Dr. Reetika Menia & Dr. Natasha Gupta
The theme for cervical health awareness month this year is “Learn, Prevent and Screen” emphasizingthe need for routine screening and timely treatment of cervical cancer.Cervical cancer despite being preventable and treatable continues to pose a significant threat to women’s health, especially in developing nations with limited resources. Despite advancements in medical knowledge and technology,the prevalence of cervical cancer remains disproportionately high, contributing significantly to female mortality rate. GLOBOCAN 2020 quoted cervical cancer as the fourth most common cancer and one of the leading cause of cancer deaths among women globally, with an estimated 6,04,127 new cases and 3,41,831 deaths. In India cervical cancer is the 2nd most common cancer in females after breast cancer. According to GLOBOCAN 2020, India accounted for 21% of new cases and 23% of cervical cancer-related deaths worldwide. The battle against cervical cancer is compounded by various challenges including limited access to screening tests, vaccination coverage gaps, insufficient health education, cultural and social barriers, poorhealthcare infrastructure, and economic obstacles.
The peak age of incidence for cervical cancer in India, ranges from 50 to 59 years, in contrast with the age range in developed countries (35 to 44 years). This disparity is attributed, in part, to a significant proportion of Indian women being diagnosed in advanced stages: 32.8% with localized disease, and for 67.2% the disease has already spread beyond the uterine cervix at the time of diagnosis. Consequently, treatment becomes more expensive, prognosis gets poorer due to late diagnosis. According to GLOBOCAN2020 , projections for 2040 indicate a 54% increase in new cases and a 61% increase in deaths in India, emphasizing the urgent need for effective preventive measures and screening programs.
Cervical cancer screening stands pivotal for early diagnosis, and the recognition of precancerous lesions such as Cervical Intraepithelial Neoplasia (CIN). This precancerous lesion CIN is graded into Low grade Squamous Intraepithelial Lesion (LSIL) or CIN I, and High grade Squamous Intraepithelial Lesion (HSIL) or CIN II/ III.
Early intervention at the CIN stage I &II is vital for better outcomes, as progression to invasive cervical cancer is higher in cases of CIN III. Treatment at the CIN III stage is associated with a significantly higher risk of persistence or recurrence compared to CIN II cases. Early-stage cervical cancer, if treated promptly, results in 95% disease-free survival rate and a 98% overall survival rate at ten years.
Screening tests are effective in preventing cervical cancer because of the existing long latent period between onset of HPV infection and development of invasive cancer.
Despite the widespread information on screening tests, the prevalence of cervical cancer screening in India, as per the National Family Health Survey (NFHS-5)is reported only 1.2% during 2019-21, a considerable decrease from 22.3% reported during 2015-16 which is an alarming situation.
Various screening methods are easily available in the healthcare setups and are also cost effective. The recommended initiation age for screening tests and follow up interval may although differ but all of them rule out existence of underlying precancerous or cancerous lesion if test result is reported negative.
The female is directed to avoid any kind of vaginal douching , medicines and intimacy with partner before 48 hours of undergoing these tests.
Pap Test (Pap Smear):According to latest WHO guidelines, routine Pap testing typically begins at the age of 30. Women are generally advised to undergo Pap tests every three years if results are normal.
HPV DNA Testing: HPV DNA testing is often recommended for women aged 30 and older. Depending on guidelines, it may be conducted alone every five years or combined with a Pap test every five years.
Co-Testing:Co-testing involves both Pap and HPV DNA tests, often recommended at 30 years. If both results are normal, screening intervals extends to every five years.
HPV vaccination
Human Papilloma Virus (HPV) infection causes cells to undergo changes. Once high-risk HPV infects cervical cells, it interferes with the ways in which these cells replicate, divide, and communicate with one another, causing infected cells to multiply in an uncontrolled manner.
If not treated these cells can, over time, become cancer cells.HPV vaccination has come up as a highly effective and safe strategy for preventing cervical cancer with only few documented side effects. Receiving HPV vaccination before the onset of sexual activity raises the efficiency of vaccination result. Girls are often encouraged to receive the HPV vaccine starting from the age of 9-14 years. Catch up vaccination is done between 15-25 years, although it can be done up to 45 years. 2 to 3 doses are recommended depending on the age at the time of receiving vaccination. HPV vaccine should be avoided during pregnancy and in patients with history of severe allergic reaction.
Collaboration between gynaecologists and pathologists is paramount in achieving comprehensive and effective healthcare outcomes.
Clear communication of results, insights into the significance of findings of screening tests and collaborative decision-making regarding patient management plans are crucial elements of this interdisciplinary effort.Regular discussions with healthcare providers remain crucial for tailored screening plans based on age, health status, and other pertinent factors.
The Crucial Role of Gynaecologists in Early Detection
Gynaecologists play a significant role in the fight against cervical cancer by promoting prevention, early detection and timely treatment.
Their involvement begins with motivating the females for routine screening tests for cervical cancer. With the help of a speculum they visualise the cervix, and collect cervical sample using a spatula or brush.
Beyond sample collection, gynaecologists conduct comprehensive clinical evaluations. They assess individual risk factors for cervical cancer taking into account patient’s age, obstetric history, HPV test and other relevant factors.
Patient education is another critical aspect for lowering the prevalence of cervical cancer. Gynaecologists are at the forefront of spreading awareness about cervical cancer, its risk factors, and the significance of regular screenings. In discussions with patients, gynaecologists also emphasize the benefits of vaccination against high-risk strains of the human papillomavirus (HPV), and the importance of follow-up regular cervical examination.
Should abnormalities be detected during Pap screening, gynaecologists will guide patients for further diagnostic tests and development of a treatment plan. This may involve procedures such as colposcopy (examination of the cervix with a magnifying instrument), biopsies, and other interventions aimed at preventing the progression of precancerous lesions. Radical treatment strategies may be opted if cancer is diagnosed.
Pathologist Integral Role in Diagnostic Precision
Parallel to the efforts of gynaecologists, pathologists play a crucial role in the diagnostic process. Once cervical smears are collected, they are sent to pathologists for meticulous analysis. Pathologists employ their expertise to identify any abnormalities in the cells, including signs of precancerous changes or early-stage cancer.
The results provided by pathologists are indispensable for healthcare providers, offering a detailed understanding of the patient’s cervical health. These reports indicate whether Pap test results are normal, suggest abnormalities that require further evaluation, or, in severe cases, indicate the presence of cancerous cells.
Quality control is a cornerstone of pathology. Pathologists maintain rigorous standards within laboratories, participating in proficiency testing programs and adhering to established protocols for specimen processing and interpretation. By ensuring the accuracy and reliability of Pap test results, pathologists contribute significantly to the diagnostic precision necessary for effective cervical cancer prevention and management.
Collaboration between gynaecologists and pathologists is paramount in achieving effective health outcomes. Clear communication of results, insights into the significance of findings, and collaborative decision-making regarding patient management plans are crucial elements of this interdisciplinary effort.
The Road Ahead: Fostering Collaboration for Change
The fight against cervical cancer is multifaceted and requires a collective effort from healthcare professionals andmasses.
Initiatives that address screening access, enhance vaccination programs, improve health education, challenge cultural barriers, strengthen healthcare infrastructure, and alleviate economic obstacles are imperative for a future where cervical cancer is no longer a leading cause of female mortality.
Empowering women’s health is not the responsibility of one discipline alone but requires a harmonious collaboration between gynaecologists, pathologists, and the broader healthcare community. By fostering an environment of awareness, education, and accessibility, we can envision a world where cervical cancer is not a silent crisis but a preventable and treatable condition that women can overcome with dignity and resilience.
(The writers Dr. Reetika Menia is Assistant Professor, Department of Pathology, AIIMS Jammu and Dr. Natasha Gupta is Assistant Professor, Department of Obstetrics and Gynaecology, AIIMS Jammu).