PRB

(November 2004) On July 23 of this year, Arati Pashi of Calcutta (Kolkata) made the news when she died after profuse bleeding at Calcutta Medical College and Hospital, a premier medical facility in that city. A doctor who was supposed to be on call was absent, and the medical college’s superintendent ordered an inquiry. The investigation revealed that Pashi had been suffering from cervical cancer.

But for the questions surrounding her death, Pashi’s case may have gone largely unnoticed. Cervical cancer—which can be prevented with timely screening and appropriate treatment—is the most common form of cancer among women in India.¹

More than 130,000 new cases—roughly one-fourth of the global total—are reported in the country every year.² In addition, an estimated 74,000 Indian women die annually from the disease, which results from the abnormal growth of cells in the cervix (the narrow opening of the uterus or womb).³

Nationwide, the disease accounts for an estimated 24 percent of India’s cancer cases among women, compared with 20 percent for breast cancer.⁴ India’s National Cancer Control Program emphasizes the importance of early detection and treatment. But the country has no organized screening program, and many Indian women lack both awareness about the disease and access to prevention and treatment facilities.

These factors put poor and rural women at heightened risk for cervical cancer. “Evidence shows that the disease [in India] is more common among the lower economic strata,” says Dr. Ranajit Mandal, a specialist in gynecological oncology at Calcutta’s Chittaranjan National Cancer Institute (CNCI).

Cervical Cancer: Definition and Risk Factors

Cervical cancer’s main underlying cause is the human papillomavirus (HPV), a sexually transmitted and largely symptomless infection for which there is currently no cure. Many young people contract HPV, but the infection may remain stable or become undetectable.

In some cases, however, HPV leads to abnormal cell changes that can progress to cancer over many years. Around the world, this cancer is most common among women 35 years and older.⁵

“Cervical cancer is the commonest cancer among middle-aged women in India,” says Dr. Meenal Kumar, a senior gynecologist and menopausal consultant in the northwestern India city of Chandigarh. Kumar notes that the incidence of this cancer begins to rise among Indian women in their early 30s and peaks at ages 40 to 50.

A number of factors indirectly heighten the risk of cervical cancer by increasing the likelihood that a woman will contract an HPV infection. These factors include early age at first intercourse and multiple sex partners.

Several other factors may influence whether women with abnormal cervical-cell changes develop cancer. These factors include early age at first birth, having many births, tobacco use, prolonged use of hormonal contraceptives, and an impaired immune system, particularly related to HIV infection.

The Vulnerability of Rural Indian Women

With almost three-quarters of India’s population living in rural areas where measures of health and living standards are low, rural women are vulnerable to many of these risks.

For instance, rural Indian women tend to marry earlier and have more children than urban Indian women. (The average number of children per woman is 3 in rural areas and 2 in urban areas, according to India’s National Family Health Survey (NFHS-2) for 1998-99.⁶) And although the legal minimum age for marriage is 18 in India, roughly one-half of rural women ages 45-49 married before age 15, compared with 23 percent of urban women surveyed.⁷

A reliance on indigenous cures in some rural Indian villages and a traditional reluctance among many villagers to seek medical assistance for gynecological and other matters may also heighten women’s vulnerability to infection and disease.

“People have this fear…a psychosis about cancer,” says Dr. Sumita Deb, a gynecologist in Calcutta. “I had a patient of 59 years who came to check for post-menopausal bleeding. I advised a biopsy as her cervix was not in a good state. But she didn’t come back.”

This is the same problem that doctors at Chittaranjan National Cancer Institute face. As former CNCI director Dr. Jayasri R. Chowdhury says: “You cannot wish away cancer by ignoring it, but [avoidance of medical care] is what happens, especially with women, whose health is not a priority in the family.”

While the mass media can play an important role in spreading critical information in poor communities, many rural women in India lack any meaningful exposure to the media. Only one-half of rural women surveyed in NFHS-2 said they had regular exposure to newspapers, magazines, television, radio, or cinemas, compared with 87 percent of urban women.

India’s Women Lack Access to Effective Pap Smear Programs

Industrialized countries have achieved success in early detection of precancerous conditions in the cervix with the Pap smear. Health officials in these countries advise women to have the test soon after becoming sexually active and to repeat it every one, three, or five years. The procedure involves scraping cells from the cervix onto a glass slide and sending the sample to a laboratory to be examined by technicians trained to analyze cell structure. Women usually receive the results within several weeks.

In less developed countries, on the other hand, Pap smear programs have proved to be too difficult to implement and costly to run. India, a country of more than 1 billion people, lacks organized Pap smear programs, and screening has not reached the vast majority of women in need.

The Institute of Rural Health Studies (IRHS) in Hyderabad points out that in rural areas, the use of Pap smears is complicated by several factors:

• High costs;
• Difficulty in preserving cell samples and transporting slides;
• A lack of trained lab technicians to analyze the results; and
• Difficulties in getting women back for follow-up tests and for treatment and referral, when necessary.⁸

As a result of these difficulties, many Indian women seek care only when the cancer is advanced and difficult to treat, according to Dr. Usha Rani of the MNJ Institute of Oncology in Hyderabad, where about one-third of cancers treated are cervical cancers.

At Calcutta’s CNCI, some 14 percent of the 6,000 new cancer cases reported annually are cancer of the cervix. And according to Dr. Mandal, 85 percent of these cases are at stage III, where the chances of survival are bleak even with the best treatments.

India’s Cancer Policies Are Evolving

India launched its National Cancer Control Program in 1975-76 in response to the increasing incidence of various cancers affecting women and men. The program’s goals included the primary prevention of cancers through health education; secondary prevention through early detection and diagnosis; strengthening of cancer treatment facilities; and palliative care for patients with advanced cancer.⁹

In 1990-91, the national government added a District Cancer Control Program (DCCP) in an effort to extend prevention and early detection services to rural communities. With some financial support from the central government in the first five years, each DCCP project was linked to one of 19 regional cancer centers or to other institutions with facilities to treat cancer patients.

However, according to Dr. Mandal, the DCCP lacked a cervical cancer focus when it was launched—“which is a pity,” he says, “since [cervical cancer] is the only cancer detectable at a precancerous stage and thus completely preventable.”

With little enthusiasm from the states to continue the program when government funding ended, the DCCP has been reoriented; its goals now include collecting cancer data. While the new program places greater emphasis on cervical cancer prevention, critics say it has been confined to a few regional cancer centers with either little funding or will to carry out the work.

Studies Test Alternatives to Pap Smears

In an effort to overcome such cost difficulties and other hurdles, researchers have been assessing new methods for early detection of cervical abnormalities in poor communities—methods that are reliable, affordable, accurate, and easy to teach at the community level. Based on these criteria, a simple visual approach, with some variations, holds particular interest for countries like India.

Data show that with adequate training and supervision, non-physicians can identify cervical abnormalities through visual inspection with a vinegar solution. The technique, called visual inspection with acetic acid (VIA), involves swabbing the cervix with the solution to highlight abnormal tissue. It relies on the trained eye of a health worker, mid-wife, nurse, or a clinician; basic supplies; and little infrastructure.

Data show that the method is at least as reliable as a good quality Pap smear at detecting severe abnormalities.¹⁰ However, it is more likely to falsely identify abnormal tissue in healthy women. A similar technique that requires the use of Lugol’s iodine instead of acetic acid has a higher level of accuracy than VIA.¹¹

“The results of visual screening with acetic acid or Lugol’s iodine are promising,” says Dr. R. Sankaranarayanan of the World Health Organization’s International Agency for Research on Cancer (WHO-IARC) in Lyon, France. “With appropriate training, a large proportion of false positive testing can be avoided.”

Low-cost screening techniques have the potential to overcome problems related to lack of follow-up for women who are tested. The visual inspection approach allows test results to be available immediately, making it possible for women with perceived abnormalities to receive treatment or referral options during the same visit. IARC is working with several institutions in India to evaluate the accuracy and cost-effectiveness of visual screening, compared with Pap and HPV testing in the early detection and prevention of cervical cancer.

However, training health providers to recognize the often-subtle characteristics of cell abnormalities remains a challenge, and some remain skeptical about such tests. “There is scope for mistakes,” says Calcutta’s Dr. Rati C. Vajpeyi, a clinical oncologist.

Some studies have focused on whether non-physicians can perform the visual tests effectively. In late 1996, the Institute for Rural Health Studies (IRHS) in Hyderabad began a research project to assess whether village health workers could be trained to effectively screen rural women for cervical cancer by using visual inspection.

The health workers compared visual inspection of the cervix with Pap smears. In the first six months, women from more than 120 villages volunteered for screening, as word about the test spread.

Village health workers examined more than 2,600 women, and all but one case of cancer was accurately diagnosed by visual inspection. They could not, however, identify precancerous lesions by visual inspection alone. Positive cases were treated immediately without cost to the women. The community and the screened women who traveled to the rural clinics also received information about cervical cancer.¹²

Building on the experience of its first project, IRHS joined with IARC in 2003 for a new 3-year study in Mahbubbnagar District in Andhra Pradesh. Among other things, the study aims to assess the long-term sensitivity of visual inspection by including yearly follow-up exams.

Next Steps To Improve Access to Prevention

The results of several large studies assessing various early detection approaches for cervical cancer will influence how cervical cancer can be prevented in different settings, according to Dr. Sankaranarayanan.

For the long term, those working on cervical cancer prevention agree on the need for a massive awareness program to motivate women to get screened and to enlist the cooperation of their extended family. Key messages for this program are that cervical cancer is completely preventable and that a woman’s family benefits when she is screened.

Dr. Sumita Deb, a gynecologist in Calcutta, suggests that such a program work with anganwadi (grassroots workers) to spread awareness among families and village women. Health officials say programs can also be made more acceptable by being sensitive to distinct regions and communities.

Other analysts also stress the need to integrate cervical cancer prevention with established services. “The best resource is the family planning centers, which India has a wide network of, to reach out to the women and their families to inform them about the danger of cervical cancer and prevention measures,” says Dr. N. N. Roy Chowdhury, a gynecologist from Calcutta.

Ranjita Biswas is a freelance writer based in Calcutta, India.

References

1. World Health Organization (WHO), Regional Office for South-East Asia, Noncommunicable Diseases in South-East Asia Region: A Profile (New Delhi: WHO, 2002).
2. J. Ferlay et al., GLOBOCAN 2002: Cancer Incidence, Mortality and Prevalence Worldwide, IARC CancerBase No. 5. Version 2.0 (IARCPress: Lyon, 2004).
3. J. Ferlay et al., GLOBOCAN 2002.
4. WHO, Noncommunicable Diseases in South-East Asia Region: A Profile.
5. PATH, Planning Appropriate Cervical Cancer Prevention Programs (Seattle: PATH, 2000).
6. International Institute for Population Sciences (IIPS) and ORC Macro, National Family Health Survey (NFHS-2), 1998-99 (Mumbai, India: IIPS, 2000).
7. Balkrishna Bhike Yeole, “Cancer in Women in Mumbai, India,” Asian Pacific Journal of Cancer Prevention 3 (2002): 137-142.
8. The Institute for Rural Health Studies (IRHS), “Current Research,” accessed online at www.irhs.org/Current_research.htm, on Nov. 1, 2004.
9. Ministry of Health & Family Welfare, Government of India, 50 Years of Cancer Control in India, accessed online at http://mohfw.nic.in/cancer.htm, on Nov. 1, 2004.
10. Alliance for Cervical Cancer Prevention, Planning and Implementing Cervical Cancer Prevention and Control Programs: A Manual for Managers (Seattle: ACCP, 2004).
11. R. Sankarananarayanan et al, “Test characteristics of visual inspection with 4% acetic acid (VIA) and Logol’s iodine (VILI) in cervical cancer screening in Kerala, India,” International Journal of Cancer 106 (2003): 404-408.
12. IRHS, “Current Research.”