In Conversation With Dr. Priya Ganesh Kumar & Dr. Sandeep Sewlikar
1. WHO wants cervical cancer to be eradicated by 2030. How do you think India is placed to achieve this?
On 17th November 2021, WHO released a vision document to eliminate cervical cancer as a public health problem by 2030 and set the threshold as 4 per 100,000 women for elimination. In India, many states are reporting 3-4 times higher number of new cervical cancer cases per 100,000 women population. In 2020, India reported >123,000 new cases and >77,000 deaths due to cervical cancer. WHO has further set the 90-70-90 targets by 2030 which specify:
● Vaccination - 90% of girls are fully vaccinated with the HPV vaccine by the age of 15 years.
● Screening - 70% of women screened using a high-performance test twice in their lifetime by the ages of 35 and 45 years.
● Treatment - 90% of women with pre-cancer treated and invasive cancer receive timely treatment.).
However, vaccination for cervical cancer is not part of the national immunization program in India, although vaccines are available against most cancerous HPV genotypes. Cervical cancer screening (at least one-time screening in a lifetime) coverage is very low and covers less than 10% of the target population.
It is a long road ahead for us to achieve the target set by WHO, considering our geographical complexity, the infrastructure required, and the prevalent levels of public awareness regarding the disease. We are facing a high disease burden due to the absence of an organized cervical cancer screening program, leading to the detection of cancer at an advanced stage.
One positive development locally has been the publication of the consensus document ‘Making a Road Map for India - Implementing Optimal Screening Strategies’ towards cervical cancer elimination on the sideline of the IFCPC (The International Federation of Cervical Pathology and Colposcopy) World Congress 2021 seminar.
2. What are the steps that India needs to take to eradicate cervical cancer?
We have to work at multiple levels to implement the robust cervical cancer elimination program.
a) Policy Change: We need major policy changes to include HPV vaccination in the national immunization program, adoption of high-performance tests like a clinically validated HPV DNA test for cervical cancer screening, and enable access to treatment for women with precancerous and cancerous lesions. Political will and insurance coverage for screening could provide a major boost to the programs. Funding support is critical for the sustainable cervical cancer elimination program and support through CSR will provide the much-needed financial support for mass-level programs.
b) Infrastructure Development: We also need a major boost in infrastructure development enabling access to quality care for daycare treatment like colposcopy, thermoablation, cryo-ablation, etc. for medical intervention at the right time. Molecular testing has received a boost in the country during the pandemic and we can use the existing setup for transitioning to HPV DNA-based screening programs and to establish more molecular diagnostics laboratories. Capacity building is equally important to have trained healthcare staff for sample collection, transport, and testing.
c) Public awareness: The most critical piece is to overcome the social barriers and encourage women to come forward screening and send their daughters for vaccination. We can use a three-pronged approach - sensitization, advocacy, and acceptance, to increase public awareness and address their myths on cervical cancer. We believe NGOs could play a big role here.
3. How do you think public and private players need to come together for this?
The public-private partnership will be highly useful to build efficiency and momentum in the cervical cancer elimination program and will serve as a sustainable model in the end. It will also address the challenges of geographical complexity, logistical issues, and lack of access to quality care including diagnostics. PPP model could help in building up infrastructure, including setting and running the molecular diagnostics labs for HPV DNA testing and for public awareness initiatives.
4. What role does early detection play in curing cervical cancer?
If detected in the early stages, cervical cancer is one of the most preventable and curable forms of cancer in women. It takes 10-15 years for precancerous lesions to develop into cancer. Persistent infection with oncogenic human papillomavirus is the primary cause of precancerous and cancerous cervical lesions. Hence, the objective of the screening is to detect women early before they develop cancerous lesions.
5. Which methods do you think are available for the detection of cervical cancer?
Cervical cancer screening can be done using cytology-based Pap test, VIA (visual inspection with acetic acid), and HPV DNA test. The HPV DNA test is clinically validated to identify women who are at risk and have high sensitivity (>90%) and high negative predictive value whereas cytology and VIA testing is subjective tests with average sensitivity ~50-60%.
The screening interval for HPV DNA is every 5 years. Various guidelines have included HPV DNA tests as a primary screening tests for cervical cancer. WHO included HPV DNA test as primary screening in the guidance document released in 2021 and also considered it for the ‘Screen and treat’ approach. Additionally, it also provides actionable results such as genotypic information to triage women appropriately for further medical interventions.
