Consider hypothetically… a cervical cancer-free India!

Dinesh Gupta

I get to attend any number of international, national or regional clinical meetings in gynaecological oncology and I have come to understand how different countries are preparing to tackle the menace of cervical cancer and cope with growing needs on their limited resources. The success stories not only come from the Western, supposedly resourceful world but many Asian neighbours too, the latest being Bangladesh.

The Bangladesh Cancer Society has recently established a visual inspection (VIA) of cervix by three to four per cent acetic acid (by well-trained community level health workers) training and service centre in its own premises. These community volunteers organise VIA camps in different areas of the country and refer the VIA positive cases to Bangladesh Cancer Hospital & Welfare Home for further management. Awareness is being created among the people regarding the risk factors, symptoms of the disease and prophylaxis/prevention. The Society aspires to screen minimum 50 per cent of rural women population in the age group of 30 to 59 years by 2020, and also intends to maintain effective call-recall system to provide long-term effectivity to the programme. Kudos to this Society that truly cares for their folks!

While success stories inspire us deep inside, the knowledge that we in India contribute a mind boggling quarter of a global burden is a demotivator as well. Factors like country-size, target women population, preventive healthcare system are deterring factors in taking a progressive step forward towards women’s health. But, is there an inherent apathy for women and their health concerns in our country? We too have built up success stories on HIV/ AIDS, hepatitis, tuberculosis, malaria, dengue, H1N1 and so forth. Why has then cervical cancer remained one of the major causes of cancer-related deaths among our women?

India’s healthcare system is largely self-sustained. Preventive public healthcare essentially in the area of oncology is non-existent. Public health programme allocation in India declined from 1.3 per cent GDP in 1990 to 0.9 per cent in 1999 but has increased to close to 3.0 per cent GDP by 2012. Central government contribution to public health expenditure is 15 per cent of GDP while the rest is made up by the respective states in India, thereby making public healthcare essentially a state subject. The private healthcare sector still contributes to over three fourth of the GDP. Hence there are striking inequalities observed between different states. Lack of community ownership of public health programmes also impacts levels of efficiency, accountability and effectiveness. The healthcare insurance sector in India is heavily biased towards curative reimbursement than preventive one. Only 10 per cent Indians have some form of health insurance, which is grossly inadequate given the population of the country. Once hospitalised for major disease, an average Indian spends about 58 per cent of the total annual household expenditure. Over 40 per cent of hospitalised Indians resort to borrowing of funds or loans and even sell assets to cover costs of expenses. Over 25 per cent of hospitalised Indians fall below poverty line because of hospital expenses.

A sorry situation

I cannot forget the face of a woman I met many years ago, a secondary school teacher from Faridabad and a mother of two young children, who came to our reference laboratory to collect her HPV report after nearly one and a half months of sampling when she was seen in a great hurry to receive a report. Her report was positive! Upon being questioned why she delayed collecting her report, she went into tears to reveal very reluctantly that almost every day she insisted her husband to fetch a report from the lab but he never paid adequate attention, let alone collecting the report from a lab in Delhi! The day when she arrived to take a report, she did not have the money to go back home!

The anguish of many such women extends beyond the asymptomatic pains to their lower genital, pelvis or back pain or occasionally symptomatic precancer stage that slowly destroys their otherwise healthy body. Though they suffer internally, their major concern still remains their family. The devastation of cervical cancer is hard to express in words. But seeing the number of strong women whose lives it claims, hearing their stories, and comforting them in their critical hours, should reinforce our conviction that India must do something sooner to end this medical tragedy for our women folks.

It is so much more bewildering since that India has world class clinical practices and state of the art, modern care medical facilities. Hordes of diseased patients from rest of the world look at us as a global healthcare destination. The world’s biggest democracy where every individual voice is heard, a country where female foeticide is a serious legal offence, yet why is there an apathy for our women who undergo deep anxiety? Our women have contributed 50 per cent to our own national GDP, earned as much as their male counterparts or have grown more agricultural produce than men did, but we seldom have cared for their good health!

Equally intriguing is an aspect of cervical cancer is that these women-deaths are 100 per cent preventable. The paradox is that however it continues to soar alarmingly with the rise of every middle class. There were 132,000 new cases of cancer cervix in the year 2002, of which 74,100 cases resulted in death. The incidence is further likely to increase to 139,864 women by the year 2015. Nevertheless, we now have better tools and technology to save our women than ever before.

Critical factors for primary prevention are low awareness about preventive healthcare and regular screening by pap smear test but most of our women in India lack access to quality screening. Although this test has brought down the incidence of cervical cancer drastically in the Western world, it is only half as accurate in identifying women with pre-invasive disease. And because this test requires experienced cytopathologists, it is apparent that India could never adopt it in our screening programmes due to the number of grey areas in this branch of medical science.

So, what are the affordable cervical screening options available to us in India?

Screening algorithm with ensured reduction in the cervical cancer incidence

Healthcare is essentially a state subject and a consensus national preventive healthcare policy is not likely to be in place before 2020. The government and quasi-government sectors benefit from free care at the government hospitals to cost reimbursement at the private hospitals on referral basis. On the contrary, a larger section of the society in the private sector has to self-sustain healthcare provisions. The major focus of our current services in any given sector is directed towards curative and palliative aspects than the preventive one. In the absence of national guidelines, the patients get considerably confused by the diagnoses, treatment and management of dreaded diseases like cancers. The disease prognoses differ from hospital to hospital, physician to physician and even experts in the given speciality, leaving financially poorer and socially detached. On the other hand, our healthcare centres continue to be overwhelmingly burdened with loads of patients at the outpatient clinics, hospital beds insufficient for those who require critical care and even the infrastructural preparedness continues to appear deficient or lacking.

The time has now perhaps come to rationalise our healthcare priorities and available resources, probably by allocating appropriate funds to upgrade the standards of preventive healthcare. It is now well realised that the incremental benefits, of upgrading capital-intensive tertiary care facilities are going to be miniscule, as compared to enormous benefits even a meagre resource would bring in, if directed towards upgrading preventive care diagnoses and treatment facilities in India.

The most doable and financially less demanding VIA-based screening algorithm could be applied to low-resource settings which may include primary and secondary healthcare centres such as rural hospitals, taluk and sub-district hospitals, district hospitals, and state medical college hospitals. The opportunistic screening and voluntary health-check camps could be conducted by any of these centres. This approach ensures cost feasibility that allows screening maximum number of people at a given time. The VIA based programme will allow risk factor identification as a single-visit approach, establish severity of assessed factors only from among those who show screen-positive outcomes, and modify risk factor by simple outpatient procedures at the clinics or the health camp itself. Though the test may be ineffective among meno- and post-menopausal women, it is well qualified to be applied to the reproductive age group. Generally VIA is followed with a Lugol’s iodine test for better demarcation of lesion. This technique assumes better adaptability within “See-and-Treat” concept as a single visit approach. The test results could be obtained immediately and spot decision can be taken to treat. The severity of assessed risks through VIA could further be ascertained by pap testing and testing for integrated form of HPV DNA (E6, E7 gene expression) at the few nodal state medical college hospitals. The E6, E7 gene expression test shows correlation with precancer disease with more than 90 per cent specificity.

Thus, implementation of a nation-wide programme of cervical screening of women between 30 to 40 years holds significant promise to reduce the cervical cancer burden in India, even as it may look hypothetical for now!