95707 Knowledge Brief Health, Nutrition and Population Global Practice Advancing Cervical Cancer Prevention in India S. Krishnan, E. Madsen, D. Porterfield, B. Varghese, J. Poehlman and O. Taylor March 2015 economic impact on families and their communities, as it primarily affects women during their most productive KEY MESSAGES: years.  Despite cervical cancer being highly Recognizing the challenge of cervical cancer, in 2013 preventable, it remains a leading cause the World Bank conducted a review of research studies of death and disability among women in on cervical cancer prevention and examined the India implementation experiences of cervical cancer screening programs in India. A recently published report  Research on low-cost and effective summarizes the current state of knowledge and practice, cervical cancer screening methods has and offers recommendations for strengthening India’s been conducted in India, but currently programmatic and policy responses to cervical cancer [3]. few organized screening programs are available to women. Study Findings  With a quarter of the global burden of cervical cancer in India alone, it is time to EFFECTIVE LOW-COST APPROACHES TO PREVENTION AND SCREENING make proven cervical cancer prevention services available to all Indian girls and Human Papillomavirus (HPV) Vaccination women [1]. A primary approach  Methods such as the Human to preventing cervical Papillomavirus Vaccination and Visual cancer is to vaccinate girls against several Inspection with Acetic Acid are low-cost strains of HPV that are approaches to prevention and screening. known to increase the chances of getting cervical cancer. Introduction Two widely In 2010, nearly 74,000 new cases of cervical cancer marketed vaccines were diagnosed among Indian women. This number is have proven safe and estimated to increase to as high as 225,000 cases by highly effective in 2025 [2]. preventing more than 90 percent of precancerous lesions in women who have not had HPV previously [4]. Cervical cancer is also the leading cause of cancer deaths in India, as most cases are not detected until they However, multiple challenges to large-scale vaccination are in an advanced stage. In addition to the cost in lives, exist: vaccines are expensive and strategies need to be cervical cancer can have a significant social and identified to reach the primary target group of Page 1 HNPGP Knowledge Brief  preadolescent and adolescent girls (especially school Conclusion dropouts) and to accurately and comprehensively communicate information about the vaccines. LESSONS FROM CURRENT PROGRAMS AND THE POLICY IMPLICATIONS Combining prevention and screening (on a mass scale) with treatment can significantly reduce both the number of Currently, only a few large-scale cervical cancer new cases and deaths from cervical cancer. programs exist in India. One is a statewide population program by the World Bank-supported Tamil Nadu Health Systems Project. This project, which offers screening to 30- to 60-year-old women once every 5 years, has Visual Inspection with Acetic Acid (VIA) demonstrated that introducing cervical cancer prevention Studies conducted in India have shown that visual into the Indian public health system is feasible and screening approaches, which do not require laboratory acceptable, particularly with sufficient and consistent infrastructure, are effective in detecting the disease in its political and administrative support, human and financial early stages. When combined with treatment, this resources, and community buy-in and involvement. approach can reduce both the number of new cases and deaths from cervical cancer. In particular, two large-scale, The programmatic findings suggest that high levels of randomized controlled trials found that use of Visual participation in screening may be required to significantly Inspection with Acetic Acid (VIA), a low-cost screening impact morbidity and mortality. Moreover, women who method, reduced deaths from cervical cancer among screen positive for a precancerous or cancerous lesion women by between 31 percent [5] and 35 percent [6]. will need to receive appropriate diagnostic and treatment services. In addition, the World Health Organization has identified screening and treatment of precancerous Given these challenges, successful implementation of lesions to prevent cervical cancer as an evidence-based future programs will likely require fostering greater “best buy” intervention because it is highly cost-effective, acceptance of screening as well as efforts to strengthen feasible, and culturally acceptable to implement [7]. linkages between screening and treatment services. Page 2 HNPGP Knowledge Brief  Recommendations EXPANDING CERVICAL CANCER SCREENING TO CLINICIANS, HEALTH CARE ADMINISTRATORS, AND ALL WOMEN PUBLIC HEALTH PLANNERS Research and programs in India have demonstrated that  Design “women-centered” programs that respond to cervical cancer prevention initiatives have the potential to women’s concerns and constraints save lives. What is needed now is universal screening —a  Use a combination of vaccination and screening, coordinated effort to make cervical cancer screening taking into account performance and practical programs available to all women in all districts and considerations as well as implementation research to regions of India. inform these decisions Whether you are a policymaker, a clinician or a concerned  Ensure strong linkages within and between different citizen, a number of steps can be taken to help establish levels of the health care system to ensure timely screening programs in your communities and begin follow-up and referrals protecting women from cervical cancer.  Establish a quality assurance plan that defines standards at different levels of care and describes INDIVIDUALS IN POSITIONS OF LEADERSHIP AND how quality reviews and improvements are conducted GOVERNANCE and by whom  Use prospective evaluation to provide feedback on  Advocate for greater governmental commitment and program quality and progress and to enable program administrative leadership to ensure adequate and improvements sustained support for comprehensive cervical cancer  Sensitize and train frontline health care workers to prevention services raise awareness about cervical  Raise awareness of cervical cancer throughout all cancer screening and treatment sectors of government and civil society  Enhance health system capacities to deliver HPV COMMUNITY MEMBERS vaccination and screening services, including relevant policies, infrastructure, and skilled human resources  Raise awareness about cervical cancer screening and  Increase health care access among vulnerable girls treatment by engaging local leaders—such as and women—including those who are older, less members of local government, village health and educated, or belong to poor or marginalized sanitation committees, and women’s self -help households—so that all girls and women can benefit groups—to mobilize support from prevention services  Develop tailored messages for the local context and target audience that address known reasons for poor acceptance of cervical cancer prevention services— these include fear of cancer, misconceptions about cancer, and fear of Page 3 HNPGP Knowledge Brief  screening tests and the instruments/ tools used  Disseminate information through reliable channels, such as community meetings, This HNP Knowledge Brief highlights the key findings from the following door-to-door visits, and advertisements at health World Bank-supported papers: facilities Krishnan, S., E. Madsen, D. Porterfield, and B. Varghese. 2013. Advancing Cervical Cancer Prevention in India: Insights from Research and Programs. Health, Nutrition and Population Discussion Paper. References Washington, DC: The World Bank. Retrieved from http://documents.worldbank.org/curated/en/2013/10/19226581/advancin 1. Institute for Health Metrics and Evaluation. 2011. The g-cervical-cancer-prevention-india-insights-research-programs Challenge Ahead: Progress in Breast and Cervical Cancer. Seattle WA: IHME. Retrieved from Krishnan, S., E. Madsen, D. Porterfield, & B. Varghese. 2014. Advancing http://www.healthmetricsandevaluation.org/publications/policy- cervical cancer prevention in India: Implementation science priorities. report/challenge-ahead-progress-and-setbacks-breast-and- The Oncologist, 18(12), p. 1285-1297. Retrieved from cervical-cancer. http://theoncologist.alphamedpress.org/content/18/12/1285?Related- 2. World Health Organization/ICO Information Centre on HPV urls=yes&legid=theoncologist;18/12/1285 and Cancer (HPV Information Centre). 2010. Human Papillomavirus and Related Cancers in India. To learn more, please contact: Summary Report 2010. Retrieved from http://www.hpvcentre.net Suneeta Krishnan, PhD 3. Krishnan, S., E. Madsen, D. Porterfield, and B. Varghese. Social Epidemiologist 2013. Advancing Cervical Cancer Prevention in India: RTI International Insights from Research and Programs. Health, Nutrition and skrishnan@rti.org Population Discussion Paper. Washington, DC: The World Bank. Retrieved from Patrick Mullen, PhD http://documents.worldbank.org/curated/en/2013/10/19226581/a Senior Health Specialist dvancing-cervical-cancer-prevention-india-insights-research- World Bank programs pmullen@worldbank.org 4. World Health Organization. 2009. Weekly Epidemiological Record. 84(15): p. 117–32. Retrieved from http://www.who.int/wer/2009/wer8415.pdf 5. Shastri, S., I. Mittra, G. Mishra, S. Gupta, R. Dikshit, and R. Badwe. 2013. Effect of visual inspection with acetic acid This work was funded by the Bank-Netherlands Partnership Program for (VIA) screening by primary health workers on cervical Sexual and Reproductive Health in South Asia. cancer mortality: a cluster randomized controlled trial in Mumbai, India. In 2013 ASCO Annual Meeting. J Clin Oncol. 31(18), Suppl Abstr 2. Retrieved from http://meeting.ascopubs.org/cgi/content/abstract/31/18_suppl/2? Sid=7801cde2-aaa8-416e-9196-d1d3b716f128 6. Sankaranarayanan, R., P.O. Esmy, R. Rajkumar, R. Muwonge, R. Swaminathan, S. Shanthakumari, J.M. Fayette, and J. Cherian. 2007. Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial. The Lancet. 370(9585): p. 398– 406. Retrieved from http://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(07)61195-7/fulltext#article_upsell 7. Bloom, D. E., D. Chisholm, E. Jane-Llopis, K. Prettner, A. Stein, and A. Feigl. 2011. From Burden to “Best Buys”: Reducing the Economic Impact of Non-Communicable Disease in Low- and Middle-income Countries. Geneva, Switzerland: World Economic Forum. Retrieved from http://www.who.int/nmh/publications/best_buys_summary.pdf The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4