensures adherence to treatment soon
VIA
Screening Methods
Cytology HPV DNA
VILI
VIA - Visual inspection with acetic acid; VILI - Visual inspection with Lugol's
iodine; NPV - Negative predictive value
lost to follow-up. (Singla S et al, 2012)
+
Recent studies have demonstrated that visual inspection
Deodhar K et al, 2012; Sankaranarayanan et al, 2004; Diaz M et al, 2008
with acetic acid (VIA) and visual inspection with Lugol's
iodine (VILI) to be sensitive and effective screening
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VI. Vaccines
VII. Guidelines for Cervical Cancer Screening
HPV is largely asymptomatic, making it difficult to
in India
recognize and detect among the general population,
which limits any behavior modification (Singh, 2005).
Vaccinations may thus provide a solution for prevention.
HPV vaccines that prevent against HPV 16 and 18
infections are now available and have the potential to
reduce the incidence of cervical and other anogenital
cancers (WHO, 2010). These two prophylactic HPV
vaccines have shown excellent efficacy against persistent
HPV infections and related cervical lesions among HPVnaive women in proof-of-principle studies. Additionally,
these two vaccines have shown potential benefits in
males, younger age groups, HIV-infected patients, and
pregnant women. (WHO/UNFPA, 2006)
As cytology based screening is highly resource intensive
and cannot be implemented in resource poor areas of
India, the guidelines for implementing a cervical cancer
screening program developed by National Cancer Control
Program and WHO-India in 2006 recommend the use of
alternative screening strategies, in particular VIA, at the
primary health care level, followed immediately by a
single visit to the district hospital (DH) for further
management. All women, who on the basis of their VIA
results are referred to the DH, should be diagnosed using
colposcopy, and treatment should be offered to the
women during the same visit itself, to avoid loss to follow
up. Confirmation of diagnosis using pap smears and biopsy
should be done subsequently. The guidelines strongly
Table 2: Comparison of HPV vaccines
Gardasil
+
Cervarix
recommend that information, education and
communication activities should be incorporated into the
screening program. In addition the guidelines provide
Target
population
Girls 9 through
26 years of age
Active
against
HPV 6, 11,
16 and 18
Prevent
against
Cervical cancer,
Vulvular cancer,
Vaginal cancer,
Anal cancer,
Genital warts,
Precancerous
Cervical, Vaginal,
Vulvular and Anal
lesion.
Girls 9 through
25 years of age
details of the roles of different healthcare professionals,
training of personnel, preparation and procedures for
HPV 16 and 18
screening, equipments required, protocols for referrals
and follow up, and procedures for monitoring and
Cervical cancer,
CIN1, CIN2 or
worse grade
diseases and
Adenocarcinoma.
evaluation as well as quality control. (WHO/NCCP, 2006)
+
Merck & co, 2009; GSK, 2009
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