News and Insights
Cervical Cancer: A Call to Action for Every Mother and Daughter
February 28, 2024
“This was a complete waste of time”, “I can’t believe I had to take an entire day off for all these tests”, “I am not doing this again”, “I am perfectly fine, why do I need to check for sexually transmitted infections?”, “Oh God, this is so awkward, I think I will skip the Pap smear and come some other time”, “I don’t think there is anything wrong with me there.”
These are some of the excuses I have heard my friends make every time they schedule their regular health check-ups and screenings. Like many educated women in India, they remain unaware of the value of getting screened as ‘there is nothing wrong with them’.
For Indian women across socioeconomic strata, regular health screening often takes a back seat not only due to lack of awareness but also due to time constraints, other familial priorities, and shame or stigma. For still others, it is a luxury they can ill afford. But how many women know that these screenings are necessary for stopping many potentially life-threatening conditions in their tracks?
One such condition is cervical cancer which silently claims the lives of thousands of women each year. For some women, lack of awareness about cervical cancer can be as dangerous as the disease itself, as it is a pandemic that is hiding in plain sight. Though preventable by a vaccine, it remains the second most common cancer in Indian women, obscured in the shadows of other concerns. The recent availability of an affordable vaccine is a welcome step. But is the vaccine alone sufficient to reduce the disease burden?
This silent yet impactful disease affects women from all walks of life, transcending geographical boundaries, cultural nuances, and socio-economic disparities. Data from the Human Papilloma Virus (HPV) information centre estimates that 123,907 Indian women are diagnosed with cervical cancer annually and 77,348 die from the disease every year. It commonly affects women in the age group of 15 to 44 years i.e. in the prime of their lives. Though an affordable vaccine now exists in resource-constrained settings, several misconceptions surrounding this disease need to be addressed to make prevention a reality.
Lack of awareness is a key challenge
India has a population of 511.4 million women above 15 years of age who are at risk of developing cervical cancer. The disease is linked to several factors such as HPV infection, age at marriage, number of pregnancies, genital cleanliness, use of oral contraceptives, nutritional condition, and smoking. Nearly 95 percent of cervical cancer is caused by persistent HPV infection and about 85 percent of people will get this infection during their lifetime, though not all will result in cancer. Hence, vaccination and regular screening are essential to prevent the march of the condition.
A study which assessed the knowledge, attitude, and practice of cervical cancer screening in tertiary care centres in India showed that only 45.7% of women had heard of cervical cancer, 78% did not know that it is preventable, and 75.8% had never heard about screening. This is also reflected in the National Family Health Survey – 5 data, which show an overall cervical cancer screening rate of 1.9 percent for urban and rural areas in women between 30 to 49 years of age. The situation is even worse in rural regions where paucity and inaccessibility of healthcare resources and widespread illiteracy exist. In such areas, women are often diagnosed with advanced cervical cancer, resulting in poor prognosis.
Knowledge about the causes, risk factors, and preventive options for cervical cancer is poor even among educated women. In one study, many women agreeable to regular cervical cancer screening wanted to ask their husbands/family members before getting screened. On the other hand, several women felt that screening was not needed due to the lack of symptoms. Other reasons for low uptake of screening included the absence of advice from friends/peer groups to undergo the test, fear of being detected with cancer and shyness or embarrassment of getting examined. This lack of awareness impacts adolescent health too. Data indicate that a majority of adolescents (8-17 years old) and their parents are unaware of cervical cancer, HPV, and HPV vaccines.
Cultural barriers
There is a significant stigma associated with cancer. For instance, people believe that cancer is a result of ‘sin’ and they may be rejected by their family and community. There is also a fear of isolation due to the misconception that cancer is an infectious disease. The spreading of accurate information on cervical cancer and its prevention is also complicated by the lack of open conversations about reproductive health issues. In some areas, the association of cervical cancer with HPV, a sexually transmitted infection, has also made prevention a challenge. Parents, for instance, were concerned about the safety of the HPV vaccine and were under the misconception that getting it would make sex safer and allow for riskier sexual behavior and promiscuity — which could damage their family’s reputation and lead to social stigmas.
Making cervical cancer eradication a reality
Several collaborative steps will be needed to make a significant dent in the country’s cervical cancer burden. As health communication professionals, here are a few messages that we need to disseminate.
- Destigmatize HPV: Increasing public awareness about HPV and HPV-related diseases and clearing the myths and misconceptions about screening and vaccination will go a long way toward strengthening the preventive framework for cervical cancer. Addressing cultural concerns, engaging with community leaders, and promoting open dialogue can help build trust. Both healthcare providers and community-based social workers have a key role in spreading accurate information through both print and audio-visual means to ensure greater acceptance. Increasing community awareness by involving schools, colleges, and via social media with the help of doctors who are influencers, can also be a way forward.
- Both boys and girls need HPV vaccination: Apart from cervical cancer, HPV infection can also cause other cancers affecting the penis, anus, and back of the throat. The key is to prevent HPV infection and detect the disease before it manifests. The affordable HPV vaccine developed in India can protect boys, men, girls, and women (9-26 years). Though it is preferable to vaccinate pre-adolescents/adolescents, the infection can occur at any age, hence it need not be limited to them alone.
- Regular screening is a must: Multiple strains of HPV exist, and vaccination protects from the commonly infective ones. Hence, even for women (30-65 years) who are vaccinated, cervical cancer screening with an appropriate test is a must and needs to be done at least once every 5 years, irrespective of the presence of symptoms. Both visual inspection with acetic acid (VIA) and a Papanicolaou (Pap) smear can detect both cancerous and pre-cancerous cervical lesions, whereas HPV DNA test confirms the presence of infection. Screening eligible mothers (30 years and above) and vaccinating their daughters can become a good starting point.
- Infrastructural support and appropriate training: There is a lack of a comprehensive national policy specifically addressing cervical cancer prevention, screening, and treatment. This leads to fragmented efforts, uneven distribution of resources and the absence of large-scale screening programs. Pap smear tests and HPV DNA testing, which are crucial for early detection, are not widely available or accessible. Some data suggest that there is a lack of clarity among clinicians about the type of cervical cancer screening test and the eligibility criteria for the same along with its cost. Though VIA is recommended for screening in resource-poor settings, not all doctors, nurses and community health workers are well-trained and/or use it routinely.
- Incorporation of the vaccine in the national immunization schedule: The 2024 Interim Budget proposed that the government would encourage vaccination for cervical cancer among girls in the age group of 9 to 14 years. As the next step, incorporation of the HPV vaccine in the national immunization schedule, coupled with information, education, and communication, is essential to spur acceptance. Widespread immunization can help prevent infection and thereby lower the incidence of cervical cancer until suitable infrastructure for large-scale screening is available and a sufficient number of healthcare professionals acquire the necessary training.
- Maintain the care continuum: An important aspect of a successful screening program is to ensure adequate follow-up of patients who have been detected with either pre-cancerous or cancerous lesions. Patients can be either screened and treated in a single sitting (screen and treat method) or they can be asked to come in for a second confirmatory test (triage) and then treated. The availability of adequate facilities and the patient’s willingness to come for follow-up play a huge role in choosing the right approach. Counselling them about the importance of treatment can help the patients make the correct decision.
Awareness, access, and advocacy
The World Health Organization’s cervical cancer elimination strategy aims to vaccinate 90% of girls with the HPV vaccine before 15 years of age, screen 70% of women with a high-performing test at 35 and 45 years of age and treat 90% of women detected with cervical disease. Though India is significantly affected by this preventable disease, the lack of awareness about the condition, its risk factors and the HPV vaccine hampers preventive and therapeutic efforts. The impact is disproportionately high in rural areas due to additional factors such as illiteracy and inadequate diagnostic facilities. Wide and effective spreading of awareness among women of varying socioeconomic strata is key for the success of any program to control the disease. The affordable HPV vaccine can become a beacon of hope for the future generation via a nationwide roll-out among schoolchildren. Convincing mothers to undergo screening at least once in 5 years with VIA (to begin with) would be the next step in this endeavour. Various stakeholders (the government, NGOs, private players, etc.) should collaboratively commit to empowering women, eradicate disparities, and redefine the narrative surrounding cervical health. India’s resounding success in the COVID vaccination drive and in eliminating polio has shown that much is possible if we come together.
As communication professionals, we hold the power to transform awareness into action, to illuminate the pathways to prevention, early detection, and treatment. Let our words be the catalysts for change, sparking conversations that dispel myths, promote screening, and empower women with knowledge. Through unwavering dedication and collaborative action, we can transcend the barriers that shroud cervical cancer, revealing a path towards a brighter, healthier future for generations to come.
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