Reducing Cervical Cancer Mortality in India

Thanks to Pap smears and human papilloma virus vaccines and tests, only about 12,000 women are diagnosed with cervical cancer in the United States every year, with about 4,000 dying of the disease. In India, where large-scale population screening is not possible due to the lack of financial resources, medical laboratories, and health care professionals, cervical cancer is the most common cancer among women. More than 141,700 cases are diagnosed annually, leading to about 77,000 deaths, nearly one third of the global burden.

Those statistics could soon improve. A team of researchers at Tata Memorial Hospital in Mumbai, India, has found that implementing a relatively simple, low-cost biennial screening program that involves visually inspecting the cervix after it has been painted with acetic acid (vinegar) could reduce cervical cancer mortality by nearly one third.

Surenda Srinivas Shastri, MD, a professor of preventive oncology, presented the team's findings on June 2 at the American Society for Clinical Oncology 2013 Annual Meeting in Chicago, IL.

In the study, which began in the late 1990s in poor communities around Mumbai, researchers randomly assigned more than 151,000 women ages 35 to 64 with no history of cancer to receive biennial screening with visual inspection with acetic acid (VIA) or no screening, which is the standard of care in India, Shastri said.

The screening was done by female health care workers from local communities. These women, chosen because they had at least a 10th grade education and good communication skills, were given an intensive four-week training program at the start of the study and took a refresher course annually.

Women in the control group (no screening) did take part in a cancer education session when they enrolled in the trial. If they later developed signs and symptoms of cervical cancer, they went to Tata Memorial Hospital or another facility of their choice for free diagnosis and treatment.

Women in the screening group received VIA screening and cancer education every 24 months, up to four times, between 1998 and 2010. Those who were VIA positive—meaning that tissue at the center of the cervix turned white when swabbed with acetic acid and that the white patch was thick and well defined—received diagnosis and treatment at no cost, as in the control group.

Shastri reported that the incidence of cervical cancer was comparable between the two groups (26.7 per 100,000 in the screening group versus 27.5 in the control group). However, screening with VIA resulted in a 31% drop in the cervical cancer–specific death rate, he said, because the disease was usually diagnosed at an earlier stage among the women who were screened.

One of the challenges in conducting the study was that “these communities were naïve in terms of cervical cancer screening, in terms of cancer screening in general,” said Shastri. “Before we could talk to the women about cervical cancer and start the screening process, we had to talk to community leaders, religious leaders, political leaders, other gatekeepers, and schoolteachers.”

Shastri later added that because researchers worked so closely with the community and used local facilities to conduct the study, people were willing to participate. “It ensured a sense of community ownership,” he said.

Based on the results of the study, implementing a similar VIA screening program for cervical cancer throughout India could prevent 22,000 deaths per year, Shastri said, adding that a global program could prevent 72,000 deaths.