Cervical Cancer Prevention Efforts in India: A Reality Check

Burden of Cervical Cancer Cancer is a major societal, public health, and economic problem in the 21st century, responsible for almost one in six deaths (16.8%) and one in four deaths (22.8%) from noncommunicable diseases (NCDs) worldwide.[1] Cancer causes three in 10 global premature deaths from NCDs (30.3% in those aged 30–69 years), and it is among the three leading causes of death in this age group in 177 of 183 countries.[2] Cancer has been associated with reduced life expectancy and substantial societal and economic expenditures that vary in degree across cancer types, geography, and gender.[3] Gynecological cancer is one of the leading causes of mortality, and the burden is increasing, largely in low and middle-income countries where more than 20 million new cases are projected per year as early as 2025. According to GLOBOCAN 2022 data, the most diagnosed cancers in women are breast cancer (157 countries) and cervical cancer (25 of 28 remaining countries, mainly in sub-Saharan Africa as well as South America and Southeastern Asia). Breast cancer and cervical cancer are the leading causes of cancer death in women in 112 countries and 37 countries, respectively, followed by lung cancer in 23 countries.[2] Cervical cancer is the fourth most common cancer in terms of both incidence and mortality in women. In 2022, cervical cancer ranked 8th in incidence overall with 661,021 new cases (3.3%) and 9th in mortality with 348,189 deaths (3.6%). Incidence and mortality rates vary at least 10-fold, with the highest regional incidence and mortality rates found in sub-Saharan Africa and Melanesia and the lowest rates found in Northern America, Australia/New Zealand, and Western Asia.[3] Cervical cancer is a fully preventable disease but remains the main cause of cancer death in women in 36 low and middle-income countries (LMICs).[4] In November 2020, the WHO launched a global initiative to eliminate cervical cancer as a public health problem. The WHO proposes a global elimination threshold of four cases per 100,000 women years and the implementation of a triple intervention strategy, consisting of vaccinating at least 90% of girls against human papillomaviruses (HPVs) by the age of 15 years, screening 70% of women using a high-performance test by 35 years of age and again by 45 years of age, and treating at least 90% of identified precancerous lesions and invasive cancers.[5] Cervical cancer screening coverage is a key monitoring indicator of the WHO cervical cancer elimination plan.[5] A review and systematic analysis published in Lancet surveyed cervical cancer screening programs and age-specific coverage estimates for 202 countries and territories worldwide found that two in three women aged 30–49 years have never been screened for cervical cancer. They found that 133 million (84%) of 158 million women aged 30–49 years living in high-income countries had been screened ever in lifetime, compared with 194 million (48%) of 404 million women in upper-middle-income countries, 34 million (9%) of 397 million women in lower-middle-income countries, and 8 million (11%) of 74 million in low-income countries.[6] The Indian Scenario Cervical cancer is the second leading cause of death due to cancer among women in India. India has a population of 511.4 million women with age >15 years who are at risk of developing cervical cancer.[7] In 2020, India accounted for 21% of new cases of cervical cancer. As deduced by the GLOBOCAN 2022 data, in India, the age-standardized rate of cervical cancer is 17.7 per 1 lakh females with an incidence of 32.1% (127,526 cases) and mortality rate of 40% (79,906 deaths) in the Asian continent. China has a higher incidence of 37.9% (150,659 cases) but a lower mortality rate of 27.9% (55,694 deaths).[4] India claims more than one-fourth of the deaths due to cervical cancer among low- and middle-income countries. The peak age of incidence for cervical cancer in India is 50–59 years, whereas in developed countries, it is 35–44 years.[8] The high age group in Indian women at the time of diagnosis of cervical cancer is because many women who are diagnosed with cervical cancer are already in the advanced and late stages of the disease, i.e. 32.8% of women have localized disease, and 67.2% of patients, the disease has spread beyond the uterine cervix at the time of initial diagnosis.[9] The delay in diagnosis makes treatment expensive and results in a poor prognosis, eventually leading to higher mortality rates. With regard to the current population growth rate, the number of new cases of cervical cancer for all ages in India in 2040 is estimated to be 191,347 – an increase of 54% over the number of new cases reported during 2020. The mortalities due to cervical cancer in India in 2040 are estimated to be 124,677 – an increase of 61% over the estimated number of deaths due to cervical cancer in 2020.[10] Evolution of Cancer Control Programs in India The National Cancer Control Programme (NCCP) was first launched in 1975, with priorities given for equipping the premier cancer hospitals/institutions. In 1984, emphasis was laid on primary prevention and early detection of cancer cases. In 1990–1991, the District Cancer Control Programme started in selected districts (near the medical college hospitals). In 2004, evaluation of NCCP was done and the program was further revised. Cancer control is now a part of the National Programme for Prevention and Control of Cardiovascular Disease, Diabetes, Cancer and Stroke (NPCDCS) program which was launched in 2010 to prevent and control major NCDs.[11] In 2016, as part of the Ayushman Bharat Comprehensive Primary Health Care Programme and the National Programme for Prevention and Control of Cardiovascular Disease, Diabetes, Cancer, and Stroke (NPCDCS), India proposed a plan for launching a national cancer screening program.[12] Population-based screening for cervical, breast, and oral cancers is being implemented under the National Health Mission as part of comprehensive care, complementing the NPCDCS. Status of Cervical Cancer Screening in India The progression of cervical cancer is such that early diagnosis should initially target women in their 30s and 40s who have a higher prevalence of high-grade precancerous lesions (Cervical Intraepithelial Neoplasia 2/3). The most effective prevention strategy for cervical cancer is the systematic screening of women through an organized program along with treatment and follow-up of the screen-detected precursor lesions.[13] The importance of screening for cervical cancer cannot be overemphasized, because diagnosis at the earliest stage of disease is the key to achieving a complete cure without recurrence.[14] Factors affecting cervical cancer screening Lack of awareness about the disease Lack of knowledge about sexually transmitted diseases Religious beliefs Educational status Children at home who need attention Autonomy in decision-making toward health care Wealth index Distance to health facility along with transportation facilities. The National Family Health Survey-5, for the first time, has provided information on oral, breast, and cervical cancer screening in all states and union territories (UT) in India from the years 2019 to 2021. It is the only source of data available to evaluate the utilization of population-based cancer screening implemented under the National Programme for Prevention and Control of Cardiovascular Disease, Diabetes, Cancer, and Stroke (NPCDCS), which will help us to understand the gap between implementation and utilization of cancer screening in India. Salient findings of National Family Health Survey-5 An alarmingly low number of cervical cancer screenings is depicted as most states fall in the range of 0–15 per thousand women[15,16] The pattern of cervical screening indicates that the southern region states have a decent screening percentage, with Tamil Nadu having the maximum percentage, followed by Andhra Pradesh and Kerala The average national prevalence of cervical cancer screening is found to be 1.97% (95% confidence interval [CI] = 1.8–2.1), ranging from 0.2% in West Bengal and Assam to 10.1% in Tamil Nadu. Tamil Nadu, Puducherry, Mizoram, and Kerala were among the first five states with the highest percentage of screening for cervical cancer. The practice of cervical cancer screening is close to insignificant in Nagaland, Ladakh, and Gujarat Tamil Nadu recorded the highest participation compared with the rest of the states and UTs in India, followed by Puducherry Mizoram state from the northeast region has the highest screening percentage, wherein cervical screening participation in urban areas was higher compared with rural areas The women living in the urban regions of Mizoram, Himachal Pradesh, Kerala, and Maharashtra have a significant number of women undergoing screening tests for cervical cancer Andhra Pradesh, Bihar, Jammu and Kashmir, Telangana, and West Bengal have more rural women participating in cervical cancer screening than those in urban areas A higher prevalence of screening is seen in: Educated women Higher age group Christian faith Scheduled caste Government health insurance coverage High household wealth. Lower prevalence of screening is seen among: Muslim women Women from scheduled tribes General category castes Nongovernment health insurance coverage High parity Usage of oral contraceptive pills Tobacco use. Marital status, place of residence, age at first sexual activity, and intrauterine device usage are nonsignificant influencers of cervical cancer screening. Steps to Promote and Implement Cervical Cancer Screening Despite the cancer control programs being in place for many years,[17] the cancer burden has been mounting, as is evident from the data coming from cancer registries across Indian states. The benefits of cervical cancer screening can be effectively availed by people if steps are taken in the right direction with the involvement of government, public, and health-care workers. Political support from international and local leaders Coordinated cooperation among multisectoral partners Broad support for equitable access in the context of universal health coverage Effective resource mobilization Health system strengthening Vigorous health promotion at all levels. Maintenance of the Cancer Care Continuum A screening program will truly be successful if women detected with precancerous and invasive cervical cancer receive a timely, affordable, and accessible treatment through a good referral system. Two of the greatest hurdles in providing a continuum of cancer care are the exhaustion of financial reserves during treatment and getting lost in the web of cancer care, which may lead to loss of follow-up Cancer care pathways in India have shown that it takes from 1 to 9 months to visit the first physician and from 3 to 24 months to reach a cancer care specialist after the appearance of symptoms. Community Participation and the Role of Auxiliary Nurse Midwives and Accredited Social Health Activists Community health-care workers can improve community awareness and help to carry out cancer screening and follow-up. Robust health education campaigns, self-help groups, and the involvement of cancer survivors can build confidence in the community.[18] The cancer screening guidelines mandate that the skilled work of conducting the screening tests should be carried out by community-level nurses ‒ also called Auxiliary Nurse and Midwife (ANM) at subcenters and primary health centers, with suspicious lesions being referred upward the community health centers and district hospitals for diagnostic tests and, where necessary, treatment. In rural areas, which account for around 70% of the population, work should be supported by community health workers called Accredited Social Health Activists (ASHAs). ASHAs are also tasked with the crucial role of explaining to the villagers about NCDs, the risk factors, and the value of early detection, to encourage them to attend the screening at their local subcenter. Role of Government and Organizations An increase in the budget for health care with a strong political commitment to strengthen the pillars of primary, secondary, and tertiary levels of cervical cancer prevention is essentially required as the burden of cervical cancer comes with economic losses as level. A well-thought program for cervical cancer control can be established under the guidance of a state program officer for each state and a nodal officer for every district. ANMs and ASHA workers must be trained to form an integral part for the implementation of the program. Regular audits, updates, and feedback can help bring about quality improvement in the program. Role of the National Institute for Cancer Prevention and Research Project Extension for Community Healthcare Outcomes (ECHO) is a “telementoring” model designed along with the National Institute for Cancer Prevention and Research (NICPR) for transferring specialist knowledge and experience to other providers, making full use of the Internet including videoconferencing technologies for cervical cancer screening. Along with the initiative of ECHO India and under the Ministry of Health, the Institute has designed a curriculum to train medical officers, gynecologists, pathologists, dental surgeons, and nurses through videoconference, presentations, and case studies. The training courses, which are free of cost for government health-care providers, are also open to private practitioners who would like to be trained in cancer screening. To date, NICPR has trained more than 1138 doctors and dentists and 232 health-care providers (including doctors from the African Union and Nepal). State governments are also providing training to health-care workers, providing capacity building under the guidance of institutes and organizations such as ICMR, CHAI, and ISCCP, and providing training and capacity building across the health-care community for cervical cancer screening. Medical colleges are also training MBBS and postgraduate students in cervical cancer screening under a mandatory screening module by National medical council (NMC). Role of Integrated Counseling and Testing Centers As per National Aids Control Organization, there are 20,756 Integrated Counseling and Testing Centers across India.[19] Cervical cancer screening and counseling at Integrated counseling and testing centers and Anti retro viral theraphy (ART) centers can help detect precancerous lesions, as women living with HIV are six times more likely to develop cervical cancer at a younger age. Women living with HIV/AIDS make up for 44% of the total 2.35 million Indian people living with HIV, thereby making screening available to a large group of people at risk.[20] Screen and treat approach Tamil Nadu screened 14.5 million women between 2012 and 2017, with a positivity rate of 3% using visual inspection with acitic acid (VIA) and only 13% of eligible women had received treatment. In West Bengal, three-fourth of HPV-positive women without any lesions at baseline screening did not return for repeat testing at 1 year. Owing to a large volume of women being lost to follow-up, the screen-and-treat approach is a better option for screen-positive women in low-resource settings.[21] Role of Practitioners and Gynecologists A gynecologist is a trusted family doctor in India who can play a pivotal role in motivating women to cervical cancer screening and vaccination of adolescents. He/she can advise them about safe sex and preventative measures in reproductive life; motivate women he/she has been treating for regular screening and treatment of precancerous lesions. Opportunistic screening during pregnancy if not performed earlier can also be carried out. Women’s participation in vaccination and cervical cancer screening programs is vital to achieve the WHO goal of Elimination of Cervical Cancer by 2030. Despite the introduction of the HPV vaccine in many countries, globally just one in eight girls are vaccinated for cervical cancer.[22] In more developed regions, 33·6% (95% CI = 25.9–41.7) of females aged 10–20 years received the full course of vaccine, compared with only 2.7% (1.8–3.6) of females in less developed regions.[23] Global coverage of the final HPV dose for 2019 is estimated at 15%.[24] Experience from the United States and Sweden has shown that HPV vaccine advocacy increases cervical cancer awareness and raises the demand for cancer screening. Empowerment of women and autonomy to make decisions regarding their health and welfare can be reinforced by government schemes such as “Beti Bachao, Beti Padhao”(education and awareness), Swachh Bharat Abhiyan to promote better toilet facilities and improve hygiene, and Ayushman Health Melas, Teleconsultation through e Sanjeevani for women who are unable to travel. Indigenous innovations such as portable colposcopes, thermal ablators, and self-HPV testing kits will further increase accessibility to screening. HPV self-sampling has been in use since 2005 and has been used in research in the US, Canada, and Africa. It does not require a trained professional to conduct it; women can collect samples themselves in the privacy of their homes. These samples can be handed over to primary health-care workers who can send them to a lab for analysis and results are as effective as sampling by a doctor. Conclusion NPCDCS must be strengthened nationwide as screening is only effective when available and being utilized by the public. Additional efforts are required to improve public awareness of cancer screening. Appropriate measures should be implemented to conduct well-organized screening programs across the country to ensure maximum participation. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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