In November 2020, WHO released a vision document to eliminate cervical cancer as a public health problem by 2030 and set the threshold as 4 per 100,000 women for elimination. In India, many states report 3-4 times higher number of new cervical cancer cases per 100,000 women population. In 2020, India reported >123,000 new cases and >77,000 deaths due to cervical cancer. WHO has further set the 90-70-90 targets by 2030 which specify:

• Vaccination - 90% of girls are fully vaccinated with the HPV vaccine by the age of 15 years
• Screening - 70% of women screened using a high-performance test twice in their lifetime by the ages of 35 and 45 years.
• Treatment - 90% of women with pre-cancer treated and invasive cancer receive timely treatment

However, vaccination for cervical cancer is not part of the national immunization programme in India, although vaccines are available against most cancerous HPV genotypes. Cervical cancer screening (at least twice in a lifetime) coverage is very low and covers less than 10% of the target population.

It is a long road ahead for us to achieve the target set by WHO, considering our geographical complexity, the infrastructure required, and the prevalent levels of public awareness regarding the disease. We are facing a high disease burden due to the absence of an organized cervical cancer screening program, leading to the detection of cancer at an advanced stage.

One positive development locally has been the publication of the consensus document ‘Making a Road Map for India - Implementing Optimal Screening Strategies’ towards cervical cancer elimination on the sideline of the IFCPC (The International Federation of Cervical Pathology and Colposcopy) World Congress 2021 seminar.

How can India eradicate cervical cancer
We have to work at multiple levels to implement the robust cervical cancer elimination program.

• Policy Change: We need to include HPV vaccination in the national immunization program, adoption of high-performance tests like a clinically validated HPV DNA test for cervical cancer screening, and enable access to treatment for women with precancerous and cancerous lesions. Insurance coverage for screening could provide a major boost to the programs.



• Infrastructure Development: We need to enable access to quality care for daycare treatment like colposcopy, thermoablation, cryo-ablation, etc., for medical intervention at the right time. Molecular testing has received a boost in the country during the pandemic and we can use the existing setup for transitioning to HPV DNA-based screening programs.



• Public awareness: The most critical piece is to overcome the social barriers and encourage women to come forward with screening and send their daughters for vaccination. We can use a three-pronged approach - sensitization, advocacy, and acceptance, to increase public awareness and address their myths on cervical cancer. We believe NGOs could play a big role here.



• Private Public Partnerships: The public-private partnership could help in building up infrastructure, including setting and running the molecular diagnostics labs for HPV DNA testing and for public awareness initiatives.

Significance of early detection:
If detected in the early stages, cervical cancer is one of the most preventable and curable forms of cancer in women. It takes 10-15 years for precancerous lesions to develop into cancer. Persistent infection with oncogenic human papillomavirus is the primary cause of precancerous and cancerous cervical lesions. Hence, the objective of the screening is to detect women early before they develop cancerous lesions.

Methods for cervical cancer screening:
Cervical cancer screening can be done using cytology-based Pap test, VIA (visual inspection with acetic acid), and HPV DNA test. The HPV DNA test is clinically validated to identify women who are at risk and have high sensitivity (>90%) and high negative predictive value whereas cytology and VIA testing are subjective tests with average sensitivity ~50-60%.

The screening interval for HPV DNA is every 5 years. Various guidelines have included HPV DNA tests as primary screening tests for cervical cancer.