Cervical Cancer in India 0

The Epidemiology of Cervical Cancer in Women in India

Savita Malik
March 7, 2005
Epidemiology HED 825

Cervical Cancer in India 1

Introduction
Worldwide, about 500,000 new cases of cervical cancer are diagnosed each year
(Planned Parenthood, 2004). Cancer is one of the leading causes of mortality in rural India
which makes up approximately 75% of the total population (Census of India, 2001). The
prevalence of cervical cancer among women in India is the highest of all the other cancers
combined. According to the World Health Organization, in 1990, twenty percent of all
female deaths from cancer in India were from cervical cancer, amounting to an estimated
61,000 deaths from this cause. In addition, the number of cervical cancer deaths in women
in India is projected to increase to 79,000 by the year 2010 (2002). Undoubtedly, cancer is a
lingering problem for Indian women. Exploration of the progression of disease, the
demographic breakdown within India and risk factors associated with the heightened
prevalence can lead to a more thorough understanding of how to prevent this disease long
term.
Disease Overview
Cervical cancer begins in the lining of the cervix. The cervix is the portion of the
uterus which connects the body of the uterus to the birth canal. Cancer of this region comes
on slowly over time and usually manifests itself as cells which go from normal to pre-cancer
and then eventually become cancerous. For a number of women, these changes in cell
structure are not harmful and go away over time. For others, treatment is necessary to avoid
full blown cancerous lesions from developing (American Cancer Society, 2005).
There are two main forms of cervical cancer. Eighty to ninety percent are known as
squamous cell carcinomas which are caused by the HPV or Human Papilloma Virus.

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The other ten to twenty percent are called adenocarcinomas which tend to be among
clustered cells and are also caused by HPV but tend to grow much more rapidly than the
squamous cell carcinomas. Sometimes cancers will contain characteristics of both types in
which case they are known as mixed carcinomas. Neither form of cervical cancer has been
proven to run in families or to be hereditary although there is evidence our immune
systems, which are inherited, may respond differently (PHSKC, 2001). HPV is spread by
direct skin contact with a partner during vaginal or anal intercourse. Infection may occur by
contact with a visible wart, and possibly also from an area of skin with no visible wart. For
the most part, HPV that becomes cancerous begins without overt symptoms in the sub
clinical stage.
Natural History of the DiseaseSub clinical
The HPV infection can be asymptomatic thereby leaving many women completely
unaware that they even have the virus. In the sub clinical stage, HPV targets the deep, basal
level of the skin and most often causes no clinical or microscopic changes in the cells of the
skin. In some cases however, sub clinical HPV may cause cellular changes that are only
detectable using clinical instruments some of which can be precursors to cervical cancer
(Planned Parenthood, 2004).
Natural History of the Disease--Incubation
The incubation period relative to cervical cancer can last anywhere from one month
to many years (Planned Parenthood, 2004). HPV has the ability to lie dormant within the
body, or can be manifested as genital warts in addition to a host of other diseases such as
herpes. Once the strain emerges, cervical cancer is detected and it moves into the clinical
stage.

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Natural History of the Disease--Clinical
Once cervical cancer has been formally diagnosed, it goes through five different
stages. It begins with stage zero which is where cancerous cells are detected in the cervix.
Stage one deals with cells that have spread into the neck of the cervix and the cancer has
become more acute. The next two stages, two and three indicate that the cancer has spread to
other areas around the pelvis. Combined treatment with surgery and radiation therapy has
increased the chances of survival at this stage. The final stage, stage four, is denoted when
the cancer has spread throughout the body. Survival chances at this stage are slim and
mortality rates are high when the cancer reaches stage four. Some combination of surgery,
chemotherapy and radiation treatment can prolong life but often, it is too late to prevent
death (Cancer Research UK, 2004).
Associated Risk Factors
HPV appears to be necessary, but not sufficient, to the development of cervical
cancer. Besides HPV type, there are several cofactors that may contribute to the
development of cervical cancer. These may include HIV infection, hormonal factors and the
presence of other sexually transmitted infections, such as Chlamydia and/or herpes simplex
virus 2 which can compromise the immune system and make the host more susceptible to
cancer (Planned Parenthood, 2004). While these factors definitively influence Indian
women, they are compounded by other issues that disproportionately affect poor rural
members of the Indian population.
Smoking and Diet
Cigarette smoking and diets that lack important vitamins have been linked to
increased rates of cervical cancer among Indian women. Tumors associated with cigarettes

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are most often manifested as squamous cell carcinomas (the same as are found in the
cervix). Once the cancer has reached the clinical stage, one study shows that women who
stop smoking experienced a reduction in the size of the lesion by approximately 20%. Diets
rich in vitamin C and Beta-carotene have been considered protective agents against cervical
cancer. Various studies have been carried out that show a link between certain levels of
micronutrients in the blood and a decreased risk of developing lesions or tumors. (Junega,
2003).
Socioeconomic Status
Studies have shown that women who belong to the lower social classes are more
likely to contract and sustain cervical cancer. Patients in the lower socioeconomic social
tracts had significantly higher rates of late stage cancer diagnosis and lower rates of cancer
survival. Incidence of mortality rates also increased with populations who are illiterate or
received little to no educational training. Women in the lower classes were less likely to be
screened and often times could not afford to go see a doctor if they did contract a
symptomatic form of HPV. Ultimately low socioeconomic status is observed to be the
confounding factor in higher cervical cancer rates (Juneja, 2003).
Sexual Behavior
According to a major study performed in Agra, India between 1960 and 1963, the
risk of cervical cancer increases with the first onset of sexual activity. In addition, the
incidence of cervical cancer declines as the age of marriage increases. However, gathering
data on sexual behavior within the population of Indian women has proven to be quite
difficult. Socially speaking, sex is not an appropriate topic of conversation for women and
many of them never see a gynecologist at all due to the fear and shame associated with

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female sexuality. Therefore, substantive data on sexual activity has not yet been established
(Juneja, 2003).
Gender Dynamics
Gender dynamics within Indian society also play a very important role in the onset of
cervical cancer. A study performed in the East Indian state of Bengal found that even with
the high incidence among Indian women, the role of sexual promiscuity has not been well
addressed as the rate of promiscuity among women is known to be very low. The study
interviewed both men and women separately and examined the sexual risk factors that
recurred among the couples. In this case, male promiscuity was discovered to be responsible
for the increased risk of cancer among women. The study also concluded that many women
grossly underestimated the number of sexual partners that their husbands had been involved
with (Biswas, 1997). The risk of contracting HPV with ten or more partners has been
reported to three to four times higher than the risk associated with just one partner (Juneja,
2003). Collaboration between public health professionals and sociologists in informing
women about cervical cancer (in a culturally appropriate way) could potentially change the
mortality rates for women long term.
Demographic Profile of India
As of the 2001 census, trends in the demographic profile have changed greatly. Both
the birth and death rates have declined nationwide and the increase in health services has
drawn out life expectancy to 62 years. Whereas communicable diseases have previously
been major killers of the Indian population, non-communicable diseases such as cancer are
coming into the foreground. Many new organizations have cropped up in the wake and there
are several registry programs that help to catalog data specific to cancer rates in India. The

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major source of information comes from the National Cancer Registry Programme (NCRP)
which was established in 1991. The NCRP gathers numbers from major cities in Bangalore,
Bhopal, Chennai, Delhi, Mumbai and Barshi who do the local data collection from the
gynecology departments of many hospitals and community clinics (Juneja et al, 2003)
Incidence and Prevalence
In India, cervical cancer is the most common female malignancy with an annual
incidence of 30 cases per 100,000 women and kills 61,000 women annually. Globally,
cervical cancer is the fifth most common cancer. Of the 460,000 new cases each year, three
quarters of them come from developing countries. 16% of the worlds cases are in India
alone and unfortunately, only 5% are in the early treatable stages (Ananth, 2000). One
specific study done in the state of Tamil Nadu from the Ambillikai Cancer Registry recorded
763 cancer cases from the years 1996-1998 in which more than half (53.9%) of all cases
were uterine cervical cancer in women. The age-specific and standardized rate therefore
recorded at 65.4 cases per 100,000 person years indicating that the prevalence within certain
communities in India is even higher than the national average. Data from the national cancer
registries also specify that more than 75% of cervical cancers develop in women who are
over the age of 35 years old. However, it is possible that the true risk for cervical cancer is
even higher, since cases in old age groups may be under-registered (Rajkumar, 2000).
Prevention
The most apparent reason for large cervical cancer rates in India has to do with
barriers to screening. The Pap smear test is the most accurate way to detect cervical cancer
and is recommended that women get them done annually once they become sexually active.
The treatment of the disease in the pre clinical phase will result in a higher cure rate than if

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the disease is allowed to progress to more invasive stages. Yet, there are a number of factors
that prevent women from receiving these potentially life saving tests. Mass screening in
India is impractical at best with a population of just over a billion people. There is a serious
lack of resources including trained professionals to administer the tests. There are also
deficiencies in the primary health care arena such as a lack of systems to properly monitor
those with detected cervical cancer (Juneja, 2003). Additionally, risk factors such as societal
shame, lack of general knowledge about cervical cancer and factors such as smoking and
diet keep cancer rates high within India.
Future Directions
The National Cancer Center Programme has made cervical cancer prevention one of
its main focal points in the next ten years. The Centers is attempting to modify individual
variables such as diet and sexual behavior through health education activities. Moreover, the
program hopes to strengthen the Maternal and Child Health Services on a national level. It
would help to initiate more screenings and take care of the pelvic infections that are often
precursors for cancer. Facilities need to be developed to reach a wider population and
conversations about sexual health also should be included as a part of regular health care
(Juneja, 2003). More empowerment of women and more education for men (to prevent
transmission) are necessary for large numbers of women to be able to receive health
treatment and ultimately prevent the onset of cervical cancer.

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Bibliography
America Cancer Society (2005). What is Cancer of the Cervix? Cancer Reference
Information Retrieved March 2, 2005 from
http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_is_cervical_cancer
_8.asp.
Ananth, R. (2000). Downstaging of Cervical Cancer. Journal of the Indian Medical
Association. vol. 98 no 2, 41-44.
Biswas L., Manna, B., Maiti, P & Sengupta, S. (1997). Sexual Risk Factors for Cervical
Cancer among Rural Indian Women: A Case Control Study. International Journal of
Epidemiology. vol. 26 no. 3, 491-495.
Cancer Research UK (2004) The Stages of Cervical Cancer. National Health Service
Pamphlet. Retrieved March 1, 2005 from
http://www.cancerhelp.org.uk/help/default.asp?page=2772#3.
Census of India (2001). Mortality Statistics. Census GIS India. Retreived March 5, 2005
from http://www.censusindia.net/.
Juneja, A., Sehgal, A., Mitra, A.B. & Pandey, A. (2003). A Survey on Risk Factors
Associated with Cervical Cancer. Indian Journal of Cancer. vol. 40 no. 1, 15-22.
PHSKC Family Planning Program (2001). Clinical Practice Guidelines:Section 3
Gynecology. Retreived February 28, 2005 from
www.metrokc.gov/health/famplan/clinicguide/cervical.doc.
Planned Parenthood (2004). HPV: The Most Commonly Sexually Transmitted Virus. HPV
and Cervical CancerQuestions and Answers. Retrieved March 2, 2005 from
http://www.plannedparenthood.org/pp2/portal/medicalinfo/sti/;jsessionid=7B18C8D
29F24709CD1B4C96A396F98A5.
Rajkumar, R. (2000) Leads to cancer control based on cancer patterns in a rural population
in South India. Cancer Causes and Controls vol. 11:433439.
World Health Organization (2002). Women of South-East Asia : A HEALTH PROFILE.
Regional Office for South East Asia, Regional Publications SEARO No. 34.
Retrieved on March 5, 2005 from http://w3.whosea.org/women/c1th.htm.