Initiatives of elimination of Cervical cancer in India so far : Guidelines For Screening and Management after WHO Advisory

1. Initiatives of elimination of
Cervical cancer in India so far :
Guidelines For Screening
and Management after WHO

2. 1. Fondly known as Teacher of Teachers
2. Director Lifecare Centre & Lifecare IVF
3. Founder & Secretary general of Delhi Gynaecologist forum , a body of over
2500 members .
4. NMC / MCI : Ethical committee member ,an apex body of 14 lacs modern
Medicine doctors since 2018
5. Business World : Included her in Top 20 Most Influential women in
Healthcare in INDIA (8/03/22)
6. DMC Expert since 2009 to till date
7. Passionate medical activist..has given leadership role in removing Female
Feticide , Movement of Anemia, Save Uterus Campaign, Save ovary
Campaign and Every Mother Counts etc.
8. Given concept of JANANI SURAKSHA YOJNA & ASHA WORKER to GOI.
9. Spearheading movement of Doctors safety /Medico legal Awareness
Unity of North India Gynaecologists
10. Decorated with many Lifetime achievement & Living Legend Award from
many bodies including LHMC AA, FOGSI ,DMA ,DGF , WOW India , Cloud
nine
11. Luminary Award from FOGSI 2022 for Exemplary work in Anemia & Cancer
Cervix Prevention
Dr. Sharda Jain
M.D. (PGIMER),
MNAMS,FICOG,FIMSA,DHM, QM
&AHO
PGDMLS (SYMBIOSIS)

3. CANCER PROBLEM & INDIA

4. India is faced with a sizable cancer incidence
burden, which is growing exponentially.
• The reported cancer incidence in India in 2022 is
estimated to be 19 to 20 lakh, whereas real
incidence is likely to be 1.5 to 3 times higher than
the reported cases.
• It "Call for Action: Making quality cancer care more
accessible and affordable in India".
• The 2020 WHO ranking on cancer burden in terms
of new yearly cases being reported had ranked India
at the third position after China and the US,
respectively.

5. Cancer disease burden in India is characterized by
poor detection with not more than 29 per cent, 15
per cent and 33 per cent of breast ,lung ,and cervical
cancers being diagnosed in stages 1 and 2,
respectively.

6. Cervical Cancer Burden and Current
Situation in India
• As per Globo can 2020, 604,100 new cases of
cervical cancer were detected globally in
2020 and 341,831 deaths were attributed to
this malignancy.
• India contributes to 1/5th of Global load of
cervical cancer.

7. • Cervical Cancer In India: A Preventable Tragedy That
Requires Urgent Attention
• It is estimated that in India, about 160 million women
aged 30-59 years are at risk of developing cervical
cancer, with fatality rate of 50 per cent
• In India, cervical cancer accounted for 9.4% of all cancers
and 18.3% (123,907) of new cases in 2020.

8. Cancer Cervix
• It still is the number one cancer in Rural India
and a leading cause of cancer-related deaths in
women in low- and middle-income group1
• Although the age-standardized incidence rate of
cervical cancer decreased substantially by 40.7%
from 1990 to 2016, it is the second leading cause
of cancer deaths for females in 12 Indian states

9. Late diagnosis of Cancer Cervix
• The majority of women are illiterate and
ignorant about the hazards of cervical cancer as
well as healthcare resources are scarce for
diagnosis.
• Poor prognosis due to late diagnosis is common
in similar resource-constrained settings around
the world, where women present with advanced
stages of Human Papilloma Virus (HPV) caused
cervical cancer and lack treatment facilities
Srivastava AN, Misra JS, Srivastava S, Das BC, Gupta S. Cervical cancer screening
in rural India: status and current concepts. Indian J Med Res. 2018;148(6):687–
96.

10. Risk Factors & CA CERVIX
• HPV INFECTION  is seen in 100 percent
cases of Cancer Cervix .
• In addition to HPV infection, factors like age
at the time of marriage, number of
pregnancies poor genital hygiene, use of oral
contraceptives, poor nutritional status,
smoking, etc., are associated with the
development of cervical cancer.

11. HPV Causes many More Cancers than just Cervical Cancer
HPV is the necessary
cause of cervical cancer
and other cancerous
lesions around anogenital
region and oral mucosa
besides anogenital warts
and respiratory
papillomatoses
1. Forman D, et al. Global burden of human papillomavirus and related diseases. Vaccine. 2012 Nov 20;30 Suppl 5:F12-23.
2. Lacey CJ, et al. Chapter 4: Burden and management of non-cancerous HPV-related conditions: HPV-6/11 disease.
Vaccine. 2006 Aug 31;24 Suppl 3:S3/35-41.
Percent of cases attributable to HPV
infection globally1,2
13-
56%
Oropharynge
al Cancer
(including
tonsils, &
base of
tongue)
88%
Anal
Cance
r
Penile
Cancer
50% 43%
70%
~10
0%
Vulvar
Cancer
Vaginal
Cancer
Cervical
Cancer
HPV: Human Papillomavirus

12. INDIAN WOMEN GET CA CERVIX EARLY
In India, the incidence of cervical cancer
significantly rises around the age of 45 years and
peaks at 55 years of age.
The natural history of the disease suggests that
early diagnosis should initially target those women
who have a higher prevalence of high grade
precancerous lesions .
Cervical Intraepithelial Neoplasia  CIN2/3—
Indian women are mostly in their 30 s and 40 s 
Consensus Document for the Management of Cancer Cervix. Indian Council of Medical Research. 2016. https://main.icmr.nic.
in/sites/default/files/reports/Cervix%20Cancer.pdf. Accessed 29 April 2021.

13. PREVENTION OF CA CERVIX
Interventions ranging from
PROPHYLACTIC HPV VACCINES
VARIOUS SCREENING approaches
visual inspection with acetic acid or Lugol’s iodine (VIA/VILI),
Papanicolaou test (Pap test or Pap smear)
HPV DNA (Deoxyribose Nucleic Acid) testing after 30 years
are used for early detection and prevention of cervical cancer

14. HPV Vaccination status
in India
Less than 1% of the eligible women
vaccinated with HPV Vaccine

15. Cervical Cancer Screening
practice in India
Bruni L, Albero G, Serrano B, Mena M, Gómez D, Muñoz J, Bosch FX, de Sanjosé S. ICO/IARC Information
Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in
India. Summary Report 17 June 2019. Executive Summary, Table 1 [ Accessed on 23-Nov 2020]
Cervical cancer screening coverage is a mere
3.1% in the general female population

16. World Health Organization, United Nations Population Fund. Preparing for the Introduction of
HPV Vaccines: Policy and Programme Guidance for Countries. Geneva, Switzerland: World
Health Organization; 2006.
Palliative
care
Cancer treatment
Secondary prevention:
Screening and treatment
of precancers
Primary prevention:
Vaccination
World Health

17. HPV Vaccination: forms the Base of
CERVICAL Cancer Control-
vaccination alone can < cancer load
by 50 %
Study

18. 1. Bruni L, Barrionuevo-Rosas L, Albero G, Serrano B, Mena M, Gómez D, Muñoz J, Bosch FX, de Sanjosé S. ICO Information Centre on HPV and
Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in India. Summary Report 10 Dec 2018. [Accessed on 25 Jan 2019]
2. Diaz M, Kim JJ, Albero G et al. Health and economic impact of HPV 16 and 18 vaccination and cervical cancer screening in India. British Journal of
Cancer (2008) 99, 230 – 238
Impact on cancer reduction*
Vaccination only
Screening only (VIA – 1x, 2x, 3x)
Vaccination followed by
screening
(VIA – 1x, 2x, 3x)
*Base case assumes 70% vaccination and screening coverage
Health impact of HPV vaccination followed by cervical cancer
screening in India
Combining Screening
and Vaccinationhas maximum impact on Cervical Cancer reduction1
Once at 40 years Twice at 35, 40
years
Thrice at 35, 40,
45 years
13%
52%
21%
56%
29%
61%
44%
Vaccination only
Study

19. HPV Vaccine-A High Impact Vaccine –
As stated by GAVI, WHO
20 Deaths Averted
per 1000 Vaccinated

20. 2020
November

21. World Health Organization (WHO) Guidelines 2020
• November 2020 WHO outlined three key steps: vaccination,
screening and treatment
• Meeting the following targets by 2030 will hopefully place
countries on the path toward elimination:
• 90% of girls fully vaccinated with the HPV vaccine by 15 years of
age,
• 70% of women screened using a high-performance test by age 35
and again by 45 as well as 90% of women identified with cervical
disease receive treatment (90% of women with pre-cancer treated
and 90% of women with invasive cancer managed).
. Basu P, Meheus F, Chami Y, Hariprasad R, Zhao F, Sankaranarayanan R. Management algorithms for cervical
cancer screening and precancer treatment for resource-limited settings. Int J Gynaecol Obstet. 2017;138(Suppl
1):26–32. https://doi.org/ 10.1002/ijgo.12183 (PMID: 28691336).

22. WHO’s global strategy towards eliminating cervical
cancer aims to set the world on the right track by
2030
• At this pace, global elimination of cervical cancer is not
predicted until 2120 (100 Years )
If no action is taken, CERVICAL CANCER DEATHS
will rise almost 50% by 2030

23. 90-70-90
Indian scenario-dismal
show
0- .1% 3% 10%

24. WHO -SAGE
The strategy also stresses that investing in
the interventions to meet these targets
can generate substantial economic and
societal returns
Akinyemiju T, Ogunsina K, Sakhuja S, Ogbhodo V, Braithwaite D. Life-course socioeconomic status and
breast and cervical cancer screening: analysis of the WHO's Study on Global Ageing and Adult Health
(SAGE). BMJ Open. 2016; 6:e012753.

25. WHO SAGE
DOSE Schedule of HPV
One Dose HPV Vaccination
Offers
SOLID PROTECTON AGANST
Cervical Cancer

26. Most effective prevention strategy
The most effective prevention strategy for
cervical cancer is the systematic screening of
women through an organized program along
with treatment and follow-up of the screen-
detected precursor lesions. The focus on the
detection and prevention and treatment of
cervical cancer must be emphasized in a highly
populated country like India

27. BOTH DOCTORS & NURSES HAVE TO
TAKE EQUAL ROLE IN PREVENTION

28. As per WHO, ACOG, OBGYNs
play a critical role in women’s
care and should assess and
vaccinate adolescent girls &
young women with HPV
vaccine during the catch-up
period*.2
1. Joneja GS, Chopra S, OBGYN and changed lifestyle of women, Med J Armed Forces India. 2012 Jan; 68(1): 2–3
2. Human Papillomavirus Vaccination. ACOG Committee Opinion No. 704. June 2017. ACOG. Committee on Adolescent Health Care. Immunization Expert Work Group. https://www.acog.org/Clinical-Guidance-
and-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Human-Papillomavirus-Vaccination?IsMobileSet=false. Accessed on 30/10/2019. * 13-26 years
OBGYN to play a PIVOTAL ROLE

29. NURSEStoo can play a
critical role in women’s care
and should assess and
vaccinate adolescent girls &
young women with HPV
vaccine during the catch-up
period if missed out earlier *
NURSES too can play a PIVOTAL ROLE

30. Evolution of
Cancer Control &
CERVICAL CANCER CONTROL
Programs
in India till Date

31. The National Cancer Control
Programme (NCCP) was first
launched in 1975
PRACTICALLY
NOTHING WAS
DONE for
CA CERVIX

32. ICMR-National Institute of Cancer
Prevention and Research (NICPR) at
Noida, in collaboration with the US
National Cancer Institute
2-day brainstorming workshop in 2013
Road Map rolled out in 2016 by ICMR +
MOHFP in 100 districts
ICMR /MOHFW / USA

33. YEAR 2021
• The Prime Minister’s office took note of this
development and emphasized the importance of
a quick release of the necessary guidelines
• Minister of Health promised that the Initial
implementation of the screening program across
100 districts will provide data for wider
implementation across India.by awareness
campaigns in the community.
Ghosh A. PMO sets 3-month deadline for the cancer screening framework.
https://indianexpress.com/article/india/india-newsindia/pmo-sets-3-month-deadline-for-cancer-screening-frame
work/. Accessed 6 May 2021

34. Global DATA on HPV
VACCINATION
Globally, it is now widely accepted
that vaccination against high-risk
strains of the human papillomavirus
(HPV) is a safe and effective means of
primary prevention of cervical cancer.

35. • Although the HPV vaccination was
introduced in India in 2008, it is yet to be
included in the universal immunization
program in India .
• an international nonprofit organization,
PATH, was started in 2009 in Andhra Pradesh
and Gujarat but had to be suspended in 2010
as a result of public concern,
Mehrotra R, Hariprasad R, Rajaraman P, Mahajan V, Grover R, Kaur P,
Swaminathan S. Stemming the wave of cervical cancer: human
papillomavirus vaccine introduction in India. J Glob Oncol. 2018; 4:1–4.
https://doi.org/10.1200/JGO.17.00030. Epub 2017 Sep 8. PMID:
30241163; PMCID: PMC6180758

36. Delhi
HPV vaccination program for school children was
launched in New Delhi, on the occasion of
National Cancer Awareness Day (November 7,
2016) which vaccinated nearly 1200 girls
It was supposed to be expanded to cover 250,000
girls per annum which never happened.
Chatterjee P: Delhi first state to launch the HPV vaccine as public health program
in schools. http://indianexpress.com/article/cities/ delhi/delhi-first-state-to-
launch-hpv-vaccine-as-public-healthpro gramme-in-schools/. Accessed 29 April
2021.

37. Punjab
The Government of Punjab initiated a similar
campaign and succeeded in vaccinating young
girls with 97.5% and 98.5% coverage initially
WHO: Punjab launches HPV vaccine with WHO support. http://
www.searo.who.int/india/mediacentre/events/2016/Punjab_ HPV_vaccine/en/.
Accessed 29 April 2021.

38. SIKKIM
Government of Sikkim also introduced HPV
vaccination along similar lines and achieved
high coverage and safety in 2018 with
spectacular success covering 95 % girls
SUCCESS STORY OF HPV
VACCINATION IN SIKKIM
SIKKIM
Sankaranarayanan R, Basu P, Kaur P, Bhaskar R, Singh GB, Denzongpa P, Grover RK, Sebastian P, Saikia T, Oswal K, Kanodia R, Dsouza A,
Mehrotra R, Rath GK, Jaggi V, Kashyap S, Kataria I, Hariprasad R, Sasieni P, Bhatla N, Rajaraman P, Trimble EL, Swaminathan S,
Purushotham A. Current status of HPV vaccination introduction in India’s cervical cancer prevention efforts. Lancet Oncol. 2019.
PMID:31674322

39. Ayushman Bharat Scheme
• The cervical cancer screening was bundled with
breast and oral cancer screening as part of the
NPCDCS program as a comprehensive package to
be delivered at the Wellness centers and
covered by the Ayushman Bharat Scheme of the
MoHFW. At the time of writing, 70,000?
wellness centers catered to 41.35 crore people
and 917 hospitals impanelled under the scheme
for oncology care, catering to slightly less than 2
lakh beneficiaries.

40. Evaluation
• A recent study, in 2020, reported that
according to the NFHS (National Family Health
Survey) report, 22% of women have
undergone a cervical examination in India and
the majority of the districts fall in the range of
10–20%
American Cancer Society. Cervical cancer screening. 2020.

41. • Whereas as per 2021 India factsheet, the
coverage of Cervical cancer screening
coverage, % has been reported to be only
3.1% [
.
• Another study conducted in 2020, in south
India revealed that only 14.3% had at least
one lifetime pelvic exam and 7.1% had
undergone cervical cancer screening
Basu P, Meheus F, Chami Y, Hariprasad R, Zhao F, Sankaranarayanan R. Management algorithms for
cervical cancer screening and precancer treatment for resource-limited settings. Int J Gynecol
Obstet. 2017; 138(Suppl 1): 26- 32
World health Organization. Guidelines for screening and treatment of precancerous lesions for cervical
cancer prevention.

42. • NFHS-5 data is also in line with the WHO
data, where percentage of women ever
undergone cervical cancer screening in India
is 1.9% (2.2% urban and 1.7% rural)
• Andhra Pradesh, Bihar, Jammu and Kashmir,
Telangana, and West Bengal have more rural
women participating in cervical cancer
screening than those in urban areas
Dessalegn MB. Cervical cancer screening uptake and associated factors among
HIV-positive women in Ethiopia: a systematic review and meta-analysis. Adv Prev
Med. 2020; 2020: 1- 10.

43. • The women living in the urban regions of
Mizoram, Himachal Pradesh, Kerala, and
Maharashtra have a significant number of
women undergoing a screening test for cervical
cancer.
• The practice of cervical cancer screening is close
to insignificant in Nagaland, Ladakh, and Gujarat
 work has to be done on WAR FOOTING.
. Gunnal GS, Guha S, Akhil PM. How do Indian states handle cancer screening among women? NFHS-5
data reveals. 2020. Down to Earth. https://www.downtoearth.org.in/blog/health/howdo-indian-states-
handle-cancer-screening-among-women-nfhs-5- data-reveals-74666.

44. Advisory by department of health
research India
suggested that a policy of screening
of the women could be a viable
approach can not be ignored

45. Practical on-Field Implementation of the
Guidelines and Challenges
• Apart from the infrastructural barriers, a recent
study reported that poor knowledge about cervical
cancer, benefits of screening service availability, as
well as a general sense of well-being,
embarrassment or anxiety related to the screening
procedure, fear of being judged for lack of modesty,
and stigma were common barriers to screening
uptake in India
29Chrysostomou AC, Kostrikis LG. Methodologies of primary HPV testing currently applied for cervical cancer
screening. Life (Basel). 2020; 10: 290.

46. Training of Health Care Workers
• As per the Operational guidelines, the
existing health care providers (HCPs) at
various facilities were supposed to roll out
the population-based cancer screening in the
country
• However, the existing HCPs lacked the skills
and were not trained in cancer screening.

47. large-scale cervical cancer screening is
also a concern in INDIA
• The ECHO model provided a cost-effective
way to exponentially expand the capacity to
mentors and train these HCPs in cancer
screening best practices
• Online training, hard copies of training
manuals were also designed by the MoHFW
for doctors and paramedical workers.

48. Way forward for
Cervical Cancer
Prevention in India

49. ADVISORY BY DEPARTMENT OF
HEALTH RESEARCH INDIA
&
INDIAN EXPERTS ADVICE

50. VACCINATION

51. HPV VACCINATION
GOI HAS MADEUP ITS MIND TO INCLUDE
HPV VACCINATION FOR ADOLESCENT GIRLS
IN
National Immunisation Program
30 % VACCINATION LOAD TO MOST
IMPORTANT GROUP IS TAKEN BY GOI
LOGISTICS are being worked out on similar
lines as covid vaccination & successful
model in sikkim state

52. 70 % HPV VACCINATION TO ADULT
WOMEN WILL BE RESPONSIBILITY OF
PRIVATE SECTOR DOCTORS
DOCTORS & PUBLIC IS READY TO GIVE FULL
SUPPORT IN CREATING AWRENESS &
VACCINATION ONCE SERUM INDIA
INSTITUTE VACCINE IS AVAILABLE IN
MARKET

53. WHAT SHOULD BE SCREENING TOOL
FOR INDIA
TO INCREASE CERVICAL
CANCER SCREENING RATE
FROM 3% TO 70 %
???

54. Way forward on Cervical Cancer Screening
India needs to develop health system capacity to
ensure efficient cervical cancer screening
program and community-level efforts to
improve knowledge about cervical cancer and
screening programs via enhancing community
participation which can only be achieved by
creating a workforce of health professionals and
paramedical workers with screening awareness
Vora KS, Saiyed S. Cervical cancer screening in India: need
of the hour. Cancer Res Stat Treat. 2020;3:796–7

55. Screening TOOL of CERVICAL CANCER
in INDIA
• There is sufficient evidence (ICMR STUDY) that
suggests that screening leads to a reduction in
the occurrence of cervical cancer cases with a
decrease in cancer deaths.
• It also concludes that among various screening
strategies, VIA /VILI every 5 year is the most
cost-effective screening method in the context
of India till locally produced HPV RAPID
DETECTION KITS are made available.

56. VIA /VILI COMPLIMENTARY
TO EACH OTHER

57. • A recent review found that community
healthcare workers (CHWs) can improve
community awareness and help to carry out
cancer screening & cryocautery and follow-up.
• Referal centres need to be created in DISTRICT
HOSPITALS + FOFSI MEMBERS inPrivate sector
for SCREEN &TREAT CLINICS.
• Adopting participatory approaches in CHW
interventions would enhance acceptability
O’Donovan J, O’Donovan C, Nagraj S. The role of community health workers in
cervical cancer screening in low-income and middle-income countries: a systematic
scoping review of the literature. BMJ Glob Health. 2019;4:e001452.

58. SEE & TREAT
35 YEARS , 40 YEARS
VIA & VILI

59. Using VIA/VILI + DO CRYOCAUTERY if found
positive in less than half of cervix in SEE &
Treat clinic
Offer COLPOSCOPY directed biopsy IN SCREEN
& TREAT CLINIC
Road Map rolled out by experts
Single Visit Approach

60. Single VISIT Approach
Screen & treat See & Treat

61. Screening and Management Algorithm for CERVCAL CANCER

63. Road Map rolled out by experts
Single Visit Approach for CIN
Detection & Treatment
Cryo Cautry & Thermal Ablation
Thermal Ablation is
batter bcz of its effect to
7 mm depth

64. 7 mm
5 mm

65. Cryotherapy in See & Treat clinic

66. HPV INFECTION & INDIA
• A recent study by Ginsburg et al. reported
that HPV has also caused a slow-moving
health crisis akin to a pandemic that is hiding
in plain sight
• This is critical for facilitating effective
intervention to prevent nearly 70 K cervical
cancer deaths in 2021 and the future
Ginsburg O, Basu P, Kapambwe S, et al. Eliminating cervical cancer in the COVID-19 era.
Nat Cancer. 2021;2:133–4. https:// doi.org/10.1038/s43018-021-00178-9

67. Recommendations
• We have come a long way since the development of
the Operational Guidelines for the management of
common cancers in India BABY STEPS ONLY
• However, on-field implementation of early diagnosis
of cervical cancer on a national scale is still a
herculean task.
• ECHO training programs and satellite clinic models do
help  both Govt of India & FOGSI should be give
real road map

68. Recommendations
• more robust commitment from the Government
is required for the full-fledged implementation of
WHO guidelines.
• a concerted approach for the implementation of
Nation-wide cervical cancer control and HPV
vaccination will hopefully bring fruitful results, as
evident from the success of the Sikkim model
• Rest 70 % will be done by gynaecologists +
pediatricians.
Salaria S. Focus on Sikkim model to check cervical cancer. 2018.
https://timesofindia.indiatimes.com/city/noida/focus-on-sikkimmodel-to-check-cervical-
cancer/articleshow/65600408.cms. Accessed 29 April 2021

69. It was recommended that visual screening tests
such as VIA/VILI could be adopted till a low-cost
reliable HPV test became available in India.
These techniques could be conducted by trained
doctors and paramedical staff, with adequate
training and quality assurance, and would also
have the advantage of on-site screen and
treatment of low degrees of abnormalities
detected