All you need to know about cervical cancer

Cervical cancer is the cancer that arises from the cervix, the lower part of the uterus. It is the 4th most common cancer amongst women globally, with more than 90% of these women living in low- and middle-income countries (WHO). In India, it ranks as the second most common malignancy amongst women. In India, cervical cancer accounted for 9.4% of all cancers and 18.3% (123,907) of new cases in 2020 (Globocan data 2020).

In spite of being one of the few cancers that can be prevented almost completely and cured when detected at an early stage, it is unfortunately detected at an advanced stage in our country, and often incurable. India accounts for nearly 1/3rd of the cervical cancer deaths worldwide. This reflects the lack of awareness, knowledge and the social stigma associated with cancer detection and treatment in our society. 

Human Papilloma Virus (HPV) is the causative factor in >95 % of the cases, and is sexually transmitted. In addition to HPV infection, factors like earlier age at the time of marriage, higher number of pregnancies, poor genital hygiene, use of oral contraceptives, poor nutritional status, smoking, co-existent HIV infection are associated with the development of cervical cancer.

The most common symptoms include white discharge per vagina, bleeding per vagina and post coital bleeding or spotting. Symptoms such as pelvic pain, lower backache can be seen when the disease has spread beyond its origin in the cervix. 

The different modalities of treatment include surgery, radiotherapy and systemic therapy, each administered depending on the extent of disease. For early stages of disease, surgery and radiotherapy with concurrent chemotherapy are highly curative with little morbidity, and chemotherapy along with targeted therapies and immunotherapy have improved outcomes in the advanced stage of the maliganancy. 

Screening and Prevention – The malignancy is invariably caused by HPV infection, and most HPV infections are spontaneously eradicated by our body. The persistent HPV infection causes the development of an invasive cancer from a normal cell lining. The progression to an invasive cancer takes up to decades. 

These changes can be picked up by a PAP smear test and hence testing for HPV virus and PAP smear regularly, can help keep a check in sexually active women. These tests can be done alone, or at the same time (called a co-test). Regular screening has been shown to prevent cervical cancers and save lives. 

Screening is recommended starting at the age of 25 years, and  may be done with either a co-test that combines an HPV test with a Papanicolaou (Pap) test every 5 years or a Pap test alone every 3 years(as per the American Cancer Society). 

In a resource limited country like ours, more cost effective tests have been developed and validated in studies such as the VIA(visual inspection with acetic acid) testing, to be done every 5 years.

Vaccination – this helps prevent development of HPV infection. There are three FDA approved vaccines for prevention Cervarix (bivalent) and Gardasil (quadrivalent and 9-valent), which are both effective against the predominant HPV serotypes 16 and 18, that are responsible for more than 70% of the cervical cancers. CDC ( Centre for Disease Control )recommends routine vaccination of preteens at ages 11 or 12 years. The vaccination series can be started as early as at age 9 years, and may be given at the same time as other vaccines. This is now incorporated into the Universal Immunisation Schedule, as per the Indian Academy of Paediatrics.

HPV vaccination schedule  is as follows (CDC):

• A two-dose series (0, 6-12 months) for those who initiate vaccination at ages 9 through 14 years
• A three-dose series (0, 1-2, 6 months) for those who initiate vaccination at ages 15 through 45 years, and for immunocompromised persons.

The Indian Government too, in view of the high incidence and mortality in our country has approved its use till the age of 45 years. The WHO in a recent new release, has announced that one single shot of the HPV vaccine provides equivalent protection to the 2 or 3 dose scheduling. This significantly reduces the cost to the patient and makes it more acceptable and accessible to people. 

Looking at the vast promising data on primary and secondary prevention, we only wish that it the public would embrace the recommended preventive vaccination and tests. This will alter the course of this cancer profoundly, both at the individual and community level, which would in turn translate to remarkable results nationally. 

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