Cervical cancer remains a significant public health issue in India, being the second most common cancer among women. According to the George Institute of Global Health, over 123,000 women are diagnosed with cervical cancer in India annually. In an interview with BW Healthcare World, Dr G K Rath, former Head of the National Cancer Institute (NCI) at AIIMS and former Head of Radiation Oncology at AIIMS, discusses the challenges of cervical cancer in India, the role of radiation oncology in treatment, and the importance of HPV vaccination in prevention.
Q1: Cervical cancer continues to be a major health issue for women in India. Can you provide an overview of the disease, its risk factors, and why it remains prevalent in the country?
Cervical cancer is the second most common cancer among women in India. The incidence varies across the country, but one of the major concerns is that around 80 per cent of patients present at advanced stages, out of which only 20 per cent can be cured. This is in stark contrast to the 20 per cent who present at early stages, where 80 per cent are curable. The earlier the diagnosis, the better the chances of recovery. This highlights the critical need for prevention and early detection, which are not only more cost-effective but also less challenging compared to treatment.
Cervical cancer management includes surgery, radiation therapy, and chemotherapy, depending on the stage. Early-stage cancer is generally treated with surgery. However, since most women present at later stages, a combination of radiation therapy and chemotherapy is required. Treatment facilities are limited, especially in remote areas where the incidence is often higher. These treatments are also time-consuming and come with side effects, making access and affordability major issues.
Q2: What are the current trends in cervical cancer incidence and mortality in India, and how have they evolved over the past decade?
While breast cancer leads in most urban cancer registries, in rural areas, cervical cancer is still prevalent. For instance, in the Papumpure registry in Arunachal Pradesh, the incidence rate is 27.7 per 100,000 women, the highest in Asia. Key risk factors include HPV infection, early marriage, high number of children, poor genital hygiene, and lower socioeconomic status.
However, with better healthcare facilities and awareness, the incidence has reduced in urban areas. In cities like Delhi and Chennai, the incidence rate is now around 14 per 100,000. In contrast, some rural registries, such as Mizoram and Aurangabad, still show increasing rates. Education also plays a significant role; illiteracy is strongly linked to higher incidence rates, with 38.8 per cent of cases occurring among uneducated women compared to only 2 per cent among those with higher education.
Q3: The HPV vaccine is a major breakthrough in preventing cervical cancer. How is the vaccine uptake in India, particularly in rural and urban areas, and what challenges do we face in improving coverage?
The HPV vaccine is the most effective strategy for preventing cervical cancer. The World Health Organisation (WHO) recommends that girls aged 9 to 14 should be vaccinated. However, uptake remains low due to various barriers, including misinformation, lack of awareness, and poor access to vaccination services. These challenges exist in both urban and rural areas, but are more pronounced in remote regions.
In my experience, many patients and their families are unaware that cervical cancer is preventable. The idea of spending on vaccination for a condition that doesn’t yet exist is not accepted by many, particularly in rural areas. I am able to convince only about 15 per cent of families I counsel to vaccinate eligible girls. To increase coverage, the HPV vaccine should be included in India’s national immunisation program, which would ensure wider reach, especially in rural areas.
Q4: How important is screening, such as Pap smears and HPV testing, in early detection of cervical cancer, and how accessible are these methods in India?
Screening is crucial for early detection. Techniques like VIA and VILLI are available but are accessed by only a small portion of the population, mostly through government and NGO programs. The most significant advancement has been HPV testing, which has transformed cervical cancer screening in many countries. However, this gold standard test remains largely unavailable to most women in India, especially in rural areas. A few institutions like AIIMS offer HPV testing, but widespread access is still a challenge.
Q5: What role does radiation oncology play in the treatment of cervical cancer, especially in advanced stages, and what advancements in radiation technology are being used in India?
Radiation therapy, combined with chemotherapy, is the standard of care for advanced cervical cancer, both globally and in India. Several advanced radiation technologies are available, such as Intensity-Modulated Radiation Therapy (IMRT), Stereotactic Guided Radiation Therapy (SGRT), Volumetric Modulated Arc Therapy (VMAT), and even proton therapy at select centers. Our results, published in peer-reviewed journals, show that outcomes in India are comparable to Western centers for similar stages of cancer. However, access to these technologies is still limited to a few major institutions.
Q6: Given the preventable nature of cervical cancer, what policy changes do you believe are necessary to enhance prevention, early detection, and timely treatment in India?
Cervical cancer is a model case of a preventable and curable disease if diagnosed early. Prevention and early detection should be the focus of national healthcare policy. These measures are more economically sustainable than expanding treatment infrastructure. While the growth of treatment facilities is happening, it is not at the pace required to address the growing number of cases.
In our experience at AIIMS and through collaborations with organisations like NCDIR and ICMR, early diagnosis, coupled with immediate treatment, has shown promising results. The government’s programs like the Tertiary Cancer Care Centers have provided significant funding to promote cancer prevention and early detection. However, more can be done to improve patient transport, awareness, and referral systems, especially in rural areas.
Q7: Socioeconomic factors significantly influence cervical cancer incidence in India. How can healthcare providers address these disparities to ensure more equitable access to preventive care and treatment?
Socioeconomic disparities are indeed a major factor in cervical cancer incidence. Healthcare providers, along with government schemes like the State Cancer Institutes, play a critical role in reducing these disparities. Financial assistance provided by the government is helping institutions offer more equitable care. NGOs have also contributed significantly, especially in terms of awareness and providing free vaccination in some areas. However, much more needs to be done to bridge the gap, particularly in rural regions where access to healthcare is limited.
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