Perspectives in Cervical Cancer Prevention in India

The married women of rural India are most at risk for cervical cancers.

Carcinoma of the uterine cervix is the most common cancer in South Indian women and occupies the top rank among cancers in women in most developing countries, constituting 34% of all women’s cancers. To an estimated annual global incidence of 500,000 cervical cancers, India contributes 100,000, ie. 1/5 of the world burden.¹ The magnitude of the problem is thus more than evident. The world pattern of cervical cancer, together with the age adjusted rate and ranking, clearly indicate that cervical cancer is predominantly a problem of poorer socio-economic societies.¹

On the other hand, uterine cervical cancer is a favourable site for an effective control program. It is easily accessible and there is usually a long latent period of intraepithelial neoplasia which is easily recognizable by the Pap smear. Furthermore, treatment at this stage is very effective.

The burden of cervical cancer in India, taken in the context of the additional problems of advanced disease at presentation, the country’s limited resources and health infrastructure, and the paucity of trained personnel emphasize the urgent need for a control program.

Primary Prevention
Accumulated evidence based on etiologic associations and the differential world pattern points to cervical cancer being a preventable disease. Sexual hygiene and the use of barrier contraception (condom) may largely achieve this objective but there is a need for long-term education and acceptance. Improvements in socio-economic standards would automatically reduce morbidity and mortality² but this again is a long-term process.

Primary prevention, then, involves the education of a large segment of the population, especially the high risk groups, through mass media such as radio, TV & video cassettes, about sexual hygiene, barrier contraception and control of HPV infection.

Secondary Prevention
Secondary prevention assumes vital importance in the context of the hurdles in implementing primary prevention methods. In a large country such India with a large, growing population and limited resources, population screening by Pap smear is neither pragmatic nor cost-effective. It is thus essential that we evolve our own strategies.

High-Risk Groups
The risk factors for cervical cancer in India are socio-economic, viz. they relate to education and income, personal lifestyle, religion, multiple partners and sexual exposure prior to the age of 18. There is no doubt that cervical cancer is closely associated with sexual activity and promiscuity. There is no recorded case of squamous cell carcinoma of the cervix in a nun.

Extensive viral carcinogenesis studies the world over point to Human Papilloma Virus (HPV) as an important factor in cervical carcinogenesis. Of the many HPV types, types 16 and 18 are documented as high-risk HPV associated with genital neoplasia. Although a cause and effect relationship between HPV and cervical cancer is yet to be proven, over 80% of cervical cancers today are associated with HPV infection.

The first IARC-sponsored case control study on HPV and cervical cancer in India, which was carried out at the Cancer Institute, Chennai, documented that 99% of uterine cervical cancers were HPV-positive compared to only 22% in the controls.

Preventive vaccination is under intensive study.

Target Population
Based on our registry data, the women most at risk for cervical cancers are married women over the age of 35 years, in the low socio-economic strata, with little or no education. Since over 80% of the population of India is rural, the focus has to be on rural women, essentially agricultural workers. This however is precisely the group that resists any progressive health program unless handled with understanding, circumspection and sympathy.

Accepted methods for early cervical cancer detection and control for a developing environment include:

1. Education; access to health care
2. Unaided visual inspection and clinical downstaging
3. Aided Visual Inspection (VIA)³
4. VIA with magnification (VIAM)
5. HPV testing
6. Cytology

Cervical Cancer Screening in Affluent Countries
Cervical cancer screening has been documented to be effective in many affluent countries. After the successful British Columbia screening campaign in 1949, it is estimated that 85% of the population now at risk are screened annually, with a sharp drop in the incidence of invasive cervical cancer by about 78% and a similar reduction in mortality. Organized screening programs in Nordic countries have demonstrated a 50% reduction in mortality in Iceland and Finland which have instituted nationwide screening. In Denmark, 40% coverage resulted in a 25% reduction in mortality while in Norway, with only 5% coverage, the mortality fell by only 10%⁴ . In the UK cervical cancer screening program, it is estimated that 800 lives are saved annually, at a cost of £124 million/year⁵ .

A healthcare worker from the Cancer Institute in Chennai visits women for cervical cancer screening in the privacy of their homes.

While effective, the cost effectiveness of such screening programs has yet to be demonstrated.

Indian Studies
A number of screening projects by individual institutions, conducted either in collaboration with IARC or on their own, have been undertaken or are ongoing. The ongoing IARC collaborative projects comprise both randomized and non-randomized, controlled intervention studies for evaluation of different methodologies in early detection. A total of 457,000 women are being evaluated in the eight ongoing studies, but this constitutes hardly 0.25% of the total eligible women at risk.

From the available studies, the most useful and affordable methodology now appears to be aided visual inspection. Cytology, colposcopy and HPV DNA testing can be included wherever possible. A study undertaken by the Nargis Dutt Memorial Cancer Hospital at Barshi, in collaboration with IARC⁶ , demonstrated a significantly higher percentage of women with early stage cancers reporting for treatment in the intervention arm, 66% with Stage I and II disease compared with 25% in the control arm. The intervention group was provided with an effective education and awareness program; no such programs existed in the control group. This highlights the vital role of education in any prevention program.

Evolution in Concepts for Cervical Cancer Control – the Cancer Institute Experience
Chingleput survey: The first hospital-based, rural survey of cancer conducted in Chingleput district in 1961-62 clearly demonstrated that routine clinical screening of all women attending the rural hospitals for whatever complaint could detect cancers in the early stages (70% as compared to 5.7% in the hospital registry (61-62)⁷ . This finding underscored the imperative need for a rural cervical screening program to clinically downstage the disease which would contribute to more effective treatment, and laid the foundation for the first WHO pilot cancer control program, established in Kancheepuram in 1969.

Feasibility Project: It is on the basis of this background that the feasibility study to train village health nurses (VHNs) in the visual and digital detection of an abnormal cervix was undertaken in 1991-92 and was funded by the ICMR.⁸ 101 VHNs were trained, 6450 eligible women were screened and abnormalities were detected in 985 women. All cancers and pre-cancers were referred to the Institute for treatment, free of charge. The project concluded that the VHN is competent and capable of being trained in the visual detection of an abnormal cervix with a concordance rate of over 90%.

The feasibility project in South Arcot also concluded that a rural cervical screening program was very worthwhile with a cervical cancer pick-up rate of 115.92/100,000 women and that a cervical smear is desirable but not mandatory. A simple visual and digital examination could detect 45% of early disease. It is realized that precancers were missed but the introduction of aided visual inspection may overcome this.

Cervical cancer screening conducted in rural hospitals as part of a routine physical exam may be effective at improving early detection.

Planning a District Cancer Control Program, 1992
Our experience in oncologic care over the last 50 years has taught us that India has to evolve her own screening strategies. The concepts of cancer control and prevention have to be based on the pattern of cancer incidence, health infrastructure and economy of the country. We cannot attempt to replicate the strategies of the affluent countries. The conclusions that we have drawn based on our experience can thus relate only to our area—India and a few other countries such as Sri Lanka and Nepal. They cannot be applied to countries like Bangladesh and Pakistan where the cancer patterns and cultural practices are different, nor to other Asian countries like China, Korea and Singapore, which have excellent healthcare infrastructure.

The incidence of late disease in most of the affluent countries is about 10-12%, in British Columbia, about 3-4%, whereas in India it is almost 70-76%. Our highest priority will therefore be to identify disease earlier, at least Stage IB where the cure rate can be as high as 85%.

It is fortunate that the uterine cervix is an accessible site with early symptomatology. The negative aspect is the ignorance of the rural women, the traditional reluctance of women to seek medical aid, especially for gynaecologic complaints, added to the readily available, indigenous medical quackery.

Since the majority of women at risk live in villages, the primary healthcare personnel that need to be motivated for early detection are the village teachers, block health inspectors and the VHN. Such personnel are generally resident in the village. The VHN is readily available and when trained and sufficiently motivated, should be the central instrument of implementation.

The district-level Cervical Cancer Early Detection Program in South Arcot District was initiated in 1992 and funded by the Government of India. The objectives were to train all women doctors in the district and Taluk hospitals and primary health centers in the early detection of cervical cancer, to train VHNs in visual inspection and digital examination for detection of an abnormal cervix and to take a Pap smear. Further aims were to train cytology technicians who would be located in the district hospital itself, to train district block health educators, village school teachers, nutrition programmers and other volunteers, and provide them with educational material on cancer and early detection. Such health education will be ongoing and the trained VHNs will motivate women to accept screening through health education.

The overall objective of this plan was to integrate the screening and education program with the State’s permanent health infrastructure and delivery system, since this could significantly reduce cost.

The project trained 258 doctors, 672 village health nurses and 30 block health educators. 59,314 women were screened, 8,514 Pap smears were done for those with an abnormal cervix on visual inspection and 20 pre-cancers were detected, with a pick-up rate of 230/100,000 screened. In addition, 310 clinical cervical cancers were detected (12.3% early and 87.7% late disease.) However, we faced significant hurdles in implementing the screening at the primary health center level. The majority of women screened were from the District or Taluk hospitals and very few from primary health centers.

Conclusion
Based on the above experience, we feel that a multi-tier model, based on the local healthcare infrastructure, is practical. Our experience however, stresses:

1. The need for a separate cancer network within the framework of the health infrastructure.
2. A very committed and motivated team, preferably supported by a non-governmental agency with adequate financial support, either national or international.
3. The program could be initiated in a limited way and later extended, depending on the results.
4. In all future projects, aided visual inspection should replace unaided inspection.
5. Women with an abnormal cervix should have additional studies including: Pap smear, biopsy, colposcopy and HPV DNA testing wherever possible.

V. Shanta
Cancer Institute (WIA),
Chennai, India

References

¹ IARC Scientific Publication No. 143, 1997

² NCRP Consolidated Report of PBCRs 1990-96 – ICMR 2001 Swaminathan R, Shanta V and Rama R Cancer Registration, Pattern and Trend in India in the last two decades. IJCP 2002 (in press)

³ Uni. of Zimbabwe/JHPIEGO Cervical Cancer Project Visual inspection with acetic acid for Cervical Cancer Screening Lancet 1999, 353, 869-73

⁴ Trends in mortality for Cervical Cancer in Nordic Countries Laarh E, Day NE, Hakama M et al Lancet 1987, I, 1247-49

⁵ Improving the prognosis in Cervical Cancer RP Symonds & David Nunna Progress in Obst. and Gyn. Vol 15, 317-331
Churchill Livingston 2003

⁶ Prevention of Cancer in Dev. Countries Thai J of Obst. & Gyn. 1999-11-35-205 Parkin DM, Sankarnarayanan R

⁷ Screening for Ut. Cervical Pathology in India WHO Seminar on Cancer Control, New Delhi 1970 V Shanta & S.Krishnamurthi

⁸ Cervical Screening in Tamil Nadu – a feasibility study of training the village health nurses Cancer Causes and Control 1996-7, 520-24 CK Gajalakshmi, S Krishnamurthi, Revathy Ananth, V Shanta