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Cervical Cancer Screening and Its Challenges in India

Authors: Sanjeev Kumar works with the Health Systems Transformation Platform (HSTP) in Research Specialist Capacity. He has worked with multiple State Health Systems in India. Dr. Amita Yadav, Founder of Progressive Foundation, is a public health professional from Johns Hopkins University. The foundation has been working in health and education for the last ten years in Uttar Pradesh, India.

Cancer Screening has the potential to reduce mortality and morbidity through early detection and treatment.  There are two preconditions for screening to slash the Cancer death rate. First, the screening ahead the time of diagnosis of cancers that are intended to cause death. Second, early treatment of these cancers must confer some advantage over treatment at clinical presentation. Carcinoma of the cervix satisfies the condition for early diagnosis and treatment. Even reliable biomarkers are also available that can predict this Cancer before its onset.

The International Agency for Research on Cancer estimated a death toll of 7,84,821 people from Cancer in India in 2018 alone, amounting to 8% of global cancer deaths and 6% of deaths from all causes in India. Cervical Cancer is one of the most significant contributors, with 23.3 % of total cancer deaths among women in India. State Burden of Disease report entails that the annual incidence of Cancer in India among women is 1-1.4 Million per year, in 2015, in which Cervical Cancer shares 14% contribution.

The Ministry of Health initiated a nationwide National Cancer Care Program in 1975, with multiple revisions from time to time. In 1984, The Government of India emphasized: “primary prevention and early detection” of Cancer, under which various schemes were introduced under the program to strengthen cancer control activities in the Country. In 2013, the Government of India introduced an integrated approach to deal with Non-Communicable Diseases and named as National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCCDCS). Under the NPCCDCS, there are five strategies adopted to implement this program: Health Promotion, Screening, early detection, Awareness generation and promotion of a healthy lifestyle, Affordable and accurate diagnosis, Access to affordable treatment, and Rehabilitation. Prioritizing Cancer Screening, the GoI launched the Screening program for Cancer in 2016. Later, in 2018,  the GoI launched the Health and Wellness Centre Program to strengthen Comprehensive Primary care Services. Under this program, the Government of India emphasized strengthening the Screening, Prevention, Control, and Management of Non-Communicable Diseases, including Cervical Cancer, through Community health workers.

The high incidence of Cervical Cancer in India is a big challenge, which later compounds with late detection. It hurts the cost of care and mortality. More precisely, a recent report shows that cancer patients’ detections at stage IV are against stage I, and the survival rate hurts by 17.2 times for Cervical Cancer. On treatment, stage IV  Cancer costs 1.5 to 2 times higher than in case of detections at stage I.

Dhillon Study, 2020  reported that Primary Care facilities the facility readiness for Providing Cervical Cancer screening lack in all the parameters like; Infrastructure, infection prevention, human resources and medicines, and laboratory, which varies from State to State. More conclusively, Infrastructure and Human Resources/staffing are the main barriers to screening Cervical Cancer Patients in Primary Care Settings.

Tripathi Study Reports four types of barriers among rural women accessing Cervical Cancer Screening Services that hinder the early detection. These are; Ignorance of the disease, fear for Cancer Detection, Poverty, and Illiteracy.

Community Health Workers-led KAP Study done in Uttar Pradesh reports that despite having good knowledge about Screening for Cervical Cancer, only 10 % of CHWs conduct the Screening test. Even knowledge about screening for Cervical Cancer among communities is lacking. It worsens in practice when the family’s males do not support participating in the screening program. The study reveals that only 22 % of women have undergone a cervix examination in India, considered measly coverage.

Human Papilloma Virus (HPV) Vaccine’s effectiveness to reduce Cervical Cancer incidence is evident. Hence, the WHO and IAP advocate the inclusion of HPV vaccine in national immunization programs to prevent cervical Cancer (74 countries have included it to date), which is under evaluation with the National Technical Advisory Group on Immunization (NTAGI), an apex body to decide Introduction, in India.

Conclusion: Screening can save multiple lives caused due to Cervical Cancer. The Government of India and State Governments are incognizant to prioritize screening for Cervical Cancer or all types of Cancer. In this regard, the Government of India launched a national program to Screen all types of Cancer in 2016. To reach the bottom of the pyramid, The GoI decided to strengthen Comprehensive Primary Care through operationalizing and strengthening Health and Wellness Centres. High incidence of Cervical Cancer, Poor Primary Care facilities, Preparedness, insufficient demand, Poor Community Health Workers Practices to participate in the Screening program, and the delay in HPV Vaccine Introduction are the Challenges in improving Cervical Cancer Screening in the Country. Fast Track evaluation on HPV Vaccine Introduction, target-based approach to strengthen demand, the inclusion of Screening Competencies for Primary Care Providers including CHWs could further strengthen Cervical Cancer Screening in India.

The authors acknowledges Rajeev Sadanandan for his valuable feedback.

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