A paradigm shift from cervical cancer treatment to prevention is the need of the hour.
By Dr. Nidhi Singh;
Some diseases should not be cured, they should rather be prevented and one such disease is cervical cancer in women and girls.
In my clinical practice I have always found it seriously disturbing to find a woman come with advanced cervical cancer. It always leaves me aching. It is hard to break the news to the woman and her family. I can never feel detached in such a scenario despite being a thorough professional. It is especially painful because it is a preventable cancer and the symptoms appear quite late.
In the past several decades commendable research and clinical efforts have gone into finding ways to detect precancerous cervical lesions and treat them effectively. Even a vaccine has been invented and is available to prevent this dreaded cancer.
So where are we lacking?
Why are we still encountering large numbers of deaths due to cancer cervix? The answer is undoubtedly the lack of awareness and inadequate preventative care at a mass scale to cope with the burden of disease. In order to understand the lacunas and to impress upon my readers what a herculean (but definitely worthy) task it is to “raise awareness”, let me narrate a true story.
The year was 1928. At a medical conference at Battle Creek in Michigan, a passionate Greek researcher was presenting a groundbreaking technique in front of an incredulous audience. He gave a detailed overview of how he had come up with a non-invasive technique to detect cancer of the uterus by gathering and smearing the cellular debris from vaginal fluid on a slide and observing it under a microscope.
He was telling his audience how his research began with the intent to observe menstrual changes in cells gathered from vaginal fluid in women until he hit upon a cancerous cell in one of the slides! This sample was from a woman who had uterine cancer and he realized that this test could be a way of detecting cancer of the uterus. “The first observation of cancer cells in the smear of the uterine cervix,” he later wrote, “gave me one of the greatest thrills I ever experienced during my scientific career.”
It took 13 years (despite his dedication and enthusiasm) for the medical community to realize the potential of this low cost test. The spell of resistance and skepticism for the test was broken in 1941 when this researcher collaborated with a gynecologist Herbert Traut and published a paper titled ‘The diagnostic value of vaginal smears in carcinoma of the uterus.’ This great researcher was Georgios Papnikolaou and the low-cost test he gave is known as Pap smear test. There was a gap of more than a decade after its discovery before the medical community recognized the Pap smear as a diagnostic test.
The second great revolution in the prevention of cancer cervix came much later in 2008. A German virologist Dr. Harald zur Hausen discovered the link between Human Papilloma Virus (a sexually transmitted virus) and cancer cervix along with finding the two strains of the virus that cause it (Type 16 and 18). He received a Noble prize for his discovery and subsequently HPV vaccination was introduced as a way of preventing this cancer.
Many controversies have lingered around the testing and efficacy of the HPV vaccine leading to gaps and confusion over its acceptance over the years. However, it is about time that the aforementioned advances now be used to sensitize the medical community so that they may be proactively included in routine practice and consequently raise awareness for and acceptance of the test and vaccine among women on a mass scale.
As I said earlier it is a humongous but worthy task. It will take time but we need to accelerate our efforts. The first step is to make the right information available to all medical practitioners in women’s health and equip them with standard protocols to conduct awareness and screening camps. In an otherwise busy and demanding medical practice, it requires constant efforts to focus on prevention. Usually pressing medical issues take precedence and one tends to forget the important issues of making continuous efforts towards awareness and prevention to reduce disease burden.
So, it is our duty as medical practitioners to educate women and offer the Pap smear test to anyone who comes to our clinics. Additionally, mass awareness activities should also be indulged in at regular intervals to spread information about HPV testing and HPV vaccine.
So what is a Pap smear test?
It’s simply picking up cells from the cervix, i.e. the lower part of the uterus and preparing a slide to be sent to the pathologist for examination. It should be done for all women who are sexually active and between 21 to 65 years of age. In case a woman is sexually active before the age of 21, the test should be done within 3 years of her first sexual intercourse or at 21 years whichever is earlier.
There are some pre-requisites for the test. The woman should not be having her periods during or immediately before the test and should not have had sexual intercourse at least 2 days before. She should avoid douching and introducing any pessaries 2-3 days prior to taking the test.
The cells collected can either be spread on a slide and fixed with a preservative or a liquid based cytology might be conducted. Both methods are equally efficient but liquid based cytology provides the advantage of simultaneously testing for HPV DNA.
The Pap smear is repeated depending on the test result. For a monogamous woman with normal smear, the test is recommended every 3rd year. In case of suspicious results, the test may be recommended 6 monthly or yearly depending on the findings.
Upon detection of abnormal Pap smear, further tests (colposcopy, HPV DNA testing, cervical biopsy) and treatment (Cryotherapy, LEEP, Conization, hysterectomy) are done as deemed necessary. Women who have had complete removal of their uterus and cervix due to benign lesions do not need any Pap smears thereafter. In women who have had hysterectomy for cancer or those for who the cervix was left intact, still need the Pap smear even after the surgery.
With the advent of DNA testing and the knowledge that HPV is a causative agent, HPV DNA testing is recommended along with the Pap smear test and is popularly known as co-testing.
HPV is a sexually transmitted virus and most sexually active people contract it at some point in time of their adult life. However, HPV does not cause any symptoms except for genital warts. As a result, people harbor it and transmit it without even coming to know about it. There is no treatment for HPV and even using condoms does not ensure prevention. In most cases it is usually cleared by the body’s own immune mechanism. However if it persists it can lead to cervical cancer .
Having described the causative organism, preventive test and available vaccines; let us now look at the burden of cervical cancer in India i.e. what it looks like in numbers.
Cervical cancer is ranked as the most frequent cancer among women in India. India has a population of approximately 365.71 million women above 15 years of age, who are at risk of developing cervical cancer. The current estimates indicate approximately 123,000 new cases diagnosed and 74,000 deaths annually in India, accounting for nearly 1/3rd of the global cervical cancer deaths. Indian women face a 2.5% cumulative lifetime risk and 1.4% cumulative death risk from cervical cancer. At any given time, about 6.6% of women in the general population are estimated to harbor cervical HPV infection. HPV serotypes 16 and 18 account for nearly 76.7% of cervical cancer in India. To put the statistics in the simplest way one woman dies of cancer cervix every 8 minutes in India!! Needless to say, that the focus needs to shift aggressively towards preventative care for cancer cervix.
It is extremely necessary that medical practitioners be aware and make use of every opportunity of contact with women in the OPD to sensitize them about the importance of prevention, whether it is by means of talking about contraception or emphasizing the need for cervical cancer screening. Those in specialties other than gynecology can also talk about preventives tests or simply refer the eligible women for screening to a gynecologist.
It should become part of our practice to talk about prevention and not wait for the disease to happen. In remote areas where a pathologist and/or DNA testing facility is not available, medical practitioners and health care providers should be motivated to make an effort to visually inspect the cervix using acetic acid and Lugol’s iodine (VIA and VILI) to look for suspicious changes.
Immense efforts are needed to direct our focus and motivation to raise awareness. This can be done at individual level, as a part of a Government led program, at the level of medical societies and at the level of NGO’s including the private sector as a part of their social responsibility.
It is reassuring to know that Gynecological Organizations like FOGSI (Federation of Obstetrics and Gynecology of India), AOGIN India (Asia Oceania Research Organization on Genital Infections and Neoplasia India) and ISCCP (Indian Society of Colposcopy and Cervical pathology) are proactively taking initiative by bringing together experts to help educate people and make preventative screening for cancer cervix available not only in the big cities but also in remote geographical locations. But owing to the sheer burden of the disease and the lack of education and health seeking behavior, especially in the rural population, the task is increasingly challenging.
I believe all available tools to publicize and propagate the message to increase awareness and acceptance for cancer cervix prevention should be deployed. In the same spirit of being a self-taught artist besides a gynecologist, I have tried to pay tribute to Dr. Georgios Nikolaou Papanikolou through my artwork called “Vibrant’’. This artwork has been created using the Pap smear kit (the Ayer’s spatula and cytobrush) and was displayed at my first solo art exhibition “Udbhav”. It was a humble effort on my part to raise awareness about cancer cervix prevention through art.
Women bring beauty and vibrance to the world. Lets preserve the beauty and colors of their lives by providing them protection from cervical cancer. It doesn’t matter if you are not a health care provider you can still be a change maker by understanding and spreading the message correctly. As responsible citizens we all can employ whatever skill we have, to bring in the talk, draw attention and motivate women and their families to seek prevention from cancer cervix.
Dr. Nidhi Singh, MD (Obstetrics and Gynecology), King George’s Medical College, Lucknow, India.
Assistant Professor at Hind Institute of Medical Sciences.
September 03, 2018
– Cervical cancer in India and HPV vaccination., K. Kaarthigeya, Indian J Med Paediatr Oncolv.33(1); Jan-Mar 2012.
– Cancer Statistics 2012, National Institute of Cancer Prevention and Research http://cancerindia.org.in/statistics/.
Disclaimer: Although this article is scientific and educational in nature, it’s hard for me to detach my medical career from the passion for writing (read storytelling) and art. Therefore, there would be diversions to narratives and art through this article.