Epidemiology of Cervical cancer

1. Dr Soni Rani Department Of Community Medicine Katihar Medical College Epidemiology Of Cervical Cancer

2. PRESENTATION OUTLINE  Introduction ( Anatomy/ Definition)  Risk factors of cervical cancer  Epidemiology/ problem statement  Signs and symptoms of cervical cancer  Screening tests  Diagnosis of cervical cancer  Staging  Prevention of cervical cancer.  NCCP/NPDCS/NCRP  Conclusion

3. CERVIX- ANATOMY  The cervix or cervix uteri (Latin: neck of Uterus) is the lower part of the uterus in the human female reproductive system.  In a non-pregnant woman, the cervix is usually 2 to 3 cm long (1 inch) and roughly cylindrical in shape.  The narrow, central cervical canal runs along its

4. CERVIX- ANATOMY  The opening into the uterus is called the internal os, and the opening into the vagina is called the external os.  The lower part of the cervix, known as the vaginal portion of the cervix (or ectocervix), bulges into the top of the vagina.  The cervix has been documented anatomically since at least the time

5. CERVICAL CANCER- DEFINITION  Cancer that forms in tissues of the cervix (the organ connecting the uterus and vagina) is known as cervical cancer.  It is usually a slow-growing cancer that may not have symptoms but can be found with regular Pap tests .  Cervical cancer is almost always caused by human papillomavirus (HPV) infection.

7. RISK FACTORS OF CERVICAL CANCER

8. MODIFIABLE RISK FACTORS NON-M0DIFIABLE RISK FACTORS  Early marriage  Early child birth  Having too many children  Multiple sexual partner  Un-protected sex  Smoking  Oral contraceptive pills  Mental stress  Decrease immunity (AIDS)  Family history / hereditary  Socio- economic status  Decrease Immunity ( Congenital)

9. RISK FACTORS OF CERVICAL CANCER  HPV (human papillomavirus) - a sexually transmitted virus. There are more than 130 different types of HPVs, at least 18 of which can cause cervical cancer.  Many sexual partners or becoming sexually active early - cervical cancer-causing HPV types are nearly always transmitted as a result of sexual contact with an infected individual.  Women who have had many sexual partners generally have a higher risk of becoming infected with HPV, which raises their risk of developing cervical cancer.

10. RISK FACTORS OF CERVICAL CANCER  Smoking - increases the risk of developing many cancers, including cervical cancer.  A weakened immune system - such as in people with AIDS, or transplant recipients taking immunosuppressive medications.  Long-term mental stress - women who experience high levels of stress over a sustained period may be less able to fight off HPV.  A study from the American Academy of Pediatrics in 2016 supported this. Principal investigator Dr. Anna-Barbara Moscicki said: "Women who reported self-destructive coping strategies, like drinking, smoking cigarettes or taking drugs when stressed, were more likely to

11. RISK FACTORS OF CERVICAL CANCER  Giving birth at a very young age - women who give birth before the age of 17 are significantly more likely to develop cervical cancer compared with women who have their first baby after the age of 25.  Several pregnancies - women who have had at least three children in separate pregnancies are more likely to develop cervical cancer compared to women who have never had children.  Contraceptive pill - long-term use of some common contraceptive pills slightly raises a woman's risk.

12. RISK FACTORS OF CERVICAL CANCER  Other sexually transmitted diseases (STD) - women who become infected with chlamydia, gonorrhea, or syphilis have a higher risk of developing cervical cancer.  Socio-economic status - studies in several countries have revealed that women with low SES have significantly higher rates of cervical cancer.

13. HPV DISEASE SPECTRUM  HPV is a member of the family Papillomaviridae.  They are small, non-enveloped deoxyribonucleic acid (DNA) viruses.  Over 130 serotypes of HPV have been discovered, of which 15–20 are oncogenic.  The lag period between the oncogenic HPV infection and the invasive cervical cancer is 15– 20 years.  Based on the association with cervical cancer, genital HPVs are further grouped into high-risk types, probable high-risk types and low-risk types.

14. HPV DISEASE SPECTRUM  Worldwide, high-risk type HPV-16 and 18 contribute over 70% of all cervical cancer cases (the most prevalent being HPV-16 in at least 50–60% and HPV- 18 in at least 10–12%).  Similarly, in Indian women, the most common prevalent genotypes are HPV-16 and 18.  Non-oncogenic HPV serotypes-6 and 11 contribute over 90% of benign genital infections such as genital warts.  Oncogenic HPV serotypes have also been implicated in the causation of anal, vulvar, vaginal, penile and oropharyngeal cancers.

15. HPV DISEASE SPECTRUM  HPVs infect the basal epithelium and are grouped as cutaneous and mucosal types.  HPV cervical infection results in cervical morphological lesions ranging from normal (cytologically normal women) to development of different stages of high-grade precancerous lesions cervical intraepithelial neoplasia:  Cervical intraepithelial neoplasia (CIN)-1, CIN-2, CIN-3/Carcinoma in-situ) and, subsequently, invasive cervical cancer (ICC)

17. CERVICAL CANCER- INCIDENCE  Cervical cancer is the fourth most common cancer in women, and the seventh overall, with an estimated 528,000 new cases in 2012.  As with liver cancer, a large majority (around 85%) of the global burden occurs in the less developed regions, where it accounts for almost 12% of all female cancers.

18. CERVICAL CANCER- INCIDENCE  High-risk regions, with estimated ASRs over 30 per 100,000, include Eastern Africa (42.7), Melanesia (33.3), Southern (31.5) and Middle (30.6) Africa.  Rates are lowest in Australia/New Zealand (5.5) and Western Asia (4.4).  Cervical cancer remains the most common cancer in women in

19. ANNUAL NUMBER OF NEW CASES OF CERVICAL CANCER BY AGE GROUP IN DEVELOPING AND DEVELOPED REGIONS(ESTIMATES FOR 2012) Data Source- GLOBOCAN 2012

20. COMPARISON OF THE TEN MOST FREQUENT CANCERS IN WOMEN AGED 15-44 YEARS BY WORLD DEVELOPING AND DEVELOPED REGIONS (FOR 2012) Data Source- GLOBOCAN 2012

21. CERVICAL CANCER- MORTALITY  There were an estimated 266,000 deaths from cervical cancer worldwide in 2012, accounting for 7.5% of all female cancer deaths.  Almost nine out of ten (87%) cervical cancer deaths occur in the less developed regions.

22. CERVICAL CANCER- MORTALITY  Mortality varies 18- fold between the different regions of the world,  less than 2 per 100,000 in Western Asia, Western Europe and Australia/New Zealand to more than 20 per 100,000 in Melanesia (20.6), Middle (22.2) and

23. COMPARISON OF THE TEN MOST FREQUENT CANCER DEATHS IN WOMEN IN THE WORLD COMPARED TO DEVELOPING AND DEVELOPED REGIONS (FOR 2012)

24. BURDEN OF CERVICAL CANCER- INDIA  In India, cervical cancer contributes to approximately 6– 29% of all cancers in women.  The ASR is highest 23.07/100,000 in Mizoram( Aizawl city) state and the lowest is 4.91/100,000 in Dibrugarh district.

25. BURDEN OF CERVICAL CANCER- INDIA  India has a population of approximately 365.71 million women above 15 years of age, who are at risk of developing cervical cancer.  The current estimates indicate approximately 132,000 new cases diagnosed and 74,000 deaths annually in India, accounting to nearly 1/3rd of the global cervical cancer deaths. (Reference- WHO/ICO Information Centre on HPV and Cervical Cancer (Available from:http://www.who.int/hpvcentre.)

26. BURDEN OF CERVICAL CANCER- INDIA  At any given time, about 6.6% of women in the general population are estimated to harbor cervical HPV infection.  HPV serotypes 16 and 18 account for nearly 76.7% of cervical cancer in India.  Warts have been reported in 2–25% of sexually transmitted disease clinic attendees in India; however, there is no data on the burden of anogenital warts in the general community.

27. BURDEN OF CANCER- BIHAR  Vaishali followed by Bhojpur, Begusarai, Muzaffarpur and Patna districts have the highest incidence of cancer in the state.  Mahavir Cancer Sansthan (MCS) has come out with a new research saying over 50, 000 deaths are caused by cancer every year in Bihar, while over 80,000 new cancer patients come up every year in the state.

29. SIGNS AND SYMPTOMS OF CERVICAL CA  Mostly asymptomatic.  When present, common symptoms of cervical cancer may include:  Vaginal bleeding: This includes bleeding between periods, after sexual intercourse or post-menopausal bleeding.  Unusual vaginal discharge: A watery, pink or foul-smelling discharge is common.  Pelvic pain: Pain during intercourse or at other times may be a sign of abnormal changes to the cervix.

30. SIGNS AND SYMPTOMS OF CERVICAL CA  Cervical cancer may spread (metastasize) within the pelvis, to the lymph nodes or elsewhere in the body.  Signs of advanced cervical cancer include:  Weight loss  Fatigue  Back pain  Leg pain or swelling  Leakage of urine or feces from the vagina  Bone fractures

31. PRESENTATION OUTLINE  Introduction ( Anatomy/ Definition)  Risk factors of cervical cancer  Epidemiology/ problem statement  Signs and symptoms of cervical cancer  Screening of cervical cancer  Diagnosis of cervical cancer  Staging  Prevention of cervical cancer.  NCCP/NPDCS/NCRP  Conclusion

32. SCREENING OF CERVICAL CANCER  Cervical screening is the process of detecting and removing abnormal tissue or cells in the cervix before cervical cancer develops.  By aiming to detect and treat cervical neoplasia early on, cervical screening aims at secondary prevention of cervical cancer.

33. CERVICAL CANCER SCREENING  Cervix is amenable to screening by a number of methods 1. visual inspection with acetic acid (VIA), 2. magnified VIA (VIAM) 3. visual inspection with Lugol's iodine (VILI), 4. the Papanicolaou test (also Known as PAP test), 5. and HPV DNA testing.

34. VIA STRENGTH AND LIMITATIONS Screening tests Strength Limitations Acetic acid applied to cervix to identify cancerous and precancerous cells •Require less training (5-15 days) than others. •Cheaper than PAP and HPV testing •Potential for immediate treatment ( Screen and Treat) •Variable sensitivity and specificity for CIN. •Possibility of overtreatment . •Acetic acid must be prepared directly before screening. • inappropriate for older women( more than 50 years) because of change in cervix position.

35. VIAM STRENGTH AND LIMITATIONS Screening tests Strength Limitations •Acetic acid applied to cervix. •Viewed under low magnification. •Require less training (5-15 days) than others. •Cheaper than PAP and HPV testing •Potential for immediate treatment ( Screen and Treat) •Same as VIA. •Magnification does not improve performance more than naked eye.

36. VILI STRENGTH AND LIMITATIONS Screening tests Strength Limitations •LUGOL IODNE applied to cervix to identify cancerous and precancerous cells •Process is often added by magnification tools. •Require less training (5-15 days) than others. •Cheaper than PAP and HPV testing •Potential for immediate treatment ( Screen and Treat) •Has a one month shelf life. •Variable sensitivity and specificity for CIN 2+. •Possibility of overtreatment ..

37. PAP TEST  The Pap test is recommended for all women between the ages of 21 and 65 years old.  can be done in a doctor’s office or clinic.  During the Pap test, the doctor will collect a few cells and mucus from the cervix and the area around it.  The cells are then placed on a slide or in a bottle of liquid and sent to a laboratory.

38. HOW TO PREPARE FOR PAP TEST?  You should not schedule your Pap test for a time when you are having your period.  If you are going to have a Pap test in the next two days—  You should not douche (rinse the vagina with water or another fluid).  You should not use a tampon.  You should not have sex.  You should not use a birth

39. HPV TESTING  The HPV test checks for the virus, not cell changes.  The test can be done at the same time as the Pap test, with the same swab or a second swab.  You won’t notice a difference in your exam if you have both tests.  A Pap test plus an HPV test (called co-testing) is the preferred way to find early cervical cancers or pre- cancers in women 30 and older.

40. WHEN TO START AND FREQUENCY OF SCREENING When to start Screening Age- 21 Years Frequ ency of scree ning PAP TEST 21-29 YEARS EVERY 3 YEAR 30-65 YEARS EVERY 3 YEAR Frequ ency of scree ning PAP+ HPV( Co- testing ) 21-29 YEARS Not recquired 30-65 YEARS EVERY 5 YEAR When to stop Age more than 65 years with adequate

41. STRENGTH AND LIMITATIONS OF PAP TEST Screening tests Strength Limitations Sample of cells taken from transformation one of cervix. Slide has to be prepared and sent to lab for cytological examination. High specificity. Relatively low sensitivity. Require lab and technicians. Lag in result may contribute to loss of follow up and delayed treatment. Require long duration of training of cytotechnicians

42. STRENGTH AND LIMITATIONS OF HPV TEST Screening tests Strength Limitations Sample of cells taken from cervix by provider or women herself. Send to lab for analysis by trained technician. High specificity and high sensitivity for HPV. Require minimal training Women can self collect sample. Has to be followed by test for dysplasia. Require lab and technicians. Lag in result may contribute to loss of follow up and delayed treatment. Costlier as

43. STUDIES PROVIDING ACCURACY OF CERVICAL SCREENING TESTS VIA IAM VILI PAP SMEAR HPV TESTING SE N SP E SE N SP E SE N SP E SE N SP E SE N SP E SHASHTRI ET AL 59.7 88.4 69.7 87.3 75.4 84.3 57.4 98.6 62.0 93.5 SANKARN ARAYAN ET AL 71.2 89.1 - - 76.9 86.3 70.0 98.6 69.1 93.6 GREVITT ET AL 31.5 6 87.4 5 - - - - 78.2 4 85.8 8 100 90.6 SUMMARY 67.6 84.3 65.3 85.7 78.2 87.1 62.1 93.5 77.8 91.5

45. DIAGNOSIS OF CERVICAL CANCER  If the Pap test showed some abnormal cells, and the HPV test is also positive, the doctor may suggest 1 or more of the following diagnostic tests:  Colposcopy  Biopsy  Pelvic examination  X-Ray

46. DIAGNOSIS OF CERVICAL CANCER  CT Scan ( CAT Scan)  PET/PET-CT Scan  Cystoscopy  MRI  Proctoscopy  Laproscopy

47. COLPOSCOPY  The colposcope is not inserted into the woman’s body and the examination is not painful, can be done in the doctor's office, and has no side effects.  It can be done on pregnant women also.

48. BIOPSY  Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis.  If the lesion is small, the doctor may remove all of it during the biopsy.  There are several types of biopsies:

49. TYPE OF BIOPSY- ECC  One common method uses an instrument to pinch off small pieces of cervical tissue.  endocervical curettage (ECC) has been done to check an area inside the opening of the cervix,.  the doctor scrapes a small amount of tissue from inside the cervical opening.

50. TYPE OF BIOPSY- LEEP/CONE BIOPSY  A loop electrosurgical excision procedure (LEEP) uses an electrical current passed through a thin wire hook.  The hook removes tissue for examination in the laboratory.  A LEEP may also be used to remove a precancer or an early-stage cancer.  Conization (a cone biopsy) removes a cone- shaped piece of tissue from the cervix.  Conization may be done as treatment to remove a precancer or an early-stage cancer.

51. DIAGNOSIS OF CERVICAL CANCER  Pelvic examination. The specialist may re- examine the pelvic area while the patient is under anesthetic to see if the cancer has spread to any organs near the cervix, including the uterus, vagina, bladder, or rectum.  X-ray.  intravenous urography

52. DIAGNOSIS OF CERVICAL CANCER  Computed tomography (CT or CAT) scan.  A CT scan can also be used to measure the tumor’s size.  Sometimes, a special dye called a contrast medium is given before the scan to provide better detail on the image.  This dye can be injected into a patient’s vein or given as a pill to swallow.

53. DIAGNOSIS OF CERVICAL CANCER  Magnetic resonance imaging (MRI). MRI can also be used to measure the tumor’s size.  Positron emission tomography (PET) or PET-CT scan. A PET scan is usually combined with a CT scan , called a PET-CT scan  A PET scan is a way to create pictures of organs and tissues inside the body.

54. DIAGNOSIS OF CERVICAL CANCER  Cystoscopy. A cystoscopy is used to determine whether cancer has spread to the bladder.  Proctoscopy (also called sigmoidoscopy). A proctoscopy is used to see if the cancer has spread to the rectum.  Laparoscopy. A laparoscopy is a procedure that allows the doctor to see the spread of cancer within abdominal cavity.

56. STAGING OF CERVICAL CANCER FIGO (INTERNATIONAL FEDERATION OF GYNECOLOGY AND OBSTETRICS) STAGING SYSTEM  Stage I. Cancer is confined to the cervix.  Stage II. Cancer is present in the cervix and upper portion of the vagina.  Stage III. Cancer has moved to the lower portion of the vagina or internally to the pelvic side wall.  Stage IV. Cancer has spread to nearby organs, such as the bladder or rectum, or it has spread to other areas of the body, such as the lungs, liver or bones.

57. STAGING OF CERVICAL CANCER AJCC (AMERICAN JOINT COMMITTEE ON CANCER) TNM STAGING SYSTEM  The extent of the main tumor (T)  Whether the cancer has spread to nearby lymph nodes (N)  Whether the cancer has spread (metastasized) to distant parts of the body (M)

59. PREVENTION OF CERVICAL CANCER  Majority of the women become infected with HPV at some point in their lives, soon after the onset of sexual activity.  The lifetime risk for genital HPV is 50–80% and genital warts is approximately 5%.  In women who undergo routine screening, the risk of having an abnormal Papanicolou (Pap) smear is 35%, CIN 20% and ICC is <1% approximately.  Both HPV Vaccination ( Primary Prevention) and Screening ( Secondary prevention) is important for prevention of cervical cancer.

60. WHY VACCINATION IS THE BEST FORM OF PREVENTION  There is no clear evidence that barrier methods of contraception, most notably use of condoms, confer a protection against HPV infection.  Secondly, except for genital warts, the infection is asymptomatic.  Adherence to routine screening by the susceptible female population through periodic Pap smears even in developed countries has been unsatisfactory.  In developing countries like India, large-scale routine screening is difficult to achieve.

61. DEVELOPMENT OF HPV VACCINE HISTORY  Recombinant DNA technology is used to express the L1 major capsid protein of HPV in yeasts (Saccharomyces cerevisiae), which self-assemble to form empty shells resembling a virus, called virus-like particles (VLPs).  The VLPs have the same outer L1 protein coat as HPV but contain no genetic material.  The vaccine uses these VLPs as antigens to induce a strong protective immune response.

62. TYPES OF HPV VACCINE  Two vaccines licensed globally are available in India; a quadrivalent vaccine (Gardasil™ marketed by Merck) and a bivalent vaccine (Cervarix™ marketed by Glaxo Smith Kline).  Clinical trials with both vaccines have used efficacy against CIN-2/3 and adenocarcinoma in situ (AIS) caused by HPV.  These vaccines do not protect against the serotype with which infection has already occurred before vaccination.

63. GARDASIL  Gardasil™ is a mixture of L1 proteins of HPV serotypes 16, 18, 6 and 11 with aluminum-containing adjuvant.  Clinical trials with three doses at 0, 2 and 6 months in more than 16,000 women aged 16–26 years from five continents, including Asia, have shown 100% efficacy .  This vaccine confers protection against both

64. CERVARIX  Cervarix™ is a mixture of L1 proteins of HPV serotypes 16 and 18 with AS04 as an adjuvant.  Clinical trials with three doses at 0, 1 and 6 months in more than 18,000 women globally has shown 90% efficacy against type 16/18- related CIN-2/3 and AIS .  Follow-up studies in a subset of participants over 4–5 years showed no evidence of waning immunity.  This vaccine confers

65. EFFICACY OF VACCINES  Participants who were already positive to any vaccine HPV types before vaccination acquired protection against disease caused by other vaccine types.  Additionally, 99–100% efficacy was reported against vaccine-type related genital warts, vaginal intraepithelial neoplasia and vulvar intraepithelial neoplasia.

66. EFFICACY OF VACCINES  Immunogenicity studies in females aged 9– 15 years showed antibody titers non-inferior to those aged 16–26 years.  In a combined analysis of all participants over 3 years and a subset through 5 years, efficacy against vaccine-HPV type disease was 95.8% and efficacy against vaccine- type-related CIN or external genital lesions was 100%.  Longer follow-up studies are under way.

67. DOSAGE AND SCHEDULE  The vaccine dose is 0.5 mL given intramuscularly, either in the deltoid muscle or in the antero-lateral thigh.  It is available as a sterile suspension for injection in a single-dose vial or a prefilled syringe.  HPV vaccines can be given simultaneously with other vaccines such as Hepatitis B and Tdap.  At present, there is no data to support the use of boosters.

68. DOSAGE AND SCHEDULE  The recommended age for initiation of vaccination is 9–12 years.  Catch-up vaccination is permitted up to the age of 26 years.  A total of three doses at 0, 2 and 6 months are recommended with Gardasil™ or 0, 1 and 6 months with Cervarix™ (minimum interval of 4 weeks between the first and the second dose, 12 weeks between the second and third dose and 24 weeks between the first and third dose).

69. DOSAGE AND SCHEDULE  If the HPV vaccine schedule is interrupted, the vaccine series need not to be restarted.  If the series is interrupted after the first dose, the second dose should be administered as soon as possible, with an interval of at least 12 weeks between the second and third doses.  If only the third dose is delayed, it should be administered as soon as possible.

70. SIDE EFFECT AND CONTRAINDICATIONS  The most common adverse reactions are local reactions like pain (mild to moderate) in 83%, swelling with erythema in 25% and systemic adverse effects such as fever in 4% of the vaccinees.  No serious vaccine-related adverse events have been reported.  The HPV vaccine is currently not licensed for use in female patients younger than 9 years or older than 26 years or for use in male patients.

71. SIDE EFFECT AND CONTRAINDICATIONS  It is contraindicated in people with a history of immediate hypersensitivity to yeast or to any vaccine component.  The vaccine should be deferred in patients with moderate or severe acute illnesses.  The vaccine may be administered in a sitting or lying down position and the patient should be observed for 15 min post-vaccination for syncope.

72. SIDE EFFECT AND CONTRAINDICATIONS  The vaccine is not recommended for use in pregnant women.  Although it has not been causally associated with adverse outcomes of pregnancy, data are limited.  Any exposure to the vaccine during pregnancy must be immediately reported.  Lactating women and immunosuppressed female patients can receive the vaccine.  The efficacy and the degree of immune response could be poor in the immunosuppressed group.

73. HPV VACCINATION IN MALE  HPV vaccine is not licensed for use among males in India.  Efficacy studies among males are under way.  Australia is the first country to approve the quadrivalent HPV vaccine in males (between 9 and 15 years old), and the vaccine was approved for administration to males between the ages of 9 and 26 years in other developed nations.

74. IAP RECOMMENDATIONS  The Indian Academy of Pediatrics Committee on Immunisation (IAPCOI) recommends offering HPV vaccine to all females who can afford the vaccine (Category 2 of IAP categorisation of vaccines).  The Advisory Committee on Immunization Practices currently recommends routine vaccination of females aged 11–12 years with three doses of the HPV vaccine.  Vaccination can be given to females as young as 9 years as well as in those aged 13–26 years who have not previously completed vaccination.

75. CONCERN AND SAFETY  The primary obstacle to HPV vaccination is financial.  Because of the high cost of the present vaccines, the affordability and accessibility of these vaccines is a major concern for a mass vaccination program in developing countries like India.

76. CONCERN AND SAFETY  One study in India has been conducted by the State governments in collaboration with the Indian Council of Medical Research (ICMR) and PATH for operational feasibility .  The other was a clinical trial to investigate the immunogenic efficacy of two doses (6 months apart) compared with the conventional three doses (0–2–6 months) of Gardasil.  There were allegations in the media of vaccine- caused death of four girls in north India, and the Union Government suspended both studies and initiated enquiry into the safety of both vaccines.

77. CONCERN AND SAFETY  The causes of death have been scrutinized by the State Government and reported to ICMR and DCGI; all were satisfied that no deaths were related to the vaccine.  The vaccines continue to remain as a licensed product approved by the DCGA.  To date, no deaths have been causally associated with HPV vaccination in India or elsewhere.

78. LACUNAE AND FUTURE  More research is needed regarding duration of protection induced by these vaccines, need for boosters, effect on prevalence and incidence of HPV types included in the vaccine.  The efficacy in female patients older than 26 years and in male patients, the role of routine HPV vaccine in males for prevention of genital warts and emergence of other rarer HPV types after the current common types are controlled has to be studied in detail.

79. LACUNAE AND FUTURE  The effect on cervical cancer screening practices, safe sex behavior and further economic analysis are a few questions to be answered in the future.  As prophylactic, vaccines will be effective pre- exposure to virus and, hence, the target population for vaccination will be 9–10-year-old pre-pubertal girls, but this will raise cultural and social issues.  There is an urgent need to conduct epidemiological studies in countries like India on the long-term efficacy, logistics and economics of universal HPV vaccination in eligible females.

81. NATIONAL CANCER CONTROL PROGRAMME NCCP-1984 NPDCS-2010 NPCDCS- 2011 MDCCPNCRP/ICM R

82. NATIONAL CANCER CONTROL PROGRAMME  The National Cancer Control Programme for India was formulated in 1984 with four major goals: 1. Primary prevention of tobacco related cancers. 2. Early detection of cancers of easily accessible sites 3. Augmentation of treatment facilities, and 4. Establishment of equitable, pain control and palliative care network throughout the country.

83. NATIONAL CANCER CONTROL PROGRAMME  National programme for prevention and control of Diabetes, cardiovascular disease and stroke (NPDCS) was initiated in 2010.  National cancer control programme (NCCP) has been integrated with NPDCS to formulate a national programme for control of cancer, Diabetes, cardiovascular disease and stroke (NPCDCS) in 2011.  The focus of NPCDCS is on promotion of healthy lifestyle, early diagnosis and management.

84. EXISTING SCHEMES UNDER NPCDCS  Financial Assistance to Voluntary Organizations  District Cancer Control Scheme  Cobalt Therapy Installation  Development of Oncology Wings in Govt. Medical College Hospitals

85. MODIFIED DISTRICT CANCER CONTROL PROGRAMME  Modified District Cancer Control Programme has been initiated in four states namely Uttar Pradesh, Bihar, Tamil Nadu & West Bengal.  This will be a Survey , in which about 12 lakh women in the age group 20–65 years are being contacted.  Health education about general ailments, cancer prevention and early detection besides ‘Self Breast Examination’ will be imparted.  The project will be completed in about a year’s time.

86. NATIONAL CANCER REGISTRY PROGRAMME( NCRP)  The NCRP commenced by the ICMR in December 1981  NCRP is now working on the objectives of collection of authentic data on cancer occurrence, and helping national programme for control of cancer, Diabetes, cardiovascular disease and stroke (NPCDCS)  NCRP began with a population based cancer registries (PBCRs) at Bangalore, Chennai, Mumbai and hospital-based cancer registries (HBCRs) at Chandigarh, Dibrugarh, and Thiruvananthapuram.

87. NATIONAL CANCER REGISTRY PROGRAMME( NCRP)  NCRP, it has been now been extended to cover other common noncommunicable diseases under the National Centre for Disease Informatics and Research (NCDIR) under the ICMR in March 2011.  The broad and overall objectives of the NCDIR is to sustain and develop a national research data-base on cancer, diabetes, CVD and Stroke  The current thrust areas of NCDIR are cancer registries, patterns of care and survival studies (POCSS) and development of software applications programmes.

88. NATIONAL CANCER AWARENESS DAY  Cancer Awareness day was first observed on 7– 11–2001.  Hon’ble Min. of State, Ministry of Communications Shri Tapan Sikdar at Vigyan Bhawan on the same day, released a commemorative stamp on Cancer and first day cover portraying Madame Curie.  A newspaper advertisement on National Cancer Awareness Day was also released in prominent dailies across the country.

89. PRESENTATION OUTLINE  Introduction ( Anatomy/ Definition)  Risk factors of cervical cancer  Epidemiology/ problem statement  Signs and symptoms of cervical cancer  Screening tests  Diagnosis of cervical cancer  Staging  Prevention of cervical cancer.  NCCP/NPDCS/NCRP  Conclusion  references

90. CONCLUSION  HPV vaccination is for primary prevention (serotype-specific with limited cross-protection) of carcinoma cervix.  A cost-effective second-generation HPV vaccine is needed for developing countries to address various issues specific to the region.  However, till such time, secondary prevention through periodic cervical cancer screening should be in place to use the existing infrastructure and cost-effective screening methods such as Pap smear and HPV DNA tests.

91. CONCLUSION  There is no risk of getting an HPV infection from the vaccine as the vaccine does not contain live virus.  HPV vaccination and regular cervical screening is the most effective way to prevent cervical cancer.

92. REFERENCES 1. World Health Organization. HPV IARC monograph summary. Lancet Oncol. 2005;6:204. 2. Dunne EF, Markowitz LE. Genital human Papillomavirus infection. Clin Infect Dis. 2006;43:624–9. 3. Carter JJ, Koutsky LA, Hughes JP, Lee SK, Kuypers J, Kiviat N, et al. Comparison of human papillomavirus types 16, 18, and 6 capsid antibody responses following incident infection. J Infect Dis. 2000;181:1911–9. 4. Myers ER, McCrory DC, Nanda K, Bastian L, Matchar DB. Mathematical model for the natural history of human papillomavirus infection and cervical carcinogenesis. Am J Epidemiol. 2000;151:1158–71 5. Bosch FX, de Sanjosé SS. Human papillomavirus and cervical cancer - burden and assessment of causality. J Natl Cancer Inst Monogr. 2003;31:3–13. 6. Munoz N, Castellsague X, de Gonzalez AB, Gissmann L. HPV in

93. REFERENCES 7. American College of Obstetricians and Gynecologists. HPV Vaccine - ACOG Recommendations. [Last Accessed on 2008, April 28]. Available from: http://www.acog.org/departments/dept_notice.cfm?recno= 7andbulletin=3945 . 8. Saslow D, Castle PE, Cox JT, Davey DD, Einstein MH, Ferris DG, et al. Gynaecologic Cancer Advisory Group. American Cancer Society guideline for human papillomavirus (HPV) vaccine use to prevent cervical cancer and its precursors. CA Cancer J Clin. 2007;57:7–28. 9. Choudhury P, John TJ. Human papilloma virus vaccines and current controversy. Indian Pediatr. 2010;47:724–5. 10. Choudhury P, Yewale V. Human papilloma virus vaccines and current controversy-reply. Indian Pediatr. 2011;48:248–9.

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