Bangalore: Jade Goody may have turned the spotlight on cervical cancer, but the lives of women less well known than the late UK television reality show star are threatened by the disease as well.
One in every four new cases of cervical cancer detected every year is from India. A new study, by doctors from India and elsewhere, in the 2 April issue of the New England Journal of Medicine says that a single round of screening for the cancer-causing human papillomavirus, or HPV, can significantly reduce the number of advanced cancers and related deaths.
India gets about 130,000 new cases of cervical cancer every year, about a quarter of the 493,000 cases that surface globally. Still, there’s been no noticeable reduction in the incidence in the last three decades, during which period the developed countries managed a significant decline in cervical cancer-related mortality.
In a study that lasted eight years and was funded by the Bill and Melinda Gates Foundation, researchers from the International Agency for Research on Cancer, or IARC, in the French city of Lyon, Nargis Dutt Memorial Cancer Hospital and Tata Memorial Centre in Mumbai, studied 131,746 women from Osmanabad district in Maharashtra in a randomized, controlled trial.
Women, in the age group 30-59 years, were randomly subjected to three types of screening—HPV DNA test (to check the infection and the virus strain), cytologic test or Pap smear (cellular test), and visual inspection of the cervix with acetic acid, or VIA.
After eight years of follow up, researchers found that the proportion of cancers detected in stage I were about 60% in the HPV and cytologic testing groups, 42% in the VIA group and 28% in the control group (which was designed to get standard care). There were 34 deaths in the HPV testing group, 54 in the cytologic testing group, 56 in the VIA group and 64 in the control group. The incidence of cancer of stage II or higher was significantly higher in other groups as compared to the HPV-testing group.
“There’s no national screening programme in India even though the country contributes the highest number of cases in the world,” says Rengaswamy Sankarnarayanan, lead investigator from IARC. He says for low-medium resource countries such as India there are no clear answers for important questions such as what screening test to use, at what time intervals, in what age groups (30-59, 30-49, 30-39) and what investigations or treatments to use in the case of screen-positive women.
“It’s a significant study and proves that HPV testing is better than Pap smear or VIA but India is too big a country to have a national screening programme,” says H.B. Tongaonkar, a surgical oncologist at the Tata Memorial Hospital in Mumbai. “Both HPV and Pap smear are expensive and require sophisticated laboratory infrastructure,” he says, somewhat surprised by the results as Pap Smear screening has “consistently shown reduction in mortality in the developed regions”.
But researchers say a cost-effective diagnostic, CareHPV test, has been evaluated in China and will soon be available in developing countries. The cost will come down once volume grows, says Sankarnarayanan.
Currently, HPV vaccines are available from Merck and Co. Inc. and GlaxoSmithKline Pharmaceuticals Ltd. The former’s brand called Gardasil, priced at Rs2,800 was launched in October in India; the latter’s Cervarix, priced at Rs3,300 was launched in March. Experts say these vaccines provide protection against types 16 and 18 which are responsible for 70-80% of the cancers. “That still leaves 20-30% cases uncovered,” says Tongaonkar.
Medical professionals say vaccines are expensive and unaffordable for public health services and for most women at risk from the disease in countries such as India. Some public-private model between the government and the manufacturer will have to emerge, rues Tongaonkar. Vaccines cannot replace screening, which, in the short term, is critical to reduce the high burden of the disease, says Tongaonkar.