Cervical cancer in India: Taboos, lack of awareness key factors behind rising cases

A Lancet commentary argues for improved awareness building for cervical cancer as the disease has high incidence and mortality rates in India. The commentary argues that given its cultural sensitivity, cervical cancer demands people from all spheres, including medical experts, policy-makers, media, and NGOs, to initiate more discussion for awareness building throughout the year and not limit it to cervical cancer awareness month in January.

“India reports 1.27 lakh cases of cervical cancer and some 80,000 deaths every year,” Dr Abhishek Shankar, the lead author of the Lancet commentary and a radio-oncologist at the All India Institute of Medical Sciences (AIIMS) in Delhi, told The Federal. India has one-fifth of the global burden of cervical cancer and a fourth of the mortality share.

Cervical cancer develops in the cervix of women, the lower narrow part of the uterus that connects it to the vagina. According to the World Health Organisation (WHO), it is the fourth most common type of cancer in women. The positive part is that this type of cancer is one of the most successfully treatable in case of early detection and if effectively managed.

Silver lining

WHO says that even in the case of late-stage diagnosis, this cancer can be controlled with appropriate treatment and palliative care; it can be eliminated within a generation by adopting a comprehensive approach to prevention, screening, and treatment.

The Lancet commentary was written in the context of the media sensation when an Indian actress faked her death. In February, actress Poonam Pandey’s official Instagram account declared that she died of cervical cancer. Within days, the actress said she was alive and that the entire episode was to create awareness about cervical cancer. She was lambasted for her recklessness.

Poonam's drama aside, yearly, thousands of women succumb to this cancer. There is an urgent need for awareness building, obviously in a way far different from hers, addressing certain questions.

Socio-economic status of states

India being on the higher side of cervical cancer incidence and mortality, it is pertinent to enquire whether there exists any pattern of geographical distribution of the disease.

Dr Abhishek throws some light into it. “In India, there are variations between states and cities in terms of incidence and mortality, contributed by several factors, including socioeconomic status, access to healthcare and public health initiatives. Higher incidence and mortality are reported in Mizoram, Tamil Nadu, Karnataka and Maharashtra. Regions with lower socioeconomic status often have limited access to healthcare services including cancer screening and early treatment,” he said.

“States with well-established healthcare systems and screening programmes such as Kerala are more effective in early detection and treatment; higher literacy rates and better public health education contribute to increased awareness about cervical cancer prevention and the importance of regular screenings,” he added.

Role of Human Papilloma Virus

The virus HPV (Human Papilloma Virus) is the main agent that drives cervical cancer in India and in the rest of the world as well. HPV is a common sexually transmitted virus. Almost every sexually active person gets infected at some point in their lives, however, usually without any symptoms. The HPV, in most cases, goes away without any treatment; in some cases, it can cause genital warts, and in others, it can lead to cancer, especially cervical cancer.

HPV, as the main agent of cervical cancer, holds true across the world. However, there are geographical variations in subtypes of HPV, which is more predominant. HPV types 16 and 18 are responsible for 90 per cent of cervical cancers. Other important cancer-causing HPV subtypes are 31, 33, 45, 52 and 58, said Dr Abhishek said.

Taboos play barriers to awareness, healthcare

With sexual path being the main way of developing cervical cancer, social and cultural taboos often act as barriers for women in accessing health programmes aimed towards its elimination.

“Variations in cultural and social practices such as early marriage and multiple pregnancies can influence the incidence of cervical cancer,” said Dr Abhishek. He said cultural sensitivity significantly impacts the success of cervical cancer vaccination and screening programmes in India.

“Many women face barriers due to a lack of awareness, misinformation and societal taboos around sexual health. Cultural norms emphasising female modesty can deter women from seeking screenings that involve pelvic exams, while male-dominated decision-making in families often influences women’s healthcare choices,” Dr Abhishek told The Federal.

Three-pronged strategy 

In 2018, WHO came out with a call to eliminate cervical cancer. In 2020, it adopted a global strategy for cervical cancer elimination to achieve and maintain an incidence rate of below four per 100,000 women.

For turning this aim into reality, WHO rested on three key pillars, commonly known as 90/70/90 strategy – 90 per cent of girls by the age of 15 are vaccinated fully, 70 per cent of women are screened using high-performance test by the age 35 and again by the age of 45, and 90 per cent of the women with pre-cancer be treated while 90 per cent of those women with invasive cancer are managed.

Responding to WHO’s call, India planned strategically to boost the efforts against HPV vaccination. “India is committed to working towards WHO’s eliminate cervical cancer efforts,” said Dr Abhishek.

Sikkim has already completed the HPV vaccination programme for the target population. Punjab and Delhi have done it on a pilot mode. The Centre has a plan to implement pilot HPV vaccination programme in select states and regions to assess feasibility and effectiveness.

However, awareness stands at a crucial position in all the efforts of cervical cancer elimination in India due to socio-economic and cultural factors, especially the taboos associated with women.

“This can be achieved by enhancing awareness and education using local languages and community influencers to disseminate information effectively. Cervical cancer care in India can become more effective, equitable, and sustainable by nationwide scaling up of HPV vaccination, strengthening screening infrastructure, leveraging technology as well as community engagement,” Dr Abhishek said.