Cervical Cancer - prevention

Women don’t need to die of cervical cancer because the disease develops slowly, after initial infection with
the human papillomavirus. Unlike most other types of cancer, it is preventable when precursor lesions are
detected and treated.

But millions of women around the world are never screened for cervical cancer—whether because of the
long journey to the nearest clinic, local myths and fears about cervical screening, or poor health services.
The result is that a half-million new cases of cervical cancer are diagnosed each year, with a quarter-
million women dying from the disease.

 Cervical cancer is the leading cause of cancer-related deaths among women in the majority of
developing countries and the second most common cancer among women worldwide especially
in India.
 Half a million women a year develop cervical cancer worldwide.
 Each year, cervical cancer causes over 250,000 deaths approx worldwide .
 Women in developing countries account for about 85% of both the annual cases of cervical
cancer and the annual deaths from cervical cancer

Incidence and mortality of cervical cancer vary according to age, reaching a peak in women aged around
40 years

The age distribution of cervical cancer is pyramidal with a higher percentage of younger women being
diagnosed with precancer symptoms and invasive disease. These women remain undetected for many years
because of lack of opportunistic screening of hospital-visiting women for cervical precancer abnormalities,
and thus become major contributors for higher rate of women mortality and morbidity when presented to
the clinicians with the early—to advanced stages of invasive carcinomas. Not only the cost of treating such
patients by radical surgeries or chemo-radiotherapies is enormous but also the success rate is very poor.
These patients keep adding to the new cases every year posing a continuous challenge to healthcare
professionals and the government GDP annually.

Screening for cervical cancer by a very simple procedure, pap smear test, introduced over sixty years ago
has led to a significant decline in its incidence and mortality among western countries where annual
screening program was introduced. However, India did not take any effort in screening our women in the
past 50 years. The Pap test has remained opportunistic laboratory investigational tool for those when
presented with early invasive carcinoma. As a result, India hardly does quarter of a million Pap tests
having nearly 120 million beneficiary women in the age group of 25 to 65, as compared to several million
tests among few million women population in western countries. No screening program on the mass scale
was ever seriously pursued in India. No efforts were put in to enhance awareness among target women
groups on how the cancer is caused, its etiology or progression. Arguably, the scourge due to cervical
cancer steadily assumed mammoth proportions in India threatening to trigger medico-social and medico-
legal concerns.
There are a number of risk factors attributed to cervical cancer. These are early age at marriage or early
onset of sexual activity, multiple pregnancies, pregnancies in quick succession, more than one sexual
partner, long-term use of oral contraceptives, malnutrition, unhygienic genital health, individual's immune
status, and smoking or even genetic predisposition. But infection due to high risk human papillomavirus
(HPV) types constitute a single most critical virologic risk factor in comparison to other socio-economic,
demographic or behavioral risk factors in triggering the oncogenesis. More than one cancer causing types
of HPV have been found in over 99 percent of cases of cervical cancers all across the world.

Women are generally infected with HPV in their early teens, twenties or thirties when they first become
sexually active. HPV is the most common STD, occurring at some point, in up to 75 percent of sexually
active women. In many women, the interval from becoming infected with the HPV and developing cancer
can be from five years to as long as 20 years.

Like most cancers, cervical cancer is largely asymptomatic disease till the time it becomes invasive. Also
the high-risk HPV infection is non-inflammatory in nature, hence the precursor lesions often confuse pap
results. However, the observed clinical symptoms manifested are, pain in the pelvic region (more often due
to chlamydial infection than HPV), persistence vaginal discharge, which may be watery, pale or dark
colored, sometimes foul smelling. There could be abnormal bleeding, between menstrual cycles, during or
after the intercourse. Often, co-infectivity due to herpes or HIV has also been observed to be adding to the
risk of HPV persistence followed by the development of cervical cancer.

Testing for HPV DNA for such symptomatic women gives fairly reliable clinical prediction of the
progression, persistence or regression of the clinical disease.

Preventive measures:

The irony of cervical cancer is that it is largely a preventable disease, often without hysterectomies or
surgical or chemo-radiotherapy interventions. Primary prevention measures include—vaccination and
social education to control high-risk behavior and efforts to reduce or avoid exposure to HPV and other
STDs such as by the use of condoms. Condom use, however, is not totally protective in preventing HPV
infection. Secondary prevention measures include treatment of precancerous lesions before they progress
to cervical cancer. This, however, implies that a screening test, such as cervical cytology or HPV testing is
available with certain degree of expertise. Unfortunately, in India, the pap test is not universally or widely
available.

A vaccine to protect against the strains of HPV that are most likely to cause cervical cancer has been
developed. However, it isn't a complete protection against all strains. As it can take 10 to 20 years for
cervical cancer to develop after HPV infection, it will take many years for an effect on the rates of cervical
cancer to be seen. Many parents are questioning whether their children should be vaccinated along with
many women who are also voicing their concerns over vaccination.

Deaths from cervical cancer in the India have fallen over the last 8 years to some extent. This reduction is
mainly because of the cervical screening programmes which may detect changes in the cells of the cervix
at a pre-cancerous stage. If abnormal cells are caught early, cancer can be prevented or treated. Although
the vaccination programme against HPV has started to be implemented, the screening programme remains
a vital process and shouldn't be ignored.

It seems more likely that this challenge is going to be more severe than being estimated currently.