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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 11-14

Challenges to reduce cervical cancer in Bihar: A review


Department of Gynecological Oncology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India

Date of Web Publication10-Dec-2020

Correspondence Address:
Sangeeta Pankaj
Additional Professor, Gynecological Oncology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Cervical cancer has a major impact on the lives of Indian women with an estimated 1,22,844 new cases diagnosed and out of them 67,477 die from disease every year. Incidence of cervical cancer in Bihar is very high. Locally advanced cervical cancer is commonly seen because of the high prevalence of associated risk factors like low socioeconomic states, poor access to health care, high parity, early age of marriage and first pregnancy, persistence of genital infection specially HPV, low immune status, poor genital hygiene and nutritional status. Besides, there is lack of organized screening programme and treatment facilities for these patients in Bihar. Increasing awareness about early signs and symptoms especially among the rural population, widespread use of HPV vaccination and simple screening techniques like visual inspection with acetic acid is urgently required to control the rising number of cervical cancer cases in the state of Bihar. A tremendous boost is also required in the availability of gynaecological oncology and radiotherapy units, other infrastructure and trained personnel in the field of oncology.

Keywords: Bihar, Cervical cancer, prevention screening


How to cite this article:
Pankaj S, Kumari A. Challenges to reduce cervical cancer in Bihar: A review. J Indira Gandhi Inst Med Sci 2018;4:11-4

How to cite this URL:
Pankaj S, Kumari A. Challenges to reduce cervical cancer in Bihar: A review. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2022 Jan 20];4:11-4. Available from: http://www.jigims.co.in/text.asp?2018/4/1/11/302976




  Introduction : Top


Cervical cancer is the most common gynaecological malignancy worldwide. Approximately 528 000 new cases are diagnosed every year worldwide and 85% of these cases occurred in less developed countries.[1] India has a population of 432.20 millions women aged 15 years and older who are at risk of developing cervical cancer. 1, 22, 844 women are diagnosed every year with cervical cancer and out of them 67,477die from disease.[2]

India bears about one fourth of the world’s burden of cervical cancer. India also has the highest age standardized incidence of cervical cancer in South Asia at 22, compared to 19.2 in Bangladesh, 13 in Sri Lanka, and 2.8 in Iran.[3] Therefore, it is vital to understand the epidemiology of cervical cancer in India and its states.

Human papillomavirus (HPV) infection is recognized as one of the major causes of infection-related cancers worldwide and represents an important global public health problem.[4] HR- HPV prevalence among cervical cancer patients in India has varied from 87.8% to 96.67%.[5],[6],[7],[8] Molecular studies have shown that HPV-16 and 18 are the two most common highly oncogenic types found in invasive cervical cancer, and out of these two HPV-16 has been found more commonly.[9] HPV 16 and 18 are has been implicated in 99.7% of the squamous cell cervical carcinoma worldwide.[10] Prevalence of other high-risk types is very low.

Cervical cancer prevention and screening programmes have been successfully implemented in the developed countries, resulting in a decreasing trend both in incidence and mortality. However, in developing or less developed countries, over 80% of women with cervical cancer continue to be diagnosed at an advanced stage, which is significantly associated with poor prognosis[1]. Barriers to the success of screening programmes in country like India include a lack of awareness about the disease among the general population coupled with the geographical and economic inaccessibility to cancer care.[11],[12]

Only few studies were done and published from Bihar regarding cervical cancer scenario of this state.[13],[14],[15] This review was done to evaluate the published data from National census and health survey in context to the known risk factors and facilities available for prevention and treatment of cervical cancer in Bihar.


  Discussion : Top


The state of Bihar is one of the less economically developed state of India. About 89% of its total population lives in villages. Agriculture is the main source of income for them and many of them work on daily wage basis on other people’s farm. The per capita income for majority of the people in the villages of Bihar is less than the national average.[16] Poverty leads to lack of nutritious and healthy diet and having low immunity and are more prone to develop chronic infections.

The females have usually no idea about the early signs and symptoms of malignant diseases due to lack of education and awareness. They are also quite hesitant to discuss their gynaecological problems with the male members of the family. They have limited access to even primary healthcare facilities resulting in inadequate treatment of vaginal infections leading to invasive cervical cancer[12]. Another problem with the cervical cancer patients of Bihar is the late stage at presentation. Low literacy rate, lack of awareness, inaccessible health care facility and lack of trained oncologist are the factors responsible for the late presentation.[10]

Bihar: Challenging issues and health facility :

Bihar is the third most populated state of India with a population of 10.41 Crores with total number of female population has been reported to be 49,821,295 and only 11.29% live in urban regions. Female literacy in urban part was 61.95% and that of rural population was only 44.30%. Even urban poverty in Bihar (32.91%) is above the national average of 23.62%).[17] Illiteracy and poverty further leads to marriage of girls at an early age, multiparity and gender inequality. A survey of the women revealed that on an average 47.7% of them were either pregnant or already mother at the age of 15 to19 years.[18]

Studies have proven that the presence of human papillomavirus (HPV) which is contracted via sexual intercourse is the most important causative factor for the development of cervical cancer.[19] During pre-adolescence, adolescence and pregnancy, oestrogen level remains high leading to acidification of the vaginal cavity and hence squamous metaplasia. When this estrogen-stimulated metaplastic transformation occurs in the presence of HPV, the probability of dysplastic changes increases resulting in neoplasia.[20] This phenomenon is dependent primarily on parity, and is more likely to occur during the first pregnancy rather than subsequent pregnancies.[21] Biological immaturity during adolescence has also been proposed as an additional susceptibility factor.

Multiparty is a marker of repeated cervical trauma and repair which can induce metaplastic changes and so a strong risk factor for cervical cancer. Further, increased endogenous oestrogen level as that seen during pregnancy can lead to persistence of HPV infection. The higher density of oestrogen receptors and their expression in the transformation zone may synergize HPV oncoproteins, decreasing levels of cytotoxic cytokines that down-regulate the cervical cell-mediated immune response and persistent HPV infections instead of clearance.[16] Similarly, poor genital hygiene also leads to persistence of HPV infections and is therefore an important risk factor for cancer especially in a state like Bihar, where clean water and other sanitation facilities are limited for majority of the rural population.[22],[23]

Population-based surveys indicates that coverage of cervical cancer screening in developing countries is 19% compared to 63% in developed countries and ranges from 1% in Bangladesh to 73% in Brazil.[24] However, older and poor women who are at the highest risk of developing cancer are least likely to undergo screening. Opportunistic screening in various regions of India varied from 6.9% in Kerala to 0.006% and 0.002% in the western state of Maharashtra and southern state of Tamil Nadu, respectively.[25],[26] In a recent reported trial by the Tata Memorial Hospital, Mumbai, performed on the rural population close to Mumbai, visual inspection with 5% acetic acid (VIA) reduced 31% cervical cancer mortality. The incidence of invasive cervical cancer after 12 years reduced in the screened women.

In addition to the presence of the above mentioned potential risk factors for the development of cervical cancer, there is also lack of an organized screening programme and treatment facilities for cervical cancer patients in Bihar. Most of the cases (85%) present in advanced and late stages, and more than half (63%-89%) have regional disease at the time of presentation.[27] Cervical cancer diagnosis and treatment in the advanced stages makes it a costly exercise, with a poor prognosis resulting in poor compliance.

T The three screening modalities are cytology, visual inspection, and HPV test. The sensitivity of VIA to detect CIN2 and 3 lesions and invasive cervical cancer varied from 49% to 96% and the specificity from 49% to 98%.28 Recently, visual inspection with Lugol’s iodine (VILI) was evaluated in cross-sectional studies in India and Africa. The pooled sensitivity and specificity to detect high-grade CIN were 92% and 85%, respectively, for VILI versus 77% and 86% for VIA, indicating a higher sensitivity for VILI but a similar specificity for VILI and VIA.[29],[30]

The newer test detecting HPV DNA was conducted at various places in India, and the sensitivity of the test varied from 45.7% to 80.9% for detection of cervical intraepithelial neoplasia grade 2 or worse.[31] However, Khan et al[32] argue that one should allow for the learning curve of the newly trained technicians and that the 85% sensitivity recorded at one of the centers of the study is in all probability replicable all over India. In another cluster randomized study by Sankaranarayanan et al[25] the death rate and incidence rate of cervical cancer was four times more in the cytological, VIA, and control groups compared to the HPV testing group. HPV testing is expensive and requires sophisticated laboratory infrastructure, although it is the most reproducible of all cervical screening tests.[28]

Out of 38 districts in Bihar, the trained gynaecological oncologist and the radiotherapy units are available only in Patna, the capital city of Bihar. Even in Patna, Regional Cancer Centre (RCC) of Indira Gandhi Institute of Medical Sciences (IGIMS) is only government centre where department of gynaecological oncology is running. Approximately 32% cases of cervical cancer presented with stump carcinoma or vault carcinoma after subtotal or total hysterectomy without ruling out of malignancy.[13] Radiotherapy facility is present only in IGIMS, and All India Institute of Medical Sciences (AIIMS), Patna in government sector. In private sector, this is present in Mahavir Cancer Sansthan and Paras HMRI Hospital.

The main elements in the guidelines on comprehensive cervical cancer control from WHO include vaccination of 9 to 13-year-old girls with two doses of HPV vaccine to prevent infection with the Human papillomavirus (HPV), use of regular cervical cancer screening screening tests like paps smear, LBC, VIA and HPV DNA, wide communication for creating awareness and addressing inequities in health care.[33]

Research on carcinoma cervix in Bihar

Vinita et al[12] showed approximately 91% of patients had lack of information and knowledge about carcinoma cervix. Richa et al[13] done study in which 42% of patients were in 50-59 years age group, 89% from rural background, and 25% were addicted to tobacco. 86% had squamous cell carcinoma and 63% had exophytic growth. Stage III was most common stage at time of diagnosis. Retrospective analysis of patients of carcinoma cervix was done at Regional Cancer Centre of Indira Gandhi Institute of Medical Sciences, Patna in which prevalence of carcinoma cervix was 52% was noted. Another study of cervical cancer screening from same institute showed unsatisfactory smears were more commonly reported by conventional method (7.1%) than with liquid based method (1.61%) and this difference is statistically significant. There was no difference in the detection of epithelial cell abnormalities by both the methods. HPV DNA for high risk oncogenic strains (16,18) were detected in 6.45% of women in this study.(both in press)

Strategy to combat cervix cancer in Bihar

India has had a national program for cancer since 1975, when the emphasis was given for establishment of equipping cancer institutions. By 1984-1985 focus was given on primary prevention and early detection of cancer cases and by 1990-1991 the district cancer control programme was started. Recognition of new regional cancer centers, strengthening of existing regional cancer centers, and development of oncology wings in medical college hospitals was the most focused point in 2008. Strengthening of the district cancer control program and the decentralization of NGO scheme were the priorities of the program in same year.[33] In 2010, cancer control became a part of National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS) which was more commprensive, where the common risk factors are addressed in an integrated manner. The present program, initiated on a pilot basis, emphasizes risk reduction and promotes opportunistic screening or screening through camps in women above 30 years at different levels in rural areas and in urban slums.[34] It also advocates comprehensive cancer care in district- level hospitals and tertiary care centers for strengthening cancer care.

In a our state, the best cost-effective solution to problem is prevention, both at primary and secondary level. We need to have a robust screening programme, which should be practical and acceptable to our population along with a stress on increasing awareness among the general population especially for women from low socio economic strata. Cost- effective methods of screening through simple visual inspection of cervix, application of acetic acid seems to be more practical for our state, as compared to recommended HPV DNA testing for which highly skilled personnel and resources are required. However, for rapid and accurate diagnosis, HPV test is more helpful and there is need to establish this facility at all government medical hospitals and also to train clinicians practising in government sectors to use this new and advance method.[25] Gynaecological oncology department should be established at state medical college of Bihar.

Primary prevention in the form of vaccination is the real hope for reducing cancer morbidity and mortality in our state. Currently, the two available HPV vaccines in the market are costly and beyond the reach of the poor rural population of Bihar, who is at high risk of developing cervical cancer.[35] Like many other countries of the world, Government of India should also strengthen its efforts to prevent cervical cancer by introducing HPV vaccine into routine immunization schedule as its use can reduce the chance of developing HPV related cancer by up to 80%. The inclusion of HPV vaccines in the National Immunization Schedule and its routine use will definitely be one of the biggest steps in the prevention of this dreaded disease among our people.


  Conclusion : Top


Cervical cancer is still a major cause of morbidity and mortality among our female population. Poverty, illiteracy, ignorance, early age of marriage, early age at first pregnancy, multiparity, lack of screening and treatment facilities are the major contributing factors. Cervical cancer can be prevented with the use of HPV vaccines and proper treatment of precancerous lesions, which can be accurately detected by molecular method, HPV DNA test in addition to simple cost effective tests like Pap smear examination and visual inspection. Besides prevention, availability of proper infrastructure and an adequate number of trained gynaecological oncologists for treatment of cervical cancer is also required in our state.



 
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