Is existing cervical cancer screening proven productive in developing nations: Time to move from the laboratory to community?

Dear Editor,

Cervical cancer is the leading cancer among Indian women with the estimated age standardized incidence and mortality rates around 2008 of 27 and 15/100,000 women years, respectively.[1] Once in a lifetime screening between 30 and 40 years of age would reduce the lifetime risk to 25 to 36%.[2] Lack of effective screening has been blamed as the main culprit for the unbalanced burden of disease in the developing world.[2] An estimated 5% of the women in low resource setting are screened appropriately.[3] Failure to decrease the morbidity and mortality of the disease in spite of being actively involved in screening since the past 30-35 years raises the concern as to whether we are going on the right path with our existing screening policy. Are we utilizing the existing resources at the proper place? Or does the existing screening policy lack the threshold which is required to generate a positive impulse?

Despite many types of promotional efforts running concurrently, no single Indian state has an effective, organized population based high-level opportunistic cervical cancer screening program leading to non-existence of routine screening of asymptomatic women.[4] Nearly 80% of India’s annual cervical smear is performed in the private health facilities and mostly opportunistically,[5] which misses the most vulnerable and underserved population who are at the greatest risk and cannot afford the cost.[6] Polarization of the screening resources mainly in the tertiary care centers in urban areas and the needy ones in rural areas seems to be the main culprit leading to the failure of the existing screening policy. Polarization decreases the compliance owing to a long distance required to travel to avail the health-care facility of which 70-80% is borne out of pocket causing worse poverty.[7] This strengthens the pre-established hypothesis that living farthar away from hospital may decrease access to the health facilities.[4]

Thus, the existing scenario provokes a shift of the screening program from our cytopathological laboratories to the community. It is very expensive and cumbersome to bear the cost of Papanicolaou (PAP) test in the developing world where economic constraints cause women to prioritize their social responsibilities, and leads them to neglect[8] their health issues, thusby curtailing their visits to screening facilities[4] mainly available in the tertiary care centers.[9] Hence being health-care providers., it isour duty to take the health-care facilities to the door step of the needy ones at the primary care level, since more than 90% of patient have some form of contact at the primary care level.[10] Availability of near to the real time screening tools like (visual inspection through acetic acid [VIA])/lugol iodine) combined with the trained non-medical personnel’s like Accredited Social Health Activist (ASHA) and availability of the facility in their society, which would increase the compliance to get screened[4] would be a promising approach in facilitating the uptake of screening among rural women. Visual screening tests are the most feasible cervical screening tests that can be administered at the primary care level since they do not require a laboratory infrastructure and consumables such as 3-5% dilute acetic acid and Lugol’s iodine can be readily made available in health centers and the test results are interpretable in real time.[10] Recent report from a randomized controlled trial in India has reported a decrease in mortality of 31% from cervical cancer, which was seen during a 15-year study duration using a simple approach of VIA technique, which does not required any cumbersome infrastructure or medical personnel.[11] The approach could be further simplified and made more promising by recruiting and training ASHA for carrying out our cervical cancer screening through VIA technique.

Recruiting ASHA will be like hitting two targets with a single bullet. Since ASHA are female and are invariably from the same or nearby community village, the women who need to undergo cervical cancer screening will likely have more faith in the procedure and its necessity for their health, which could encourage more women to get screened. ASHA could act as the key link for awareness and recruiting through personal communication as it has been seen that trying to improve awareness of the disease and its prevention without personal communication may not be fully effective.[12] This will open the door of screening for those women who defer screening owing to existing purdah system, cultural beliefs and custom barriers, e.g., feeling of shyness which prevents the woman from discussing her problems and prevents her from getting screening by a male doctor.[4] This will also facilitate screening among women who unable to get a male to escort them to the reproductive health facility,[4] site for most of the existing opportunistic screening in India, situated remotely from their place and the unmarried women who are not in need of reproductive health facilities and think that the test is meant for the sexually active women only.[4] Studies have shown that involvement of trained community health workers, village health nurses and volunteers has increased the compliance and detection of cervical abnormalities and breast cancer in asymptomatic women in low-income rural communities.[41314]

It is time to learn from the success of polio micro plans which captured every family through door to door visits, which helped established a relationship between the marginalized section of the population rather than just sitting and waiting at the immunization center for their arrival.[15] An institutional home delivery system for providing PAP test, especially to registered below poverty line and underserved community can be tuned up with grand successes of similar framework. Someone had once said that “If you fail to reach the target, you should not change the goal instead you should change the way you reach it.”