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COMMENTARY
Year : 2017  |  Volume : 13  |  Issue : 3  |  Page : 389-391

Prospects of cytological cervical cancer screening in India: Exploring adjuvant approaches


1 Department of Neurology, Institute of Human Behavior and Allied Sciences, New Delhi, India
2 Division of Molecular Oncology, National Institute of Cancer Prevention and Research, Indian Council of Medical Research; Department of Health Research, Ministry of Health and Family Welfare, Government of India, Noida, Uttar Pradesh, India
3 Department of Medicine, Rukmani Birla Hospital, Jaipur, Rajasthan, India

Date of Web Publication31-Aug-2017

Correspondence Address:
Sandeep Singh
Institute of Human Behavior and Allied Sciences, New Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.204886

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How to cite this article:
Singh S, Hussain S, Badaya S. Prospects of cytological cervical cancer screening in India: Exploring adjuvant approaches. J Can Res Ther 2017;13:389-91

How to cite this URL:
Singh S, Hussain S, Badaya S. Prospects of cytological cervical cancer screening in India: Exploring adjuvant approaches. J Can Res Ther [serial online] 2017 [cited 2020 Jun 4];13:389-91. Available from: http://www.cancerjournal.net/text.asp?2017/13/3/389/204886

Going through the article entitled, “Limitations of cytological cervical cancer screening (Papanicolaou test) regarding technical and cultural aspect in rural India,” it tracked down us to contemplate several thoughts regarding the suggestions expressed by research scholars.[1] Although it is a well-versed written article describing the limitations of existing cytological screening modality in Indian scenario, it still remains incomprehensive toward construing the intended purpose. This urges us to further explore unearthed consideration by the authors to evolve newer aspects on this topic.

The authors of the article best described the term, “preventable but not prevented.” Cervical cancer is highly preventable disease through organized and effective screening program. In spite of being preventable disease, our women are still on the verge of contracting the disease. This article stipulates the approach and status of our screening scenario and tries to look into the feasibility of suggestions provided in the article entitled, “Limitations of cytological cervical cancer screening (Papanicolaou test) regarding technical and cultural aspect in rural India” by Nikumbh et al.[1]


 > Cervical Cancer Screening Status in Indian Scenario Top


It is the fourth most common cancer among women worldwide along with the leading cause of cancer-related deaths in Indian women.[2] In India, private health facilities remains the sole screener, with the total number of women being screened to be only 5% in the low-resource setting.[3] The main screening mechanism being utilized in Indian and other developing setup is of “opportunistic screening.” However, there is starvation for effective high-level organized screening program.[3] The process how a woman undergoes during the screening program is depicted in [Figure 1]. Impedance in any of the steps in the chain of command will lead to failure of the opportunistic screening of these women.[4]
Figure 1: Algorithmic approach for opportunistic cervical cancer screening

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 > Existing Barrier Faced by the Existing Conventional Cytology Through Opportunistic Approach Top


This opportunistic screening program faces a number of barriers ranging from logistic to the patients' psychology.

  1. It is an opportunistic program, so it misses a normal healthy woman
  2. Even if the women are aware, they have to travel a long run at tertiary care center to avail the screening facility
  3. Slides have to be transported to the cytopathology laboratory, which always bear chances to get damage
  4. It requires trained cytopathologist to report the slides
  5. The generated reports are being communicated manually to the screening facility requiring workforce
  6. It requires next visit by the women to collect the report, overburdening the financial crisis due to long distance travel
  7. If women fail to visit, it hits the screening program with a designed term called loss to follow-up.



 > Barriers to Human Papillomavirus Vaccination Top


Several barriers to human papillomavirus (HPV) vaccination have been reported in various studies. The World Health Organization stipulates that an optimal epidemiology of the disease is required to justify its prioritization, and while assessing the impact of a vaccine intervention, an adequate surveillance system must be existent as well.[5] The major barrier seems to be aware regarding the disease and HPV vaccination.[6] Reports from Indian studies suggest a very low knowledge about the disease, its screening and HPV vaccination among nursing fraternity, graduates, and postgraduates. Such reports should make us rethink before looking for vaccination as a viable tool to fight the disease. Surprisingly, when the health-care fraternity which is regularly exposed to the medical knowledge and its updates holds lower learning about cervical cancer, it is difficult to expect satisfactory disease literacy in the general population which is distant from any medical resource pool. Since adolescents are the prime target for the vaccination, lack of knowledge among them could adversely affect the vaccine acceptance as well.[6]

There are several other hindrances regarding the vaccine acceptance and among the targeted population as shown below.

  1. High cost[7]
  2. Moral, social, religious, and ethical issues due to unacceptability of premarital sex[7]
  3. Familial perception regarding the disease and vaccine safety[7]
  4. Vaccine effectiveness in older age women[7]
  5. No adequate surveillance and monitoring system.[8]


Unfortunately, prevalent epidemiological evidence and cancer surveillances are unjustifiable/insufficient for present and upcoming unfolding of HPV vaccination program either in India in entirety or just in those two states where PATH conducted their research.[8]


 > Newer Innovative Approaches Top


Looking into the failure of opportunistic screening program and nonfeasibility of HPV vaccination in present scenario, we have to readopt for the alternative approaches until and unless we could get cost-effective prophylactic and/or therapeutic HPV DNA vaccine in India. The efforts are being made world over including India by the Indian Council of Medical Research to have indigenous HPV DNA vaccine.[9] In addition, resource polarization and communication barriers are the major problems faced by the cervical cancer screening in any developing nation. Therefore, system requires a strong communication mode to generate awareness among women regarding the disease and the available screening facility and preventive/therapeutic measures. We are required to depolarize resources from a tertiary care center to resource limited area where the needy ones dwell, especially in our rural setup. Newer approaches are required to overcome screening failure and increase screening uptake: approach for real time result generation, way of easy and immediate dissemination of the reports to the patient, timely follow-up of previously screened women, increasing community perception toward role of primary prevention rather than secondary prevention, concept of cervical cancer card, and many more.[10]

Using the telecytology and laser-induced breakdown spectroscopy approach suggested by Singh et al. can assist in easy depolarizing of resources in remote areas. This could provide a door-to-door approach to aware women and collect the cytology samples.[11],[12] This approach can lead to real-time generation of results, easy overcoming the issue of recruitment of healthy women, heavy loss to follow-up faced during the opportunistic screening program, generating newer jobs for the local people, etc. Using mHealth, reports could be easily disseminated to the patients and even to the screening facility.[13] After this depolarization of resources from a tertiary care center, there will be needed for women recruitment to be screened. Involving community health workers such as accredited social health activist (ASHA) from the local community, the women getting screened will have more faith in them and it would be easy to recruit newer healthy women too.

Liability assigning role of ASHA for timely visit of previously screened women could easily curtail loss to follow-up.[14] Watch and treat approach through visual inspection with acetic acid (VIA)/visual inspection with Lugol's iodine (VILI) being tested by Indian government will also be a better tool. Since VIA/VILI is a real-time modality and requires very simple logistics, it provides a feasible tool being used in remote areas.


 > Conclusion Top


Adjuvant approaches are not to be taken as supplement, but it is an opportunity to even supplant conventional systems to generate more effective outcome on health parameters and social standards as suggested through few of the fast developing techniques such as telecytology, which is equally synchronized with the highly ambitious Government of India Program of “Digital India,” for a decisive move towards achieving “Affordable and Timely Healthcare for All.”

 
 > References Top

1.
Nikumbh DB, Nikumbh RD, Kanthikar SN. Limitations of cytological cervical cancer screening (Papanicolaou test) regarding technical and cultural aspect in rural India. South Asian J Cancer 2016;5:79.  Back to cited text no. 1
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2.
Cervical Cancer Estimated Incidence, Mortality and Prevalence Worldwide in 2012. Available from: http://www.globocan.iarc.fr/old/FactSheets/cancers/cervix-new.asp#INCIDENCE. [Last cited on 2016 Jun 26].  Back to cited text no. 2
    
3.
Singh S, Badaya S. Factors influencing uptake of cervical cancer screening among women in India: A hospital based pilot study. J Community Med Health Educ 2012;2:157.  Back to cited text no. 3
    
4.
Singh S, Badaya S. An urgent need to re-strategize loss to follow up in cervical cancer screening program in India. J Cancer Policy 2015;6:23-4.  Back to cited text no. 4
    
5.
Disease Control in Humanitarian Emergencies and World Health Organization. Vaccine Introduction Guidelines: Adding a Vaccine to a National Immunization Programme – Decision and Implementation. Geneva: WHO Department of Immunization, Vaccines and Biologicals. Available from: http://www.who.int/vaccines documents/. [Last cited on 2016 May 17; Last accessed on 2016 Oct 23].  Back to cited text no. 5
    
6.
Hussain S, Nasare V, Kumari M, Sharma S, Khan MA, Das BC, et al. Perception of human papillomavirus infection, cervical cancer and HPV vaccination in North Indian population. PLoS One 2014;9:e112861.  Back to cited text no. 6
    
7.
Bharadwaj M, Hussain S, Nasare V, Das BC. HPV and HPV vaccination: Issues in developing countries. Indian J Med Res 2009;130:327-33.  Back to cited text no. 7
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8.
Mattheij I, Pollock AM, Brhlikova P. Do cervical cancer data justify HPV vaccination in India? Epidemiological data sources and comprehensiveness. J R Soc Med 2012;105:250-62.  Back to cited text no. 8
    
9.
Kumar A, Hussain S, Sharma G, Mehrotra R, Gissmann L, Das BC, et al. Identification and validation of immunogenic potential of India specific HPV-16 variant constructs: In-silico & in-vivo insight to vaccine development. Sci Rep 2015;5:15751.  Back to cited text no. 9
    
10.
Singh S, Badaya S. A strategy to increase the uptake of cervical cancer screening in India: A lesson from the ongoing programs. South Asian J Cancer 2013;2:201.  Back to cited text no. 10
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11.
Singh S, Bdaya S. Laser induced breakdown spectroscopy (LIBS) for cervical cancer screening: The desired destination for the protracted hunt. J Cancer Policy 2015;5:23-4.  Back to cited text no. 11
    
12.
Singh S, Badaya S. Tele-cytology: An innovative approach for cervical cancer screening in resource-poor settings. J Cancer Res Ther 2016;12:481-5.  Back to cited text no. 12
    
13.
Badaya S, Singh S. Missing cervical cancer patients in India: Time to rejuvenate follow up strategy through mhealth. J Cancer Policy 2015;3:3-4.  Back to cited text no. 13
    
14.
Singh S, Badaya S, Multani MK. Is existing cervical cancer screening proven productive in developing nations: Time to move from the laboratory to community? South Asian J Cancer 2013;2:242.  Back to cited text no. 14
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