Partha Basu
Head, Gynecologic Oncology

Cervical cancer – a major public health problem

Cervical cancer is the most common cause of cancer deaths among women in the developing countries including India. More than 100,000 new cases of cervical cancer occur each year in our country and nearly 75,000 women die annually from the disease. The data from the Indian cancer registries show that the incidence rates start increasing from the age group 30 to 34 years and reach a peak between the ages of 55 to 65 years.
Because of lack of awareness, non-availability of early detection facilities and various socio-cultural reasons the cancer is detected at an advanced stage when no curative treatment if possible.

Cervical cancer can be prevented by screening

Cervical cancer develops slowly over 10 to 15 years. The epithelial covering of the cervix first undergoes a precancerous change known as Cervical Intra-epithelial Neoplasia (CIN). If left undetected and untreated, the CIN can progress to invasive cancer. Once the disease becomes invasive cancer the treatment becomes cumbersome, time-consuming and expensive. As compared to that, treatment of precancer disease is simpler, inexpensive and chance of cure is much higher. If the disease is detected at the precancer stage and treated, the possibility of developing invasive cancer in the future is substantially reduced. So the objective of cervical screening is to apply a simple test on all the women in a certain age group to detect the disease at the precancerous stage and to treat them.

Who should be screened and how frequently?

At the precancer stage the women will not have any complaints and only the screening tests can detect the disease. So the screening test is done on apparently normal women irrespective of whether they have any symptoms or not. Women between 30 to 60 years of age who have ever been sexually active should be screened every 5 years.

What are the different screening tests available?

An ideal screening test would be one that is simple, painless, can be done rapidly on a large number of individuals, low cost and able to detect the disease accurately. Till date Pap smear (cytology) has been proved to be the screening test effective in reducing the incidence and mortality from cervical cancer. However, Pap smear has certain drawbacks that limit its usefulness, specially in the low resource settings. It is a laboratory based test and needs infrastructure and highly skilled manpower that may not be easily available.
To overcome these limitations a lot of research has been done to find out alternative tests to Pap smear that may be more suitable for the low resource and low technology set ups. Visual Inspection after Application of Acetic Acid (VIA) has shown promising results and has been recommended by Expert Group formed by Government of India as the test of choice for cervical screening in primary health setting in India. HPV DNA testing as a screening method has been found to be most accurate but expensive.

Evaluation of the women with abnormal tests

Being positive on screening test by itself does not mean that the woman is having disease. The diagnosis is to be confirmed by further tests. All women with positive test results (Pap smear or VIA) should have colposcopy. With a colposcope the doctor can have a magnified view of the cervix and can confirm whether there is any abnormality. If such an abnormality is found a biopsy should be taken and sent to the laboratory. Decision to treat the woman is made on the basis of the biopsy report.

Management options for cervical pre-cancers

The pre-cancers (CIN) are treated either by removing the abnormal area or by destroying the abnormal cells of the lesion. The first procedure is known as Loop Electrosurgical Excision Procedure (LEEP) and the second procedure is known as Cryotherapy. Rarely hysterectomy (removal of uterus) is required.