Cervical cancer: Why screening matters

Cervical cancer is largely preventable through vaccination, detectable through screening, and treatable, when identified early. There’s a significant screening gap in India.

The country has nearly one-fifth of the global burden of cervical cancer cases. In 2022, there were 1,27,000 new cases and 80,000 deaths, according to the Global Cancer Observatory (Globocan). 

Despite efforts to increase awareness about gynaecological cancers, low screening coverage remains the biggest gap. According to the National Family Health Survey-5 (2019 - 2021), only 22 - 30 per cent of Indian women have undergone screening, way below the WHO’s goal of 70 per cent coverage for women by the ages of 35 and 45.

Gaps in routine PAP smear screening

While HPV vaccination, which has now become a mandate for all girls under 14 years, is a major step forward, it is important to recognise that vaccines are prophylactic, not therapeutic. They don’t eliminate existing HPV infections or treat established precancerous lesions, leaving a large cohort of adult women at continued risk.

Adding to this are deep rooted sociocultural stigma around gynaecological cancers, rural access gaps, and limited diagnostic ability that further push women to suffer in silence instead of seeking help. There is also an over-reliance on Visual Inspection with Acetic Acid (VIA), which is practical but less sensitive than HPV DNA testing. While the WHO 2021 guidelines recommend HPV DNA testing as the preferred method for cervical cancer screening, its adoption in India remains limited.

Cervical cancer has a long pre-invasive phase, making it ideal for detection during routine screening. The disease progresses from HPV infection to the precancerous stage called Cervical Intraepithelial Neoplasia (CIN) before developing into invasive cancer after many years. Not many Indian women opt for routine health checks, which leads to a delay in diagnosis with limited treatment options. 

Screening can also detect pre-cancer, not just cancer. Pap smear or HPV testing identifies pre-invasive lesions, enabling treatment before cancer develops while reducing incidence and mortality rates. When detected early, cervical cancer has excellent survival outcomes. The WHO emphasises screening with immediate treatment of pre-cancer (screen-and-treat approach) to prevent progression.

Prevention of cervical cancer

There are three strategic approaches to preventing cervical cancer.  Primary prevention focuses on the prevention of HPV infection before it occurs through HPV vaccine to girls between the ages of 9 and 14, ideally before they are sexually active. Safe sexual practices and health education are also important to prevent incidences.

Secondary prevention focuses on the pre-cancerous phase through screening methods like HPV DNA testing, pap smears, or visual inspection with acetic acid (VIA) for women between the ages of 30 and 49. It is followed by a screen-and-treat protocol that uses interventions like loop electrosurgical excision procedure (LEEP) or cryotherapy.

Tertiary prevention manages established cancer with stage-specific treatments including surgical interventions or chemo radiation, structured follow-up protocols to monitor for recurrence and palliative care (HIPEC/PIPAC - chemotherapy treatments) for advanced cases, as clinically indicated.

(The author is consultant - obstetrics and gynaecology at a Bengaluru hospital.)