Dr Abdul Ghafur, Consultant in Infectious Diseases, Apollo Cancer Hospital, Chennai emphasises that the benefit of screening in reducing the incidence and mortality rates of cervical cancer has been well-documented worldwide, yet India struggles to implement widespread and efficient screening strategies
Cervical cancer presents a significant health risk to women worldwide. According to the WHO, it is diagnosed in over 600,000 women annually and results in more than 300,000 deaths every year. By 2030, the annual number of new cases is projected to rise to 700,000, with deaths expected to reach 400,000. This disease is the second leading cause of cancer-related deaths among women in India, highlighting a critical public health issue. Notably, with more than 100,000 new cases and over 60,000 deaths each year, India accounts for twenty-five percent of all cervical cancer deaths globally, a stark indication of the disease’s severe impact on the country’s female population. In India, the age-standardised incidence and mortality rates stand at 22 and 12.4 per 100,000 women per year, respectively.
The discrepancy in cervical cancer outcomes between India and other regions can be largely attributed to the absence of effective screening programs and limited access to timely and appropriate treatment. The benefit of screening in reducing the incidence and mortality rates of cervical cancer has been well-documented worldwide, yet India struggles to implement widespread and efficient screening strategies. Furthermore, the accessibility and quality of treatment for cervical cancer vary significantly across different parts of the country, exacerbating the issue.
Survival rates for cervical cancer in India starkly underscore the importance of early detection. The overall 5-year relative survival rate for all stages of cervical cancer is approximately 46 per cent. However, this figure conceals the substantial disparities in outcomes depending on the stage at diagnosis. For localised cancer, the 5-year relative survival rate is considerably higher at 73.2 per cent, highlighting the potential for successful treatment outcomes when the disease is detected early. In stark contrast, the survival rate for advanced-stage cervical cancer is a mere 7.4 per cent, emphasising the dire consequences of delayed diagnosis.
Strategies to prevent cervical cancer
These statistics highlight the urgent need for India to improve its cervical cancer control strategies. Preventing cervical cancer requires a multi-pronged approach, including ,screening, vaccination, and the early treatment of pre-cancerous conditions.
Cervical cancer screening
The World Health Organization recommends a screening rate of 70 per cent for eligible females and most developed countries have achieved this milestone. Most BRICS countries had crossed the 50 per cent screening mark, but India still has a lot of ground to cover.
Cervical cancer screening has the potential to significantly reduce mortality by 30-70 per cent, depending on the method used. Conducting primary VIA (Visual Inspection with Acetic Acid) screening every 5 years, which is the least expensive strategy, can alone lead to a 40 per cent reduction in cervical cancer cases and a 50 per cent reduction in mortality. Even the most conservative estimates, derived from one of the largest Indian series conducted in Mumbai, show a one-third reduction in mortality due to early detection of cancer. This early detection could result in 22,000 lives saved annually in India, given the current annual death toll of approximately 66,000 due to cervical cancer. This data emphasises the vital importance of implementing and maintaining regular cervical cancer screening programs to significantly affect mortality rates and enhance public health outcomes in India.
The inclusion of Primary HPV screening, a PCR-based mass screening technology, combined with the very low-cost VIA screening, can significantly improve the impact of screening. India has sufficient facilities and expertise for PCR testing, thanks to the highly successful COVID-19 PCR testing strategy it followed. Mass testing can be conducted at a fraction of the cost currently offered in private labs, due to our experience from the COVID-19 testing campaign.
Current level of screening in India
Despite these recommendations, India’s national average screening rate stands at about 1.2 per cent, one of the lowest in the world. This low rate contributes to the high incidence and mortality of cervical cancer in the country, as many cases are diagnosed at advanced stages when treatment options are more limited and less effective. The reasons for this low screening uptake include a lack of awareness, cultural barriers, issues with accessibility, and insufficient healthcare infrastructure, particularly in rural and underserved areas. Enhancing the screening rate is vital for the early detection and treatment of cervical cancer, which can significantly improve outcomes and reduce mortality rates.
HPV vaccination
Reduction in cases and deaths: HPV vaccination has the potential to significantly reduce the incidence of cervical cancer. Some models predict a reduction in cases and mortality by up to 70-90 per cent in vaccinated cohorts over the long term. Achieving high vaccination coverage rates among the target population, typically girls aged 9-14 years, before they become sexually active, is crucial for this reduction. Real-world published data shows an 88 per cent reduction in cervical cancer among vaccinated individuals, according to the Swedish registry. A meta-analysis published in 2019 demonstrated more than an 80 per cent reduction in HPV infections, more than a 60 per cent reduction in anogenital warts, and more than a 50 per cent reduction in precancerous lesions (CIN2+).
Timeframe for impact: The effects of HPV vaccination on precancerous cases (cervical intraepithelial neoplasia, CIN) can be seen within a few years after vaccination. However, the decrease in actual cervical cancer cases and the consequent mortality will take longer to appear, often several decades, due to the slow progression from HPV infection to cervical cancer.
WHO recommendations: The WHO recommends the HPV vaccine as an essential part of cervical cancer prevention strategies. The WHO has initiated a 90:70:90 campaign aiming for 90 per cent of girls to be fully vaccinated with the HPV vaccine by the age of 15, 70 per cent of women to be screened using a high-performance test by the age of 35 and again by the age of 45, and for 90 per cent of women with precancer to be treated and 90 per cent of women with invasive cancer to be managed.
Balancing immediate and long-term strategies in cervical cancer prevention
We have two primary strategies at our disposal: vaccination and screening. Which is more crucial, vaccination or screening, or perhaps both? I believe it’s both. Vaccination may take a decade or two to exhibit its full impact. If we vaccinate young girls now, it will aid in reducing the prevalence of cervical cancer when they mature, which is in 10 to 20 years. Conversely, screening currently helps to identify precancerous lesions and cancers, offering an immediate and long-term impact. By focusing solely on vaccination, aren’t we potentially overlooking the adults who are at risk of cervical cancer? The sole method to detect cervical cancer in its early stages is to identify the precancerous lesions promptly and take the necessary action. Therefore, resource allocation is key. If resources are ample, we should focus on both vaccination and screening. However, if resources are limited, it’s crucial to determine whether to concentrate on vaccination or screening. While vaccination effectively prevents cancer in the long term, screening remains the most dependable method to detect and decrease the incidence of cervical cancer in adults. It’s essential to prioritize screening efforts for early detection and prevention to decrease cancer cases in women. Currently, the rate of cervical cancer screening in India is a mere 1.2 per cent among eligible females, one of the lowest globally. The World Health Organization recommends a screening rate of 70 per cent for eligible females, a milestone most developed countries have reached. Many BRICS countries have surpassed the 50 per cent screening threshold, but India still has considerable progress to make.
The ongoing push to vaccinate young girls without a corresponding effort to increase the screening rate in adult women could lead to dire outcomes. Every year, more than 60,000 women die from cervical cancer in India. Without effective screening, we face the grim reality of witnessing the deaths of at least half a million women in our country over the next decade or two. The strategy of preventing future deaths with vaccines after 10-20 years without a concerted effort to reduce deaths in adults in the near term is not a demonstration of intelligent policymaking or proper resource utilisation.
The Sikkim model: Pros and cons
Let us consider the example of Sikkim, the one Indian state that has vaccinated more than 95 per cent of eligible girls—an exemplary accomplishment. This initiative may significantly reduce the incidence of cervical cancer in these girls as they age. However, Sikkim currently has one of the lowest cervical cancer screening rates in India, at just 0.5 per cent, compared to the national average of 1.2 per cent. Consequently, the state has not made considerable progress in preventing deaths from cervical cancer among adult women in the near future. If this approach is replicated across the entire country, I fear it may lead to a flawed public health strategy.
Why can’t we do both? We should aim to vaccinate all our girls and simultaneously escalate the screening rate for adults—let’s say to over 50 per cent within three years. However, this is unlikely to occur. Vaccination is a simpler task than screening. It is easier for governments to administer vaccines to schoolgirls than to mobilise adults for screening. Screening requires dedication and commitment from all stakeholders. Vaccination, being relatively straightforward, might offer a false sense of security, suggesting that adequate action is being taken to prevent cervical cancer deaths. A successful HPV vaccination campaign without a corresponding and impactful screening campaign is indicative of a failing public health system. If we promote vaccination through government programs and utilise all resources, it is inevitable that screening efforts will fall by the wayside as the momentum and resources will be consumed by the simpler task of vaccination.
The way forward
Our national immunisation campaign should introduce the HPV vaccine only if there is a commitment from the union health ministry and all states to allocate the necessary resources for a time-bound screening campaign. The Indian Ministry of Health should not encourage states to proceed with state-level vaccination programs unless the states make time-bound commitments to screening. A practical recommendation could be that only those states which achieve significant progress in screening within the next 2-3 years should begin allocating funds for HPV vaccination campaigns. If the Union Health Ministry or state health ministries are not in a position to guarantee screening, then their dedication to vaccination efforts might be perceived as lacking full commitment.
While government funds should initially be utilised for the expansion of screening programs, it is also crucial to encourage vaccination uptake by those who can afford it out of pocket. Awareness campaigns on the benefits of vaccination would be beneficial in this regard. Once the government succeeds in achieving a satisfactory level of screening, we should then incorporate vaccination into the national program.
It is high time our country initiated a debate on this significant public health issue. Should we save our young daughters, or should we save our wives, sisters, and mothers, or should we save both? This dilemma is akin to difficult childbirth scenarios: should we save the mother, the baby, or both?
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