Cervical Cancer- Care Delayed-Care Denied and Death Invited

Introduction

With about 78 billion global population, 19 million new cancers and nearly 1 million deaths due to all types of cancers estimated to occur in 2020. Cervical cancer does not figure in top 5 most common cancers in both sexes globally, but with 6.5% incidence it forms the fourth top among women worldwide. The cancer registry data across the country in India with simple average of the most recent local rates applied to 2020 population estimates a figure of 1324413 cases and 851678 deaths in 2020 and cumulative prevalence around 2.7 million cases in last 5 years of all categories of cancers in India [1]. Cervical cancers in India account for 10% of all cancers in both sexes and about 18% of cancers among women in India as per the international agency for Cancer Research (Globocan 2020). Nearly one- third of the global cervical cancer deaths occur in India. It is a preventable condition as it has a long pre-cancerous stage amenable for screening and treating. Cervical cancer Cervix uteri is no 3 with about 123 907 cases (9.45%) next only to Breast and Oral cancers with a 2.01 cumulative risk. While the incidence and mortality rates of cervical cancer in the world are 13.1/ and 6.9/ per lakh population, in India, it is estimated to be 14.7/and 9.2/ per lakh population. This will be about 96,922 new cervical cancer cases and 60,078 deaths ranking second among women cancers in 2020 [2]. India is experiencing a rapid health transition with a rising burden of Non-Communicable Diseases (NCD) surpassing the burden of Communicable diseases. Cervical cancer is the leading cause of cancer deaths in women in India. The human papillomavirus (HPV) is responsible for virtually all cervical cancers has given way for developing a vaccine for preventing this disease [3, 4, 5, 6, 7]. Though cervical cancer is on the declining trend according to the population-based registries; its screening has not yet penetrated rural India and it continues to be a major public health problem for women in India. Multifactorial causation, potentials for prevention, and the sheer threat it poses, make cervical cancer an important disease for in-depth studies and countrywide interventions [4]. Disparities of access to health care and poverty play a major role in high mortality rate. To control and prevent major NCDs, the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) was launched in 2010 with focus on strengthening infrastructure, (HRD) human resource development, health promotion, early diagnosis, management, and referral [2]. Nationwide education, promotion screening services are still short due to lack of awareness about the importance and urgency among rural and slum population and inaccessibility of such services in subdistrict level. The routine human papillomavirus (HPV) testing and vaccination can reduce in cervical cancer deaths. Studies on HPV DNA testing and the low-technology method of “screen and treat” are promising. In addition, decreasing the cost and increasing the availability of HPV vaccines in developing nations brings hope and promise to the next generation of women.

Cervical cancer can be prevented by doing PAP smear screening and getting HPV vaccine done. Symptoms include bleeding in between periods and also after sexual intercourse. Foul smelling white discharge, low backache and lower abdominal pain may also occur. In some cases there may not be any symptoms. Almost all cervical cancers are caused by human papillomavirus. HPV is a common virus that spread through skin-to-skin contact and by sexual intercourse. Treatments include surgery, radiation, and also chemotherapy (Figure 1).

Click to enlarge

Discussion

Regular smear test can discover the sign of precancerous cell and treat the patient according to the result. The Classification for Pap smear Analysis aims at classifying the Pap smear cells whether it is affected or not by using the extracted features of grey level co-occurrence matrix technique. Cervical cancer stages use in India cancer program are [8].

• Stage 1: Cancer has formed and is found in the cervix only.
• Stage 2: The cancer has spread to the upper part of the vagina or the tissue surrounding the uterus, but it hasn’t spread to lymph nodes or distant sites.
• Stage 3: The cancer  has spread to the lower third of the vagina and/or to the pelvic wall and/or has caused kidney problems, and/or involves lymph nodes.
• Stage 4: The cancer has spread beyond the  pelvis or has spread to the lining of the bladder or rectum or has spread to other parts of the body.
• Stage 4A: The cancer has grown into nearby organs such as the bladder or rectum or is spreading out of the pelvic area.
• Stage 4B: The cancer has spread to the liver, lungs, bones, or distant lymph nodes.

Cervical cancer is one of the leading causes of cancer death among females worldwide, more often a silent killer. As observed in this case cervical cancer was diagnosed at very late stage and not treatable as she was symptomatic only for about 4 months. The cancer had spread out of the pelvis to other areas of the body in the first consultation itself. Indian Cancer Society standard treatment protocols were used in this case that included radiation therapy with chemotherapy to slow the growth of the cancer & help relieve symptoms [8].

This case emphasizes the need for regular screening for all women over 35-45 years and HPV vaccination for adolescent girls and early care seeking behavior in India. Many women avoiding PAP smears screening is not simply a matter of personal choice or being irresponsible. Other reasons include psychological factors like fear, discomfort, social stigma about cervical cancer, distrust of medical services & faith in traditional healing methods. Rural people approach traditional healers more for the treatment [10].

If diagnosed at an early stage cervical cancers are curable. These cancers are preventable with access to periodic screening tests, high-quality care, and regular follow-up [8]. The strategies to reduce the high burden of cervical cancers include risk factor intervention, screening, vaccination, and early diagnosis [11].

Cancer prevention with the help of a vaccine is a comparatively new concept, awareness and education will have important implication in the implementation of this strategy. A study after giving awareness about HPV vaccine among target population, seen increased overall acceptance of HPV vaccine to 67.8% [12].

A cross sectional study done in south India on screening and awareness among women indicated that very few women are screened as only few had adequate knowledge of the disease. This study suggested community-based education followed by screening campaign is the need of the time to reduce the prevalence of cervical cancer in population [11, 12, 13, 14].

Conclusion

Despite being one of the top Cancers among women in India, and national program since 2010 many women are dying due to lack of awareness, accessibility of services of the disease especially in rural & tribal areas. To add to the problem belief in traditional healing methods because of accessibility, affordability is influencing delayed seeking appropriate care. The national NCD screening program has not yet widely spread and influenced creating awareness about screening activities & HPV vaccine. As even the educated girls are neither aware nor vaccinated, starting an exclusive mandatory vaccination for school and college girls is the need of the time.

Take Home Message

1. Popularizing HPV vaccine for girls in the age group of 9-25years is a priority.
2. Increasing accessibility for screening tests of cervical cancer through H&WCs.
3. Avoiding unsafe sex & smoking.