In the past few months, several reputed medical journals have published articles on innovative ways in which India is waging the war against cervical cancer, the leading cancer among women in this country.
Cervical cancer is a major global public health issue, particularly in developing countries with approximately 500,000 new cases and 250,000 deaths occurring from it annually. India unfortunately leads the pack, with 25 per cent of the world's cervical cancer cases occurring here. Every year in this country alone, there are nearly 130,000 cases of cervical cancer and 75,000 deaths as a result. In other words, a woman dies every 7 minutes from cervical cancer in India!
Saving women's lives by fighting cervical cancer has become a high priority in the global health agenda. Cervical cancer peaks in women between the ages of 35-50 and not only takes their lives but also devastates many young families as a result.
Traditional Pap test
Fortunately, unlike many other cancers, we can gain control over cervical cancer because we know what causes it (the Human Papillomavirus or HPV, which is transmitted both non-sexually and sexually, but primarily through sexual intercourse); how to screen for it (a simple Pap test); and how to treat it (safe and effective methods are available when detected early).
The Pap test detects precancerous changes of the cervix (the opening of the uterus) before they progress to invasive cancer.
A doctor uses a brush to collect cells from the cervix, which is then transported to a laboratory and analysed. Results are relayed to the doctor, who communicates them to the patient and advises her on future follow-ups.
The Pap test alone has slashed the incidence of cervical cancer by 75 per cent in places where proper testing exists. However in India, since 70 per cent of the population lives in rural areas, trying to develop and maintain such a cumbersome programme is not feasible.
Therefore, various individuals and health organisations are exploring innovative and alternate screening methods to reach this vulnerable population and their efforts have met with varying degrees of success.
Alternate testing approaches
Visual inspection with acetic acid (VIA): Here, the cervix is painted with vinegar (the kind you buy in the grocery store) and abnormal tissue turns white within a few minutes. The test is conducted by trained non- physicians such as a dai, midwife, nurse, or a clinician.
Mobile vans or temporary units are set up in villages to “screen-and-treat”; so that women whose tests are positive can have cryotherapy — freezing of the cells with a probe — on the spot. These “one-stop” or “single visit” programmes minimise the patients' costs associated with transportation and time off from work.
HPV DNA Testing (Care HPV): Training non-physician health providers to recognise the often-subtle changes of abnormal cells with VIA sometimes poses challenges. To eliminate subjective errors, a newer method that directly detects the genetic material of the virus has been found to be more accurate, objective, and less demanding in terms of training and quality control.
This HPV DNA test can be performed in about 2.5 hours and does not require any electricity or running water. In addition, a woman can take her own vaginal swab in the privacy of her own home and then provide it for testing.
Only abnormal results will need pelvic exams, which are considered taboo in many rural settings.
Vaccines
Currently, there are two vaccines available for HPV which prevent 70-80 per cent of cervical cancers. Both are preventive and are ideally recommended to be given to girls between the ages of 10-12. A series of three shots administered over 4-6 months is required to obtain maximum benefit.
Research shows that the synergy of vaccines and screenings can reduce cervical cancer deaths by half. However, the biggest deterrent to the widespread use of the vaccine is the cost. To make it more cost effective, there should be a strong partnership between community, local, state, and federal health officials and policymakers. In addition, seamless cooperation between national and international organisations in both the public and private sectors will be necessary to negotiate prices with pharmaceutical companies and secure the necessary financing.
In order to more effectively prevent cervical cancer, the developers of future vaccines should attempt to have a broader range of coverage, streamline the current three shots series to one, and look for alternate routes of administration and those which do not require refrigeration. Also, more research must be done on how malnutrition and low-protein diets among the poor affect the effectiveness of the vaccine, and how effective the current vaccines will be in countries where geographic variations of HPV types exist.
Health officials will also need to use innovative methods to spread information about the vaccine. Although the media typically plays a critical role in spreading information, only 50 per cent of rural women have access to newspapers, magazines, TV, radio or cinema compared with nearly 90 per cent of urban women.
Besides, many rural women work in the fields during the day, so a more intensive door-to-door education campaign in the evening hours would be more effective than traditional outreach methods.
For long-term prevention of cervical cancer, launching a massive awareness programme will be necessary to not only motivate women, but also men who play a pivotal role in disease transmission and decision making for their wives' and children's health.
The key message here is that cervical cancer is almost completely preventable and that a woman's family benefits when she undergoes testing and when her daughters (and hopefully sons) are vaccinated.
With some creativity, flexibility, and well-focused use of resources, the fight against cervical cancer can be won, and can be erased as a major chapter from the book of women's health.
The writer is a New York-based physician and author of The HPV Vaccine Controversy: Sex, Cancer, God and Politics . Website: http://www.thehpvbook.com
