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Table of Contents
EDITORIAL
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 796-797

Cervical cancer screening in India: Need of the hour


Department of Maternal & Child Health, Indian Institute of Public Health Gandhinagar, Gandhi Nagar, Gujarat, India

Date of Submission16-Oct-2020
Date of Decision01-Nov-2020
Date of Acceptance12-Nov-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Kranti Suresh Vora
Indian Institute of Public Health Gandhinagar, Opp. Airforce Head Quarters, Near Lekawada Bus Stop, Gandhinagar-Chiloda Road, Lekawada, CRPF P.O., Gandhi Nagar - 382 042, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_321_20

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How to cite this article:
Vora KS, Saiyed S. Cervical cancer screening in India: Need of the hour. Cancer Res Stat Treat 2020;3:796-7

How to cite this URL:
Vora KS, Saiyed S. Cervical cancer screening in India: Need of the hour. Cancer Res Stat Treat [serial online] 2020 [cited 2021 Jan 26];3:796-7. Available from: https://www.crstonline.com/text.asp?2020/3/4/796/304990



Cervical cancer is a major killer of young women in India, being the commonest cancer after breast cancer affecting women. Cervical cancer is also a unique cancer as it is preventable and starts as an infectious disease, leading to a noncommunicable disease-cancer. Cervical cancer incidence is one of the indicators of inequity for women living in low-resource settings. Low-income countries have four times higher age-standardized incidence rates (ASRs) compared to more affluent countries.[1]

In India, more than 130,000 cases are reported every year and more than 70,000 deaths occur due to cervical cancer, which is higher than maternal deaths. India accounts for about 20% of cervical cases globally. Wide ranging ASRs of 9 and 40 per 100,000 women indicates lack of data and differential access. No systematic cervical cancer screening programs are available at the national level.[1]

A study based on secondary data analysis of National Family Health Survey (NFHS)-4 reported that only 30% of 336,777 women between 30 and 49 years of age reported ever undergoing cervical cancer screening. Cervical cancer screening prevalence varied by geographic region, between 10% in the Northeast region to 45% in the Western region of lifetime screening.[2] This low uptake of cervical cancer screening can be attributed to a number of factors, as demonstrated by the literature, including low level of knowledge and awareness, low level of perceived risk, stigma associated with cancer, fear of cancer, cost, and familial obligations.[3] Education of the women and their partners also matters as the probability of screening increased with years of education of women and their partners.[2]

India needs to develop health system capacity to ensure ef?cient cervical cancer screening program and community level efforts to improve knowledge about cervical cancer and screening programs to enhance community participation in the same.

Developing countries have implemented high-quality cytology-based cervical cancer screening with efficient coverage of the population at risk. This led to significant declines in cervical cancer in these countries by 35%-90%.[4]

A study of Pap Smear in 277 high-risk persons reported that 19% of women had epithelial abnormalities and more than 50% had nonspecific inflammation. Younger women were more likely to have epithelial abnormalities compared to older women.[5] Limitation of the study is that findings are not generalizable and also women who came forward for the screening may be more conscious about their health, hence different from high-risk women who did not come forward for the screening. This indicates the importance of regular screening and timely treatment of precancerous conditions to prevent cervical cancer among high-risk population such as sex workers.

DNA-based Human papillomavirus (HPV) detection is one of the most reliable of all cervical cancer early detection tests.. The most commonly used HPV DNA-based testing in clinical practice is a test based on hybridization, Hybrid Capture II. It detects the presence of 13 high-risk HPV types for viral DNA above a certain threshold. Although it is an accurate test, it requires the presence of high-end laboratory infrastructure and skilled personnel. Negative HPV test gives a longer period for retest. There are simple rapid portable tests for diagnosing 14 high-risk HPV types for single visit approach. Liquid cytology is traditional screening method, which is also expensive and requires skilled people.

Cytology or HPV-based screening methods are not practical for population-based screening in India due to large population and lack of funding, trained staff, and infrastructure. Low-resource and effective cervical cancer detection methods that can be performed by paramedical staff should be identified and implemented.

Visual inspection with acetic acid (VIA) or triage of VIA-positive women with cytology can be a reasonably accurate way of cervical cancer prevention. The “screen-and-treat” approach is an alternative strategy where the decision is based on the screening results.[6] These strategies can help reduce prevalence, morbidity, and mortality from cervical cancer.

Preventive strategies cannot work unless there is adequate community participation. To improve community participation, limited-resource countries such as India need paramedical workers for screening and awareness generation. Community health workers (CHWs) have been suggested as an option to help reduce the incidence of cervical cancer morbidity and mortality. A review found that CHWs can improve community awareness and help in or carry out screening and follow-up. Adopting participatory approaches in CHW interventions would enhance acceptability.[7]

Lack of knowledge and awareness about the importance of preventive health care and near absence of evidence-based practices is common in the community, especially among women. Sociodemographic characteristics including education are important predictors of participation in the screening program.[8] A qualitative study done among community women and service providers in South India noted that unawareness and poor understanding of the screening process, fear associated with the procedures and the disease, no financial and family support, and sociocultural beliefs are the barriers to follow-up for cervical cancer screening. Establishing a community rapport and using local community-based organizations/CHWs to track the women increases follow-up and community-based screening. Follow-up through phone calls and home visits along with improved awareness about the screening process and its benefits can mitigate the loss to follow-up.[9]

In conclusion, cervical cancer is a preventable cancer with effective population-based screening and effective community-based follow-up. DNA-based HPV screening and VIA triage are evidence-based strategies for low-resource settings. Involvement of community-based workers in developing rapport with the community and screening/follow-up process will increase participation of eligible women in the elimination of cervical cancer. The incidence of cervical cancer will not reduce unless low-resource settings such as India strive to eliminate cervical cancer employing evidence-based screening strategies.



 
  References Top

1.
Hull R, Mbele M, Makhafola T, Hicks C, Wang SM, Reis RM, et al. Cervical cancer in low and middle-income countries. Oncol Lett 2020;20:2058-74.  Back to cited text no. 1
    
2.
Van Dyne EA, Hallowell BD, Saraiya M, Senkomago V, Patel SA, Agrawal S, et al. Establishing baseline cervical cancer screening coverage - India, 2015-2016. MMWR Morb Mortal Wkly Rep 2019;68:14-9.  Back to cited text no. 2
    
3.
Vora K, McQuatters L, Saiyed S, Gupta P. Knowledge, attitudes, and barriers to screening for cervical cancer among women in India: A review. WCRJ 2020;7:e1504.  Back to cited text no. 3
    
4.
Mishra GA, Pimple SA, Shastri SS. Prevention of cervix cancer in India. Oncology 2016;91 Suppl 1:1-7.  Back to cited text no. 4
    
5.
Kanthimathy SD, Kizhakkebhagam NG, Aravind S, Parambil NA, Therayangalath B, Keloth SN. The spectrum of cytologic patterns in cervical smears of a high-risk group: Retrospective analysis of a cancer detection camp experience. Cancer Res Stat Treat 2020;3:692-9.   Back to cited text no. 5
    
6.
World Health Organization. Annex 3. Flowcharts for Screen-and-Treat Strategies (negative or unknown HIV status). WHO Guidelines for Screening and Treatment of Precancerous Lesions for Cervical Cancer Prevention. World Health Organization; 2013. Available from: https://apps.who.int/iris/bitstream/handle/10665/94830/9789241548694_eng.pdf; jsessionid=30F1012A04CA1F8DDF736486E5B247A8?sequence=1. [Last accessed on 2020 Oct 12].   Back to cited text no. 6
    
7.
O'Donovan J, O'Donovan C, Nagraj S. The role of community health workers in cervical cancer screening in low-income and middle-income countries: A systematic scoping review of the literature. BMJ Glob Health 2019;4:e001452.  Back to cited text no. 7
    
8.
Vora K, Saiyed S, Joshi R, Natesan S. Community Level Barriers for Cervical Cancer Screening in Marginalized Population. Int J Reprod Contracept Obstet Gynecol 2020;9:5006-11.  Back to cited text no. 8
    
9.
Vidhubala E, Shewade HD, Niraimathi K, Dongre AR, Gomathi R, Ramkumar S, et al. Loss to follow-up after initial screening for cervical cancer: A qualitative exploration of barriers in Southern India. Cancer Res Stat Treat 2020;3:700-7.  Back to cited text no. 9
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