Cervical cancer is a type of cancer that affects the cervix, the lowermost part of the uterus. It is a significant health concern in India, with one out of every six cervical cancer patients in the world being an Indian woman. This means that one out of every 32 Indian women will be diagnosed with cervical cancer and one out of 42 women will die from it in their lifetime. Globally, cervical cancer is the fourth most common cancer among women. In 2020, the majority of cervical cancer cases were reported in Asia, a whopping 58.2% of cases. In India, the age-standardized incidence rate of cervical cancer is 14.7 per 100,000 women, and the age-standardized mortality rate is 9.2 per 100,000 women. These figures are significantly higher than the global figures.
“Cervical cancer is associated with several factors, including poor genital hygiene, early age of marriage, multiple sexual partners, and repeated pregnancies. Other factors such as long-term contraceptive use and smoking are also associated with HPV infection, which is a leading cause of cervical cancer. Certain populations of women, such as those in correctional facilities, are at a higher risk of cervical cancer than women in the general population,” says Dr Nivedita Kaul, Dept of Obs & Gynae at the CK Birla Hospital (R), Delhi.
Cervical cancer incidence is increasing in India and globally. This is attributed to several factors such as early onset of sexual activity, unhealthy sexual practices, and an increase in habits such as smoking. These factors put women at a higher risk of developing cervical cancer. It is important to raise awareness about the risk factors and preventive measures to combat this disease.
Dr. R. Sankaranarayanan, Director, Preventive Oncology, Karkinos Healthcare, Karkinos Healthcare, says, “Cervical cancer is caused by persistent infection with one of the 14 related types of cancer-causing, high-risk human papillomaviruses (HPV). These HPV types can cause cervical lesions which, if left undetected and untreated, can progress to cervical cancer within 5-10 years. It’s important to be aware of HPV and its associated risks, as well as getting regular cervical cancer screenings and HPV vaccines if recommended by a healthcare provider.”
The goal of screening for cervical cancer is to find precancerous cell changes at an early stage, before they become cancer and when effective, simple, safe and affordable out-patient treatment can prevent their progression to cervical cancer.
Early signs of cervical cancer include
- Vaginal bleeding that occurs between menstrual periods or after menopause
- Vaginal discharge that is thick, odorous or tinged with blood
- Menstrual periods that last longer than usual
- Vaginal bleeding or pain during sexual intercourse
- Vaginal bleeding during a pelvic examination
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How can cervical cancer be prevented?
Cervical cancer is a highly preventable cancer. Cervical cancer can be prevented by having regular screenings with Pap tests and human papillomavirus (HPV) tests to find any pre-cancers and treat them. It can also be prevented by receiving the HPV vaccine.
Dr Kaul notes down additional actions that can help prevent cervical cancer:
- Delaying first sexual intercourse until the late teens or older
- Limiting the number of sexual partners
- Practicing safer sex by using condoms
- Avoiding sexual intercourse with people who have had many partners
- Avoiding sexual intercourse with people who are infected with genital warts or who show other symptoms
- Quitting smoking
Role of screening in the prevention of cervical cancer
Screening is a crucial tool for detecting precancerous changes or early cancers before symptoms occur. There are several screening tests available for the early detection of cervical precancerous lesions, including Pap smear, liquid-based cytology, visual inspection with 5% acetic acid (VIA), and testing for high-risk HPV infection. “The Pap smear test has been in use for more than six decades and is widely accepted. However, the quality and accuracy of the test can vary, leading to the need for frequent repetition,” adds Dr Sankaranarayanan.
On the other hand, HPV testing is highly recommended by the World Health Organization (WHO) as the most accurate and preferred cervical screening test over Pap smear or VIA screening. It identifies women infected with high-risk HPV types, which are the cause of cervical cancer, and allows for early detection efforts to be focused on HPV-positive women. “One of the major advantages of HPV testing is its high negative predictive value, meaning that women who test negative for HPV are unlikely to develop cervical precancerous lesions or cancer in the following 10 or more years,” feels Dr Sankaranarayanan.
The following tests and procedures may be used to screen for cervical cancer:
- Pap test. The Pap test is most common screening test for early changes in cells that can lead to cervical cancer. It involves gathering a sample of cells from the cervix. It is often done at the same time as a bimanual pelvic exam as part of a gynecologic checkup. A Pap test may be combined with an HPV test.
- HPV test. This test is done on a sample of cells removed from the cervix, the same sample used for the Pap test This sample is tested for the strains of HPV most commonly linked to cervical cancer. HPV testing may be done by itself or combined with a Pap test.
- Visual inspection with acetic acid (VIA). VIA is a screening test that can be done with a few tools and the naked eye. During VIA, a dilution of white vinegar is applied to the cervix. The health care provider then looks for abnormalities on the cervix, which will turn white when exposed to vinegar. This screening test is very useful in places where access to medical care is limited.
The World Health Organization (WHO) recommends that cervical cancer screening should start as early as age 30, with screening intervals of 5-10 years in between. This is to detect any precancerous changes or early cancers before symptoms occur, and to ensure that appropriate treatment is given in a timely manner. It’s important to follow your healthcare provider’s recommendations regarding cervical cancer screening schedule.
What is the right age of getting the HPV vaccine?
Across the world, HPV vaccination is recommended at ages 11 or 12, even though it can be started at the relatively young age of 9. The vaccination is highly recommended for all women till age 26, especially if they are not properly vaccinated against HPV earlier.
“The vaccine works best when the person is not exposed to HPV yet. Since most sexually active people are exposed to HPV, the benefit is limited. The HPV vaccine does not eliminate the HPV infection if it is already there; it only helps prevent it. For this reason, it is important that the vaccine is given at a younger age,” adds Dr Kaul.
What are some challenges in preventing cervical cancer in India?
Cervical cancer is the second most common cancer among females in our country. Low age at marriage, early age at first intercourse, higher parity raises the risk of HPV acquisition among Indian women. Cervical cancer mostly affects women from rural areas with poor socioeconomic status. Lack of screening and treatment has been identified as a factor leading to the development of invasive cancer, which leads to death. The situation is alarming in the rural settings where the majorities of women are illiterate and have poor hygienic conditions.
High incidence of cervical cancer, Poor Primary Care facilities, poor community health workers practices to participate in the screening program, and the delay in HPV Vaccine introduction are the challenges in improving cervical cancer screening in the country.
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