Cervical Cancer: When Prevention is the Cure
Even with vaccines and reliable preventives, why do thousands of Indian women die of cervical cancer every year?
Rani*, 52, lived a happy life with her husband and five children, and even had her own business of rearing buffaloes and supplying milk to households in Rajokri, a village in Delhi, close to the Gurugram border. But Rani’s busy life didn’t spare her the time to focus on her own health. It was only in December 2017, in a chance encounter at a community mobilization programme held by the NGO CAPED (Cancer Awareness, Prevention and Early Detection trust), that she realized the symptoms she was noticing in her body (such as sharp pain while urinating) were actually signs of cervical cancer. Determined to heal, she soldiered on and after a six-month course of medication at Delhi’s All India Institute of Medical Sciences, Rani’s tests in April 2018 delivered the good news—she was cancer-free. For Rani, this health scare left her rattled. Since then, she has taken it upon herself to educate other women in her village about cervical cancer and encourage them to get tested.
Cervical cancer, an insidious, deadly disease, is the second leading cause of cancer deaths among women in India. The numbers speak for themselves—every year, almost 97,000 women are diagnosed with cervical cancer and close to 60,000 die of it. In fact, estimates suggest that cervical cancer will occur in approximately one in 53 Indian women during their lifetime compared with one in 100 women in more developed countries.
Which begs the question, if the problem is so rampant, why do so few people know about it?
A cancer-causing virus
Cervical cancer affects a woman’s cervix and is caused by the human papilloma virus (HPV). There are more than 100 kinds of HPV, of which 13 are cancer-causing, and hence, high-risk. The most worrying of them all are HPV-16 and HPV-18, which cause 83.2 per cent cases of invasive cervical cancer. “HPV can be sexually transmitted. Therefore, safe sexual practices are an important aspect of preventing this disease,” says Dr Sudeep Gupta, director, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre (TMC), Mumbai. One of the primary reasons for HPV transmission is limited sexual health education among women and their partners (men who practise low sexual hygiene can be carriers of HPV) and an absence of preventive measures. As a result, this avoidable cancer (only five to 10 per cent of all cancers are hereditary), affects an alarming number of women every year.
However, not everyone who is sexually active or has HPV will get cervical cancer. Gupta explains: “Only a small number of women who get the HPV infection go on to develop cervical pre-cancer, and only a fraction of those who develop pre-cancer go on to develop frank, invasive cancer. The HPV infection that is worrisome is the ‘persistent’ one, which does not spontaneously clear itself.”
Women need to look out for other risk factors such as “multiple sex partners, early initiation into sexual activity, a weak immune system, presence of other sexually transmitted diseases and smoking”, lists Dr Sabhyata Gupta, chairperson, gynaecology and gynae–oncology, Medanta–The Medicity, Gurugram.
Let’s talk about it
Dr Kausar Neyaz, PhD and founder of Bio-Services, a web-based scientific knowledge portal with a focus on women’s health, explains, “The high incidence of cervical cancer in India is due to lack of awareness, limited access to health services and poor preventive health education.” In many cases, women ignore symptoms or they are misdiagnosed due to poor hospital care and a dearth of diagnostic centres.
Shashi*, 50, was constantly plagued by lower abdominal and pelvic pain, which often became so excruciating that she had to walk hunched over. Her local hospital prescribed painkillers that only gave her temporary relief. Shashi had never heard of cervical cancer, and it was only when a CAPED awareness camp set up in her town did she find volunteers talking of pain symptoms similar to hers.
Another alarming reason cervical cancer spreads is due to the stigma surrounding sexual practices and reproductive health. Since HPV is transmitted sexually, the taboo around sex in India ensures discussions about it simply do not take place. Large numbers of women in India are too embarrassed to discuss sexual health and only go to the gynaecologist when pregnant, ignoring or misreading symptoms, which, in case of cervical cancer, are fairly subtle to begin with. Hence, diagnoses are made late, sometimes with fatal repercussions. This was almost the case with Sakshi*. When the 54-year-old volunteer joined CAPED and underwent a screening test, she was shocked to discover she had cervical cancer. She had zero symptoms.
Five minutes to save a life
Common cervical cancer symptoms are excessive, malodorous vaginal discharge, bleeding or spotting between periods, pain during sexual intercourse followed by vaginal bleeding and pain in the lower abdomen. But one should not wait for symptoms to emerge to rush to the doctor, emphasizes Neyaz. “Cervical cancer can be prevented with the right tests at the right time.” Women between 21 and 65 years are advised to get a Pap smear, a test available in most gynaecological facilities as well as in many public health camps. The test, in which a medical practitioner collects a small sample of cells from the cervix to be analyzed for the presence of precancerous and cancerous cells, is minimally invasive, almost painless and takes no more than five minutes.
According to the Centers for Disease Control and Prevention, USA, women from 21 to 30 years old should get a Pap smear done every three years, whether or not they are sexually active or prone to other risk factors. Women between 30 and 65 years should do the same every five years, and also get an HPV test, which can identify the presence of cancer-causing HPV DNA, for faster and more accurate detection of cervical cancer. Regular screening is a sure-fire way of keeping cervical cancer at bay. Another option? Get vaccinated.
More than 10 years ago, vaccines such as Cervarix and Gardasil entered the market and promised to protect against HPV-16 and HPV-18. The vaccines are recommended for girls between the ages of 9 and 18, before the start of an active sexual life.
There has been some debate about the side effects of these vaccines, though. In 2016, a group of women in Japan aged between 15 and 22 filed suits alleging they experienced side effects ranging from headaches, fatigue and mobility impairment after getting vaccinated between 2010 and 2013. More controversies in Denmark, Ireland and India contributed to the spread of fear of these much-needed vaccines. However, in June 2017, the World Health Organization (WHO) concluded that there wasn’t enough evidence to support the claim that a causal link existed between the HPV vaccine and neurological and chronic fatigue disorders.
The vaccines may be widely available today but awareness about them is still low. Also, priced at around Rs 2,000 to Rs 3,000 per dose, they are out of reach for many Indian women with financial constraints. However, their efficacy against cervical cancer is agreed upon unanimously by doctors.
Another major reason these vaccines are sidelined is that most government immunization efforts, such as the Universal Immunization Programme (UIP), do not offer them. This means women, particularly those from remote areas, cannot afford or access these potential life-savers. Dr Abraham Peedicayil, head of the gynaecological oncology department at Christian Medical College, Vellore, is hopeful, however: “[The vaccines] will diminish cervical cancer risk by about 70 per cent. They are expensive, but hopefully we will soon have less expensive HPV vaccines made in India.”
The fight continues
Renewed focus and research have resulted in improved treatment solutions. In 2015, the WHO updated a list of 30 anti-cancer medicines with proven clinical effectiveness in treatment regimens. Gupta, the lead author of a major study on cervical cancer treatments by TMC, indicates two significant developments from 2018 that go beyond traditional solutions. “I urge all women who plan to undergo surgery for cervical cancer to consider open surgery as the standard treatment [rather than] a minimally invasive technique. A recent study published in the New England Journal of Medicine showed superior survival outcome with the former.” Gupta’s own study “proved that a strategy of simultaneous radiotherapy and chemotherapy (called ‘concurrent chemoradiation’) resulted in better outcomes in these patients compared with chemotherapy followed by surgery”.
Of all the possible options, however, prevention through timely screening remains the best one. According to a 2016 report in the Indian Ministry of Health and Family Welfare’s Operational Framework for the Management of Common Cancers, early detection results in a five-year survival rate of 73 per cent while late detection results in a 7.9 per cent five-year survival rate.
According to TMC’s Gupta, “An interesting fact about cervical cancer in India is that incidents have been continuously declining across rural and urban areas for the past few decades—even in the absence of detection or vaccination. However, India still has a large number of women with advanced cervical cancer, and this is principally due to lack of systematic population-wide screening for this disease.”
As CEO of CAPED, Mridu Gupta, who has been working tirelessly to spread awareness about the disease, puts it, “It is going to be a long journey. Preventive care in India is non-existent; we need a major change in the collective mindset.”
For now, the focus remains on advocacy through non-profits and medical practitioners making screening tests easily available. Because in the fight against cervical cancer, prevention still offers the best chance for a cure.
*Names changed upon request