Cancer Fight Suffers as India Delays Technology

It is now well known that the commonest types of cancer in women are detectable and treatable at initial stages if they are regularly screened. But fourteen years since India adopted a policy of screening for oral, breast and cervical cancers, the test numbers are dismal. Breast and cervical cancer top the list of women’s cancers with the highest incidence. Despite discussions for many years, vaccination against cervical cancer is yet to make it to the Universal Immunisation Programme. The last Union Budget made a vague reference to “encouraging” HPV vaccination, but it is still the decision of individual states whether to roll it out or not.

As the world observes January as cervical cancer awareness month, a hard look at the way forward for India in controlling this disease that kills an estimated 77,000 Indian women every year, is the need of the hour. According to data from the National Family Health Survey 5 (2019-2021) only 1.9% Indian women were screened for cervical cancer and 0.9% for breast cancer. Low awareness and policy priority have been two of the biggest challenges in increasing screening coverage but one of the reasons for the dismal numbers also is India’s outdated choice of visual inspection with acetic acid (VIA). The method, though inexpensive, is overly reliant on the ability of field workers to distinguish between malignant/pre-malignant cells and normal cells.

WHO recommends HPV DNA testing which uses the polymerase chain reaction principle to detect the presence of the human papilloma virus (HPV) as a test of choice but India has so far not adopted the technology in the National Health Mission. Persistent infection with HPV, which is a sexually transmitted infection, can cause cervical cancer.

Expressing his concerns over the progress, former health secretary C K Mishra said: “Cervical Cancer continues to be a major health concern. Yet the levels of detection and screening are rather low. Obviously not enough is being done and efforts that have been put so far are not working. Of course, we need more awareness but one of the reasons for poor uptake also is the lack of trained field manpower. Using acetic acid is cost effective but needs a level of experience of the health worker to be optimally used. We should evaluate emerging technologies and use them wherever appropriate rather than stick to business as usual even when that is not giving desired results. WHO recommends HPV DNA as the primary screening method. We should look at that. And surely start vaccinating urgently.” 

When the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) was launched in 2010, screening for cervical, breast and oral cancer was a part of its mandate. According to official sources, homegrown HPV DNA testing options are being tried out in the field but deployment of these technologies at scale may still be a few years away.

According to a 2023 Lancet Commission report captioned “Women, Power and Cancer,” it was estimated that two of every three cancer deaths in Indian women were preventable, more than one in three are treatable provided there is timely diagnosis and treatment; this means that 6.9 million cancer deaths in women were preventable and 4.03 million were treatable.

Cervical cancer vaccine has a chequered history in India.  In 2017 when a recommendation was first made by the National Technical Advisory Group on Immunisation (NTAGI), it ran afoul of right-wing organisations who saw in the decision a pandering to big pharma. Since  then, many states, including Delhi, Punjab and Sikkim, have introduced programmes for school children to be administered the shot but the Centre’s commitment has stopped at “encouragement”. For a long time, the vaccine was thought to be “too expensive” for introduction in the public health programme. The two foreign manufacturers Merck and GSK had priced it upwards of Rs 2000 per shot but two years after the announcement of Serum Institute of India’s relatively cheaper HPV shot, there is no announcement yet for a countrywide rollout.

There is now also an increased realisation in the health ecosystem that for a country of the size and diversity of India a one size fits all approach will not work and neither will the expectation that the government can and will be able to take the lead in everything. That is why a group of academic institutions, NGOs, private sector players and sector experts have come together to form the Cervical Cancer Elimination Consortium under the aegis of the Global HPV Consortium to propel the country towards WHO’s 90-70-90 approach to cervical cancer elimination. It has set three targets - 90% girls to be fully vaccinated within 15 years, 70% women to be screened using a high-performance test by the time they are 35 and then again by 45 and treatment for 90% women with pre-cancer and management for the same percentage of women with cancer. 

Says Dr. Raj Shankar Ghosh of Healthcare Lead of Nangia LLP, a key member of the consortium: “Today there are excellent solutions available to diagnose cervical cancer early with sophisticated technologies, including self-testing kits, and prevent cervical cancer with a single dose of HPV vaccine. The challenge lies with access to screening, treatment, vaccination and awareness among the community. The Cervical Cancer Elimination Consortium -India is a consortium of partners and subject matter experts advocating with policy makers and communities with evidence that cervical cancer elimination is possible in India with an integrated SAVE strategy: access to screening, treatment, vaccination and empowering communities with information, and education.”

A meaningful and strategic partnership of the government with other stakeholders including academia, private sector and philanthropic organisations can change the landscape of women’s cancers in India drastically.  Cancer spares none.  It comes unannounced and can ravage individuals and families - physically, mentally and financially. To not leverage science for its prevention, detection and treatment is not any option any more.