Cervical cancer, a preventable and treatable disease, continues to pose a significant health burden on women in India. Estimates suggest that despite cervical cancer being the second most common cancer among Indian women, its early detection and timely management remain elusive due to various factors.

This blog aims to shed light on the challenges hindering cervical cancer awareness and screening in India and advocate for urgent action to address these issues.

What is cervical cancer?

Cervical cancer is a type of cancer that is developed in the cervix or the mouth of the uterus (womb). The main cause is a human papillomavirus (HPV) infection spread by sexual contact.¹

Did you know?

Cervical cancer claims the lives of 200 Indian women every day!²

The Reality of Cervical Cancer in India

Cervical cancer can be easily prevented through vaccination against HPV and regular screening and if caught early, it is one of the most successfully treatable forms of cancer.¹

However, the screening coverage in India remains at a distressingly low average of <2%, with higher acceptance of screening among women who are educated, of a higher age group, higher income status or women with government insurance. ³

The crux of the problem could be a lack of awareness about the disease, its diagnosis and treatment.

Barriers to Cervical Cancer Screening in India

The barriers to early detection of cervical cancer in India can be broadly categorised into

• Lack of awareness
• Cultural barriers and
• Limited access to healthcare

1. Lack of awareness or the knowledge gap

An interesting cross-sectional study conducted by Kadian and colleagues, published in 2020 in the Journal of Cancer Education assessed the level of awareness about cervical cancer and HPV vaccine among females of rural and urban areas of Haryana aged between 21 to 30 years and had at least a college-level education.

The results showed that women from rural areas had very poor knowledge about cervical cancer and its symptoms, the screening for early detection, about HPV infection or vaccines as compared to the urban women.⁴

Another survey conducted by Tripathi and colleagues in a rural area of Maharashtra painted a similar picture. Not surprisingly none of the women were aware of HPV infection, only 3% were aware of Pap smear, while only 4% were aware of screening. Women were better aware of the symptoms, tests and causes of breast and oral cancer than cervical cancer.⁵

Another important barrier in this category is the lack of early signs and symptoms as compared to other cancers like breast and oral, which dissuades most women from getting themselves screened.⁵

2. Cultural Barriers

Studies have shown a general lack of willingness of Indian women to undergo screening for cervical cancer. Although the reason for this can be attributed to a lack of awareness, most of the studies cite cultural barriers as a huge hindrance to screening.

Some of the cultural barriers highlighted were the inability to leave household work, lack of time, preoccupation with family problems, denial by husbands, feeling shy or fear of diagnosis.

There exists a huge taboo among Indian women, especially those who reside in rural areas, to speak about reproductive cancers, mainly because they are associated with sexually transmitted diseases (STDs). In addition, there is an obvious sense of embarrassment and the stigma or fear of being judged for the lack of modesty associated with the nature of the screening procedure are factors that can hinder the screening process. A lack of support from family members, especially the spouse is also seen as a barrier.⁶

3. Limited Access to Healthcare

Access to healthcare continues to remain a major challenge, especially in rural India. Studies have revealed that distance to a screening centre, and lack of awareness about centres with cervical cancer screening facilities contribute largely to the overall low diagnosis.⁵

Who Should be Tested for Cervical Cancer?

World Health Organization (WHO) recommends cervical cancer screening be done once in 3 years for all women above the age of 211. It is most commonly diagnosed in women between the ages of 35 and 44, but women above the age of 65 can also be at risk, if not screened⁷.

Women who have been vaccinated for HPV also need to undergo cervical cancer screening as often as those who have not been vaccinated, since vaccination does not provide immunity against all types of HPV infections⁷.

What is the Test to Diagnose Cervical Cancer?

Pap smear is the most common test, but its sensitivity, meaning the test's ability to find something that is actually there varies between 55 to 80%.⁷

The recommended frequency of Pap smear testing is every 3 years from 21 to 65 years. An HPV test with or without a Pap co-test can be done every 5 years. Your doctor may recommend more frequent testing if you are at a high risk, have a prior history or a family history of cervical cancer.⁷

Alternatively, DNA Ploidy is a test that can detect cellular abnormalities, and cancerous and precancerous changes upto 2 years in advance. It can detect malignant changes at an earlier stage than traditional methods, even before histopathological changes become apparent.⁸

DNA Ploidy test offered by Cervisure has 100% Specificity (ability to confirm when something is not there), and 98% sensitivity with just a <0.01% chance of false positives.^9,10

Are There Signs of Cervical Cancer to Watch Out For?

Early stages of cervical cancer have no signs and symptoms, however, in advanced stages patients experience abdominal pain, and bleeding before and before intercourse, back pain which is often persistent, white or smelly discharge from the vagina and an HPV infection.⁴

Why Early Detection Will Help?

Early detection means that the disease can be treated better and the number of deaths due to the progression of cervical cancer will decrease. Studies have shown that the 5-year survival is more than 90% when cervical cancer is detected earlier.

What are the steps ahead?

Keeping the huge cervical cancer burden and the simultaneous ability to treat and cure it if diagnosed early, the World Health Organisation (WHO) set its first-ever global commitment to eliminate cervical cancer by 2030. It aims to initiate this by vaccinating 90% of girls below the age of 15 years and screen at least 70% of women by the age of 35.

Subsequently, the Indian Government also followed suit, commencing a program to screen all women aged 30-64 years for cervical cancer every 5 years with visual inspection using acetic acid (VIA) under the National Program for Prevention and Control of Cancer, Diabetes, CVD and Stroke of the National Health Mission.¹¹ [MOHFW]

The Government of India has also initiated The National Cancer Control Programme (NCCP) with the primary objective of preventing cancers through education, screening and vaccination.¹²

Cancer registries are also being set up to provide a picture of the magnitude of cervical cancer, screening camps are being organised especially in rural areas.¹²

Yet, the numbers of cervical cancer continue to grow. To effectively combat cervical cancer in India, it is crucial to address these challenges through a multi-faceted approach

Increased Awareness is the Need of the Hour

• Launch of nationwide public health campaigns to educate women about cervical cancer, its symptoms, risk factors, and the importance of early screening.
• Improved Access to Healthcare: Expand access to quality healthcare services, especially in rural and underserved areas, to ensure that women can easily access cervical cancer screening and treatment.
• Community-Based Programs: Implement community-based programs to raise awareness and provide education on cervical cancer prevention and early detection.
• Government Initiatives: The government should prioritize cervical cancer prevention and control by allocating adequate resources and implementing national screening programs.
• Healthcare Provider Training: Enhance the training and capacity of healthcare providers in cervical cancer screening, diagnosis, and treatment.

By addressing the barriers to cervical cancer screening and promoting awareness and access to healthcare, India can make significant strides in reducing the burden of this disease. Through a concerted effort from policymakers, healthcare providers, and communities, we can empower women to take control of their health and prevent cervical cancer or detect it at an early stage.

References:

• WHO. Non communicable diseases. Cervical Cancer. Available [Online] at: https://www.emro.who.int/noncommunicable-diseases/campaigns/cervical-cancer-awareness-month-2024.html#:~:text=It%20is%20important%20to%20have,the%2025%20years%20of%20age. Accessed on 10 Sept 24
• Globocan 2022 Incidence & mortality data for India: https://gco.iarc.fr/today/en/dataviz/tables?mode=cancer&group_populations=1&multiple_populations=1
• Muthuramalingam, M R, and V R Muraleedharan. “Patterns in the prevalence and wealth-based inequality of cervical cancer screening in India.” BMC women's health 2023;23(1): 337.
• Kadian L, et al. Journal of Cancer Education. 2020. https://doi.org/10.1007/s13187-020-01712-6
• Tripathi N, et a. South Asian Journal of Cancer. 2014;3(3):122-127.
• Dsouza JP, et al. Asian Pac J Cancer Prev, 21 (8), 2209-2215.
• Cancer.org. https://www.cancer.gov/types/cervical/screening
• Bechstedt, N.; Pomjanski, N. et al. Evaluation of Static DNA Ploidy Analysis Using Conventional Brush Biopsy-Based Cytology Samples as an Adjuvant Diagnostic Tool for the Detection of a Malignant Transformation in Potentially Oral Malignant Diseases: A Prospective Study. Cancers 2022, 14, 5828. https://doi.org/10.3390/ cancers14235828
• Böcking A, Hilgarth M, Auffermann W, Hack-Werdier C, Fischer-Becker D, von Kalkreuth G. DNA-cytometric diagnosis of prospective malignancy in borderline lesions of the uterine cervix. Acta Cytol. 1986 Nov-Dec;30(6):608-15. PMID: 3466496.
• Böcking A, Nguyen VQH. Diagnostic and Prognostic Use of DNA Image Cytometry in Cervical Squamous Intraepithelial Lesions and Invasive Carcinoma Cancer (Cancer Cytopathol) 2004;102:41–54
• MOHFW. National programme for prevention and control ofnon-communicable diseases (2023-2030) India2023. Available Online]https://mohfw.gov.in/sites/default/files/NP-NCD%20Operational%20Guidelines.pdf Accessed on 10 Sept 24
• Bhatla N, Indian Journal of Gynecologic Oncology. 2021:19:41. https://doi.org/10.1007/s40944-021-00526-8(0123456789().,-volV)(0123456789,-().volV)