Shailaja Tetali and Usha Rani Poli

Last week, this newspaper reported (‘Govt set to roll our vaccine drive to fight cervical cancer’, IE, January 12) that the government is planning to include cervical cancer vaccine in the universal immunisation programme; an inoculation campaign targeted at girls in the nine to 14 age group is likely to commence this year. This is a positive development.

Cervical cancer is the second-most common cancer among women in India, mostly affecting the middle-aged. With 1,23,907 new cases and 77,348 deaths in the year 2022, India contributed to one-fifth of the global burden. The main cause is the presence of persistent high-risk type of Human Papilloma Virus (HPV) infection along with co-factors like low socioeconomic conditions, low immunity status, other genital infections, smoking etc, that facilitate initiation and progression to cancer. Cervical cancer is preventable and curable if detected early.

Most cervical cancer and precancer cases can be detected in the reproductive age group. Cervical cancer has a long pre-invasive phase that lasts for 10–15 years. This provides a window of opportunity to detect and treat the neoplasia in pre-invasive stages by simple outpatient treatment modalities, preceded by early detection of cancers. When cervical cancer is detected and managed at an early stage, it is found to have over 93 per cent cure rate. Cervical cancer can be prevented through HPV vaccination of girls.

Women can be screened for pre-cancers and treatment can be initiated. Lack of awareness, fear of cancer, early symptoms of disease not being evident, and women not being screened are the reasons that detection of the disease happens in advanced stages, resulting in high mortality.

This was confirmed through findings from a population-based cross-sectional study that was conducted by the Indian Institute of Public Health-IIPH Hyderabad in 2021 to evaluate cancer-care pathways in five districts of Andhra Pradesh. It showed that for 68 per cent of patients, the first point of contact after having cancer symptoms was traditional healers and only 3 per cent had received HPV vaccination.

Similarly, for Telangana, the projected increase in the number of cancer cases and the workload for cancer care using radiation, surgery and chemotherapy treatments are estimated (by IIPHH researchers) to increase by about 28 per cent in the next decade. This is in addition to the existing leakages from “screened-positive” to the “diagnosis confirmation” step in the patient journey funnel for cancer care. The estimated patient leakage varied from around 70-90 per cent from “screened-positive” till “treatment completion”.

Cervical cancer is the only non-communicable disease that can be eliminated, with the potential to make significant contributions to Sustainable Development Goal 3.4 of reducing premature deaths by one third by 2030. The WHO advocates for interventions that are simple, feasible, scalable and are already showing initial successes in many low or middle income countries (LMICs). WHO’s global strategy incorporates clear targets and means of accountability, along three strategic pillars — widespread HPV vaccination, screening, and early diagnosis and treatment of cervical pre-cancer and cancer.

The proposed targets are 90 per cent girls fully vaccinated by 15 years of age with two doses of HPV vaccine; 70 per cent women screened with a high-performance test at 35 and 45 years of age; and 90 per cent of women with cervical pre-cancer and cancer receiving treatment, including palliative care, to achieve a goal of less than four cases per 1,00,000 women.

The Government of India has implemented cancer screening by trained nurses even in primary health centres under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke — the NPCDCS programme. Screening tools like visual screening tests and HPV tests are simple and easily available. Even if any precancerous abnormality is detected, it can be treated by simple, painless outpatient treatment methods. Evidence-based management algorithms are in place for guidance. Similarly increased uptake of the HPV vaccine by eligible girls will prevent the disease.

Indigenous HPV test kits and HPV vaccines can be a boon for resource-scarce settings, enabling scaling up of activities further. The promising new developments like single dose HPV vaccination, self-sampling for HPV testing, artificial intelligence technologies for easy and accurate diagnosis and treatment will further accelerate the future potential in elimination of cervical cancer even in LMICs.

However, there is an urgent need to strengthen population-level awareness on causes as well as prevention methods for cervical cancer, encourage the uptake of HPV vaccine, devise strategies to overcome vaccine hesitancy, and encourage age-appropriate screening, especially using HPV testing. This must be combined with capacity building for scaling up pre-cancer treatment processes, smooth referral linkages, ensuring quality cancer treatment and palliative care services as required, and ultimately strengthening the health systems to be prepared to cater the entire gamut of services for cervical cancer.

Efforts will have to be consistent to ensure screening programmes, integrating latest technology for accurate and early diagnosis. This should be coupled with strengthening cancer registries both at the population level and hospital based, with improved referral linkages. Mechanisms to reduce the financial burden for care should be strengthened. Along with all these, it is essential to build and strengthen partnerships at the primary, secondary, tertiary hospital level with NGOs working in communities, innovators striving to develop tests at individual level, and public health professionals.

It is, therefore, vital to connect all the dots in patients’ care pathways — swiftness in diagnosis and referral for treatment, improving quality of care, while incorporating digital technologies and easy communication. It will be useful to issue followup reminders and linking palliative care early on, which is essential to strengthen the efforts towards elimination. Collaborations and partnerships in latest research and adopting successful models in community outreach and care pathways are equally crucial to enable us to march towards eliminating cervical cancer.

Tetali is Additional Professor, Dean-Research and Policy Support, Indian Institute of Public Health Hyderabad and Usha Rani Poli is Senior Consultant Gynec Oncologist, Hyderabad