Dr. Sharda Jain
Gynaecologist
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Dr. Sharda Jain
MD. ( PGIMER), MANMS, FICOG,FIMSA, DHM, QM & AHD
 
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Down Staging Cervical Cancer In Resource Poor Settings Like India
Dr.Sharda Jain
Chairman, Global Institute of Gyneacology At
Pushpanjali Crosslay Hospital

Worldwide cervical cancer is the second most common cancer among the women with an estimated 493,000 new cases occurring annually and 274,000 deaths occurring each years. After introduction of the pap smear cytology by Dr. Goerge papanicolau in 1940, today it is widely accepted as the most effective cancer screening test for cervical cancer. Well organized and well implemented cytology based screening programms have drastically reduced the incidence and mortality due to cancer cervix in the developed countries. Based on experience of the countries with mass screening programs, International Agency of Research on Cancer (IARC) reported 93% reduction in cervical cancer incidence when women aged 35 to 64 years were screened at 1 to 3 yearly, 84% reduction when screened 5 yearly and 64% reduction when screened 10 yearly.(1)

India still remains far from making cytology available to the masses due to non availability
of pathologists and cyto technicians to read Pap smears.

Due to lack of infrastructure and trained personal, the incidence of cervical cancer has remained as high as 80% in developing countries. According to the program for appropriate technology in Health (PATH), an international non- governmental organization, “an important reason for the high incidence in developing countries is the lack of effective screening programs to detect precancerous conditions and treat them before they progress to cancer”.

According to the Indian council of Medical research (ICMR), the incidence of cervical cancer in India varies from 20 to 35 / 100,000 women between the age group pf 35 years to 64 years while in developed countries it is as low as 1-8 /100,000 women. In India, 132,000 new cases are reported annually with 74,000 deaths occurring each year hence, every 7th minute a women dies due to cervical caner. It is predicated that figures are expected to double by 2020 if no action is taken.

The challenges and failure in implementing cervical cytology screening in resources poor setting has resulted into exploring.
Alternative methods for down staging of the cervical cancer during last decade. Some of theses methods are
  1. Visual inspection of cervix with acetic Acid(VIA), Visual inspection of cervix with lugol’s iodine (VILI).
  2. Use of Magnascope instead of Colposcope
  3. Single visit approach
  4. Treatment with cryosurgery for VIA+ ve women
  5. Self collected sample for cytology and Human Papilloma virus (HPV) – DNA testing
  6. Education and counseling
  7. Increasing coverage by camp approach
  8. Low cost HPV test
  9. HPV vaccines.
In 1982, ottaviano and La taro reported that when women were examined visually by simple speculum and colplscopically after application of 3% acetic acid to cervix, they observed equal detection rates of cervical abnormalities by both techniques.(2)

This led to the development of low technology screening test for down staging of cervical cancer in resources poor settings . After applying 3% acetic acid to cervix “white patches” appear due to coagulation of cellular proteins and indicate the abnormal epithelium which is thick and does not allow the light reflection to pass through (VIA). When lugol’s iodine is applied to the cervix, the normal cells containing glycogen stain dark brown. The abnormal cell are rapidly dividing and are deficient in glycogen hence, remain unstained which are further evaluated (VILI). IARC studies in India and Africa proved that VIA performed by trained paramedics has sensitivity of 64 to 90% and specificity of 73 to 91% which is comparable to conventional cytology.(3)

In 2007 many studies have reported that the specificity of VIA was increased by adding adjunctive test like VILI.

Advantages of Visual techniques are immediate results, making cost effective and has more than 99% negative predictive value. Ten to fifteen percent VIA +Ve women require referral for colposcopy and if necessary colposcopy guided biopsies . Generally inflammatory lesions and low grade squamous intraepithelial lesions(LGSIL) are treated conservatively and followed up High Grade lesion & cancer require specialised treatment.

In single visit approach cryothrepy is offered to all those women who are VIA+ ve and cannot visit more than once for this test. Randomized trial conducted in Tamil Nadu for the single visit approach reported that follow up after 7 years showed a significant 25% reduction cervical cancer incidence, a significant 35% reduction in cervical cancer mortality and 27% reduction in the incidence of stage II or advanced cancer compared to control group (4)

Educating women for utilizing the health camp system after completing family especially
in rural areas and nationwide education programs for women regarding awareness, prevention and early warning symptoms of cervical cancer can result into marked reduction in mortality. Similarly , camp approach and self sampling in rural areas can also down stage the disease in resource poor settings.

It is now well understand that persistent infection with at least one the 15 cancer related, high risk human papilloma virus (HPV ) causes the development of cervical cancer (70 % due to type 16 to 18 IARC reported that there sufficient evidence to support the use of hybrid capture 2 (HC2) HPV – DNA testing as primary screening . HPV testing is an objective test which identifies both women with precursor lesions and women with high risk for cervical cancer in future. However, HPV test is less speccitiaty compared to cytology but specific increases in women over the age of 35 years. The major advantages of using the test for primary screening is its very high negative predictive value resulting into minimal risk for developing cervical cancer within the next 10 years and hence, the inter – screening period can be extended, making a better use in the resources poor setting. The new rapid affordable HPV test – care HPV test is appropriate for resources poor setting. A clinical study in china amongst 2500 women reported that it is comparable to HC-2 & better than VIA. The sensitivity and specificity of the care HPV for CIN 2+ was 90% and 84% respectively compared to 97% and 86% for HC2.

Conclusion:
VIA and VILI are useful screening alternative to cytology in resource poor setting. Under the national cancer Control Program. Govt. of India is recommended to provide VIA based screening at the primary health centers by trained health care providers and then a single visit approach for colposcopy and management at district hospital. Law cost, rapid HPV DNA test, self collection of smears with cytopathologist to read the smears looks a distance dream.HPV vaccine will definitely prevent and down stage the cervical cancer in resource poor setting in near future, provided gynarcologists take this challenge.

References
  1. Control of cancer of the cervix uteri. A WHO meeting, Bull World Health organ; 1986:64:607-30\
  2. Ottaviano M.,La torre P. Examination of cervix with the neked eye using acetic acid test. Am. J. Obstet. Gynecol 1982; 143 :139 – 142
  3. International Agency of research on cancer (IARC) Handbook of cancer prevention. Cancer cervix screening IARC france, 2005 – 10
  4. Sankaranarayanan R. Esmy P.O., Rajkumar R et al , Effects of visual screening on cervical cancer incidence and mortality in tamil Nadu , India: A cluster randomized trial Lancet 2007 : 370 :398 - 406
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