The Cervical Cancer Paradox

It started in early 2022, with a few spots of blood between menstrual cycles. Aditi Sharma (name changed), 38, then a PhD student in Delhi, didn’t tell anyone; she had just broken up with her partner and begun seeing someone else. The bleeding stopped in a few hours, but just a day later, she experienced intense pain during intercourse. “I thought it would pass,” says Sharma.

The spotting and pelvic pain remained intermittent and Sharma kept dealing with them with over-the-counter painkillers. It was only when she started having trouble breathing that she knew something was terribly wrong. “My friends had to rush me to the ICU,” she says. Within a few hours of reaching the hospital, Sharma’s life took a turn that she continues to grapple with even today. She was diagnosed with advanced stage of an aggressive form of cervical cancer, which had spread to her lungs. Sharma has been under treatment for nearly two years now. “I have had two long surgeries, and I cannot have children now as my uterus had to be removed,” she says.

She has also been through several sessions of chemotherapy and radiation, and may have to undergo treatment for the rest of her life to prevent a relapse. Things would have been different if only she had reached out for medical attention on time. “But I was too ashamed to talk of vaginal bleeding,” says Sharma. “I thought my parents would come to know I had sex.

”Sharma is still among the luckier ones. Only one in two—or 51 per cent—of women diagnosed of the disease in India survive, according to a study published in The Lancet in 2023. India also accounts for the highest number of cervical cancer cases in Asia. Around 96,922 women are diagnosed with it on an average every year in the country, of which 60,078 succumb to the disease, according to estimates from the HPV Information Centre. Usually caused by the human papillomavirus (HPV), cervical cancer is transmitted through sexual activity. Within the country, it is the second most common cancer among women, after breast cancer, which, at 80 per cent, has a better survival rate.

The glaring irony? As the only type of cancer for which a vaccine has been available for 17 years, cervical cancer is entirely preventable. True, India had to import HPV vaccines until last year and they would cost around Rs 3,000 to Rs 4,000 per dose. But with the Serum Institute of India (SII), Pune, launching a homegrown HPV shot, Cervavac, last year, that problem is eased too. The vaccine costs as low as Rs 200 to Rs 800 per dose, depending upon the provider.

It was proven to have a high efficacy too—a double-dose shot taken six months apart and followed by a booster has been reported to have an antibody response that is 1,000 times higher than the baseline against all targeted HPV types and in all doses and age groups, and it works even against high-risk versions of the virus such as types 4, 6, 11, 16 and 18. Although recommended for girls under 19, those who are already sexually active or over 19 can also take it after a screening test.

And yet, there have been hardly any takers for the shot, thanks to the enduring stigma around female sexual health in India.

A Dangerous Oversight

“There is no point even storing this vaccine—the interest has been so low,” rues a doctor at Delhi’s LNJP Hospital. Even timely screening is a rarity in India. “This cancer is very commonly detected in an advanced stage because of this,” says Dr Nidhi Nayyar, Consultant, Gynaecologic Surgical Oncology & Robotic Surgery, BLK Max Super Speciality Hospital, New Delhi. “Many women don’t come for screening or checkups even when they see symptoms like post-menopausal bleeding, which should be an immediate cause for alarm. There is a lot of shyness and fear of people finding out about their private lives.”

In many cases, by the time a person decides to seek help, it’s too late. “If you come very early, then you can avoid chemotherapy,” says Dr Lalit Kumar, chairperson, Oncology & BMT, Artemis Hospitals, and former head of the department of medical oncology at AIIMS Delhi. “Though, even then, this is not an easy cancer. For those who are yet to have children, it means you won’t be able to do so any longer. The surgery itself is quite a big one and recovery takes time. That is why if one can prevent cancer altogether, there is no reason to get to this stage at all.”

Symptoms in the early stages may include disturbance in the menstrual cycle, intermittent bleeding between periods, vaginal discharge, post-coital bleeding or pain, and lower abdominal pain. The treatment may require surgery for the removal of the uterus, cervix and the tumour, without any need for radiation.

However, once the cancer progresses, it can lead to obstruction of the kidneys, recurrent urinary infections, distended abdomen, among other problems. It can also infect other organs and lead to tumours. And this is where intensive treatment methods like radiation come in, along with mounting expenses. For early treatment itself, various studies estimate costs to be anywhere between Rs 1.6 lakh and Rs 4 lakh.

The expenses multiply as the cancer worsens, with treatment often continuing for life to avoid relapse. And all that with no guarantee for cure. “In the late stage of cervical cancer, cure is not even possible and the success is less, I would say, almost half of that in breast cancer,” says Dr Nayyar. Add to this the myriad side-effects of drugs and radiation, and you have a situation made tragic not least by the simple fact that it could have been avoided. “There is extensive use of radiation, and that has its own side effects … Even if the normal surrounding tissues are shielded, a small amount of radiation can impact the rectum and bladder and women often have urinary side-effects, diarrhoea and pain after treatment,” Dr Nayyar adds.

Over the past few years, oncologists have noted a rise in cases in urban areas as well as among women aged 40 to 55 years, which was uncommon before. “I would say people having multiple partners but not having enough awareness or not complying with proper sexual hygiene and protection, has led to the rise,” says Dr Reshma Puranik, a Pune-based oncologist.

FAR FROM THE TRUTH 

Lack of awareness is the primary reason for poor vaccination rates. The LNJP doctor says that in the past four months, he has tried to advise many young girls and parents to get the shot. Out of around 50 such people, only three agreed. The rest, he says, had excuses that ranged from “But my daughter will have sex only after marriage, how can she get an STI?” to “She is too young to take a vaccine”.

“There is poor awareness on adult vaccines, more so for a sexually transmitted virus like HPV. People also fall victim to social media misinformation,” says Dr Ashok Vaid, chairman of oncology at Medanta, Gurugram.

Fear of side effects was what kept 29-year-old Aryushi Arora, a Pune-based art teacher, from taking the vaccine. “I had read it can cause vaginal dryness. But when I finally went for a pap smear, the doctor told me this was untrue. I went ahead and took the vaccine,” she says.

Experts agree that the immediate need is to educate people about both the disease and its prevention, especially given the immense promise the vaccine holds in reducing India’s cervical cancer burden. “We need to assure people that there are virtually no side-effects of the vaccine. At best, mild body ache. Allergic reactions to this vaccine is extremely rare and it is perfectly safe for young girls to take. I sometimes attend vaccination camps and feel awareness and outreach will help tackle hesitation,” says Dr Puranik.

Screening also needs to be expanded massively to detect the cancer early. “The biggest problem is late-stage diagnosis; screening for those above 35 has to be increased,” says Dr N. K. Arora, chairman of the National Technical Advisory Group on Immunization. Countries like Bhutan, the Maldives, Myanmar, Sri Lanka and Thailand have already introduced nationwide vaccination programmes to prevent cervical cancer.

Given the success of India’s Covid vaccination drive—the largest in the world—experts now hope that the government will come up with a similar programme for cervical cancer. The country does, after all, have a robust vaccination framework in place already. All that’s needed is intent.

From India Today Magazine, issue for the week 19–25 December 2023. Reproduced with permissions.