In the serene tapestry of Vidya Nagar, Meera, a vibrant 35-year-old wife, and mother, found herself entwined in an unexpected narrative—one marked by resilience and the urgency of prevention in the heart of India. The tranquil town’s peace was disrupted when Meera received an unforeseen diagnosis of cervical cancer. Yet, in the midst of this upheaval, a symphony of support unfolded. Raj, Meera’s unwavering husband, stood by her side, a pillar of strength and love. Inspired by a survivor group that had weathered similar storms, Meera discovered a wellspring of resilience within.
Meera’s journey became an allegory for early detection and the critical importance of prevention in the Indian context. Amidst the colours of family unity and the harmonies of adversity, she transformed her struggle into a powerful advocacy for cervical cancer awareness in a nation where timely detection can rewrite destinies.
The focus of the government towards promoting the overall well-being of women has started bearing fruits. The convergence of several government schemes and policies is gradually impacting lives and is providing much-needed freedom of decision-making to women. Whilst the ‘Beti Bachao, Beti Padhao’ initiative is thriving on the broader vision of gender equality, addressing the declining child sex ratio, promoting education and empowering girls; the ‘Pradhan Mantri Ujjwala Yojana’ scheme, aimed to provide free LPG connections to women from below-poverty-line families, is promoting clean cooking and improving health. Similarly, ‘Sukanya Samriddhi Yojana’, a savings scheme for the girl child is encouraging parents to save for their daughter’s future and ‘Swachh Bharat Abhiyan’, while not exclusive to women, is campaigning for clean sanitation facilities. This has a significant impact on the health and dignity of women.
While the Indian government has made commendable efforts to prioritise women’s issues, there remains a critical need for intensified focus on women’s wellness. Urgent emphasis on urban and rural women’s health towards addressing non-communicable diseases, especially cancer, through awareness, prevention, and tailored interventions for holistic well-being is much needed.
Cervical cancer and the need for intervention
With annual mortality of more than 850,000 and an incidence of over 1.3 million, cancer has rapidly grown into one of the leading drivers of mortality and morbidity in India. Late detection and inadequate access to quality treatment imply that outcomes are despairingly poorer as compared to developed countries. Not surprisingly, even cancers such as those of breast, cervical and oral that are amenable to screening and early detection account for over 33 per cent of the incidence and 28 per cent of the mortality.
The challenges vis-à-vis cervical cancer are even more acute. With an incidence of approximately 124,000 and a mortality of over 77,000 in 2020, it is the second leading cause of cancer amongst women, accounting for over 18 per cent of the cancer burden (by incidence). Poor awareness and knowledge gaps, limited geographic (limited availability and concentration of cancer services) and economic access (low insurance penetration and high cost of treatment in the private sector) to quality screening and treatment services, further magnified by gender-related issues and privacy concerns, are significant barriers in accessing care. This typically translates into delayed detection of cancer and poor prognosis leading to high mortality levels (mortality to incidence ratio, or MIR, of 62.4 per cent).
In India, the overall pooled data of cervical cancer five-year survival was 51.7 per cent. The number of cervical cancer cases prevalent for five years is approximately 2,83,842 women. The National Sample Survey (NSS) 75th round conducted during July 2017–June 2018 has revealed an alarming picture associated with cancer care in India. Based on data recently released, at the national level, the average total cancer care expenditure was around Rs 1,16,218, 93 per cent of this is out-of-pocket (OOP) expenditure. Late-stage diagnosis is common due to limited awareness and healthcare infrastructure, leading to reduced treatment efficacy and higher mortality. Globally, every fourth woman dying from the disease is Indian; we lose 187 women to cervical cancer every day in India.
The world is continuously combating this problem despite the fact that this problem is largely preventable and easily treatable. Cervical cancer has a long pre-cancerous window during which time it can be identified, and pre-cancerous lesions treated, thereby preventing progression to cancer. Screening and treatment of pre-cancerous lesions are amenable to decentralisation and can potentially be undertaken at primary and secondary-level facilities. In November 2020, the World Health Organisation (WHO) announced a global strategy to accelerate the elimination of cervical cancer as a public health problem. This, amongst other interventions, recommends that 90 per cent of girls be fully vaccinated with the HPV vaccine by the age of 15, 70 per cent of women screened with a high-performance test by 35 years of age and again by 45 years of age, and ensuring that 90 per cent of women identified with cervical disease receive treatment.
Cervical cancer is preventable
Cervical cancer initiation often begins with dysplasia, emphasising the importance of early detection and intervention. Recognising and addressing dysplasia can significantly contribute to the prevention and effective management of cervical cancer, underscoring the role of regular screenings in women’s health. Dysplasia may be referred to as stage 0 when abnormality or abnormal cells are confined to the surface layers and have not invaded any deeper. With the introduction of new technologies, the abnormality may be treated with thermal ablation devices in less than 1 minute by means of a walk-in procedure.
Regular follow-up screenings are essential to monitor the cervix and ensure that any recurrence or progression is promptly addressed. It’s crucial for individuals with dysplasia to work closely with their healthcare team to determine the most appropriate treatment plan based on the severity and extent of the abnormalities and prevent them from falling into the cervical cancer trap.
Preventive health-seeking behaviour and need for NCD screening
Preventive health-seeking behaviour involves taking proactive measures to avoid illnesses through regular check-ups, vaccinations, and healthy lifestyle choices. Promotive health-seeking behaviour focuses on actively improving overall well-being through early screening and seeking health-related information and support, as needed.
The objective and need for NCD (non-communicable disease) screening, particularly for cervical cancer is to detect these conditions at early stages. Early detection allows for timely interventions and treatment, significantly reducing mortality rates. Regular screenings are essential to promote better health outcomes, improve survival rates, and enhance the overall well-being of individuals at risk of these cancers.
The five-year survival rates for early-stage cancers are 60.2 per cent, 76.3 per cent and 73.2 per cent for oral, breast and cervical cancers respectively. The prognosis for advanced stage on the other hand is poor, with five-year survival rates being 3.3 per cent, 14.9 per cent, and 7.9 per cent for these cancers.
According to a study conducted in Palghar, Maharashtra, approximately half of the tribal women perceived fever, headache, body aches, general weakness, itching, dysuria and tuberculosis as common ailments. Although they had heard about diabetes and hypertension, they did not have detailed information about these conditions. Few participants had heard of oral and breast cancer but were unaware of cervical cancer.
Regular screenings play a vital role in identifying cancer at its initial stages, enabling timely interventions and improved treatment outcomes (National Cancer Institute). As per NFHS-5, only 1-2 per cent of citizens of the country have ever undergone screening for oral, breast and cervical cancer. Given the government’s focus to screen 37 per cent of India’s population, add-on solutions are required to complement the efforts of the government.
Strategies for Eliminating Cervical Cancer in India by 2030
Leveraging AB-PMJAY: Pradhan Mantri Jan Arogya Yojana (PMJAY) provides financial protection to over 100 million vulnerable families. The scheme primarily focuses on secondary and tertiary healthcare.
- Whilst treatment of the pre-cancer has been allocated in PM-JAY, re-distribution of the same amount given the introduction of new treatment technologies like thermal ablation will aid in saving approximately 50 per cent of the allocated costs.
- Screening methodologies like HPV DNA testing, given their high negative predictive value, will reduce the number of screenings in a lifetime by 71 per cent.
- 20 per cent of the same amount if reallocated to wellness will help reduce the incidence of cervical cancer greatly and also aid in the prevention of the disease by including vaccination as a component lowering the economic burden greatly.
The inclusion of specific preventive services such as cervical cancer screening in the Ayushman Bharat package may evolve over time; however, will be revolutionary and instrumental in driving the cervical cancer 2030 elimination anthem. Including cervical cancer screening in Ayushman Bharat would be a significant step toward promoting preventive healthcare and early detection, aligning with global efforts to reduce the burden of cervical cancer.
PM JANMAN: Inaugurated amidst Jan Jatiya Gaurav Divas on November 15, 2023, by Prime Minister Narendra Modi, this initiative seeks to extend its outreach to 7 lakh PVTG families across 18 states. Leveraging this initiative, the amalgamation of conscientious awareness campaigns, especially tailored for cervical cancer prevention and screening, will signify an unprecedented shift in preventive paradigms. The Health Ministry has achieved a significant milestone with regard to Sickle Cell Anaemia which is more common in the tribal population of India. More than 1 crore people have been screened for the disease under the National Sickle Cell Anaemia Elimination Mission.
Similarly, with an exclusive focus on PVTGs, PM JANMAN shall stand at the precipice of becoming quintessential for their holistic well-being, spreading awareness of the need for cancer screening, early diagnosis and prevention. Harnessing the advantages of PMJAY for this susceptible cohort, the initiative will undoubtedly assume a metamorphic role in mitigating the incidence of cervical cancer and also reduce OOP expenses by diagnosing early. Accentuating early detection, augmenting healthcare accessibility, and executing precisely targeted vaccination programs will stride significantly towards the formidable objective of eradicating cervical cancer by the year 2030.
Comprehensive Vaccination Programs: Incorporating HPV vaccination into the national immunisation programs of the US and UK, coupled with success stories in LMICs, offers India a blueprint for an impactful rollout strategy. By studying the effective integration, community engagement, and accessibility measures implemented in developed nations and adapting them to suit the Indian context, we can design a comprehensive plan. Leveraging international successes ensures equitable access, cost-effectiveness, and increased public acceptance. This strategic approach, built on global experiences, positions India to effectively combat cervical cancer, fostering population health and contributing to the global effort to reduce the burden of HPV-related diseases. Serum Institute’s Cervavac is a potential game-changer in India, offering an indigenous and affordable cervical cancer vaccine. With broad accessibility, it has the capacity to significantly curb cervical cancer rates nationwide.
High-Quality Screening Initiatives: Establish robust screening programs, including Pap smears and HPV testing, ensuring widespread access and timely detection of pre-cancerous lesions. The sensitivity of HPV DNA testing is well-supported by scientific evidence. Numerous studies and clinical trials have consistently demonstrated the high sensitivity of HPV DNA testing in detecting high-risk human papillomavirus (HPV) infections, particularly those associated with an increased risk of cervical cancer.
- Numerous large-scale clinical trials, such as the ATHENA trial, have demonstrated the superior sensitivity of HPV DNA testing compared to traditional methods like Pap smears for detecting cervical intraepithelial neoplasia (CIN) and cervical cancer.
- Meta-analyses of multiple studies consistently show that HPV DNA testing has higher sensitivity for detecting high-grade cervical lesions compared to Pap smears.
- Various longitudinal studies, population-based studies including both high-risk and general populations, have consistently shown the high sensitivity of HPV DNA testing in identifying women at risk of developing cervical cancer.
- HPV DNA testing allows for better risk stratification, identifying women at higher risk for cervical cancer and enabling targeted interventions, including early treatment and close monitoring.
Health Infrastructure Strengthening: Invest in healthcare infrastructure, particularly in rural areas, to ensure accessibility and affordability of cervical cancer screening and treatment services will aid in effective delivery. Building on successes in Low- and Middle-Income Countries (LMICs), particularly in Africa, thermal ablation emerges as a potential game-changer for cervical cancer in India. Demonstrating effectiveness and accessibility, this technology offers a promising solution to enhance treatment outcomes and address the unique challenges faced by resource-limited settings, providing hope for a transformative impact on cervical health across the nation.
Holistic wellness through a parallel cadre: India grapples with a strained patient-nurse ratio, urging the incorporation of a parallel cadre, to emphasise holistic wellness may be thought off. In India, strengthening rural livelihoods mission initiative has emerged as a vital strategy to empower women in rural areas. By diversifying the roles of these SHG members, proactive engagement in preventive healthcare to reduce illness rates may be achieved. This innovative approach not only optimises healthcare resources but also fosters a community-centric strategy, fostering a healthier populace and mitigating the burden on the healthcare system.
Public Awareness Campaigns: Launching a nationwide campaign in India starting from areas of high incidence to raise public awareness on cervical cancer is a critical requirement. Through informative sessions, community outreach, and media engagement, the campaign should aim to educate on prevention, importance of quality screenings, and early detection. Empowering communities to prioritise cervical health strives to reduce the burden of this largely preventable disease.
Policy Advocacy: Championing policy advocacy is crucial for cervical cancer prevention. Lawmakers should enact comprehensive legislation, ensuring widespread vaccination coverage, address vaccine hesitancy along with evidence-based screening guidelines, and enhance treatment accessibility will greatly help. These policies will fortify public health efforts, fostering a proactive and inclusive approach to combat cervical cancer, ultimately safeguarding the well-being of women and reducing the burden on healthcare systems.
In the pursuit of eliminating cervical cancer, a holistic approach anchored in sensitivity and strategic implementation is paramount. Leveraging the Pradhan Mantri Jan Arogya Yojana (PMJAY) as a cornerstone, alongside comprehensive vaccination initiatives and meticulous screening strategies, we forge a path toward a cervical cancer-free future. PMJAY’s commitment to universal health coverage ensures that women across the nation have access to crucial preventive measures, diagnostics, and treatment.
Coupled with robust vaccination programs, we lay the foundation for a resilient defence against high-risk HPV strains. As we navigate this collective endeavour, promoting awareness and fostering an environment of compassion and understanding is indispensable. Together, through PMJAY, vaccination, and a multifaceted approach, we strive for a future where cervical cancer becomes a relic of the past, offering every woman the right to a healthy and dignified life.
As Meera’s story echoed through the lanes of Vidya Nagar, it carried a resonant message—a call to action in the face of cervical cancer, emphasising the vital role of awareness, support, and the pressing need for preventive measures in the fabric of India’s healthcare narrative.
The author, AVP, Karkinos has been extensively working on cervical cancer elimination in public and private sector. Views expressed in the above piece are personal and solely that of the author. They do not necessarily reflect News18’s views.
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