Cancer of the cervix is a major public health problem. With 527,624 new cases of cervical cancer added every year and to this, India contributes about 122,844 cases. India accounts for about one-third of the cervical cancer-related deaths, with women facing a 1.6% cumulative risk of developing cervical cancer and 1.0% cumulative death risk from cervical cancer. In India, it is the second most common cancer after breast cancer and leading cause of cancer-related deaths. In low- and middle-income countries, due to poor awareness and availability of preventative measures, cervical cancer is often identified at advance stages of the disease. Also, treatment facilities of such late-stage diseases (for example, surgery, radiotherapy, chemotherapy) may be very limited, resulting in a higher rate of death from disease in these countries.
CAUSES AND RISK FACTORS
HPV infection is considered to be the most important risk factor for cervical cancer, the other factors for HPV persistence and development of cervical cancers include:
• Immunocompromised individuals such as those living with HIV are 6 times more likely to have HPV infections and more progression to pre-cancer and cancer
• Co-infection with sexually transmitted agents, such as Chlamydia, gonorrhoea, and herpes simplex
• Multiparity (number of babies born) and young age at first birth.
• Smoking
• Multiple sex partners.
ASSOCIATION BETWEEN HPV INFECTIONS AND CERVICAL CANCER
Cervical cancer is by far the most common HPV -related disease. Most people get infected shortly after the onset of sexual activity. Two HPV types (16 and 18) cause 70% of cervical cancer and pre-cancerous cervical lesions.
HPV is sexually transmitted, but penetrative sex is not must for the transmission even skin to skin contact is sufficient for transmission. HPV infections usually clear up without any active intervention for same, but a small number of infections can persist and progress to cervical cancer. HPV infection is also known to be associated with a portion of cancers of the anus, vulva, vagina, penis, and oropharynx, which are preventable using similar primary prevention strategies as those for cervical cancer.
PATHOGENESIS
HPV is a DNA virus that causes infection and mutation in the epithelium lining, activation of oncogenes and eventually leading to the development of cervical cancer.
SCREENING, PREVENTION AND VACCINATION
Screening is a useful tool for prevention and early detection of disease where it has a high potential for cure. Screening is done for healthy individuals and particularly useful for lesions which take many years to convert into frank disease after onset of infection. Screening is recommended for every woman from aged 21 and regularly afterwards (frequency depends on the screening test used). For women living with immunocompromised status who are sexually active, screening should be done earlier, as soon as they know their HIV status. Screen detected lesions can be treated with help of cryotherapy, thermal ablation and Loop Electrosurgical Excision Procedures. Screening tests that are currently available include:
· conventional (Pap) test and liquid-based cytology (LBC)
· Visual inspection with Acetic Acid (VIA)
· HPV DNA testing for high-risk HPV types.
Three globally licensed vaccine, a quadrivalent vaccine (Gardasil 4™ marketed by Merck), a non-a valent vaccine (Gardasil 9™ marketed by Merck) and a bivalent vaccine (Cervarix™ marketed by GlaxoSmithKline) are available. Best time for vaccination is between 11 to 12 years of age if missed boys can be vaccinated up to the age of 21 years and girls can be vaccinated up to the age of 26 years. 2 doses of vaccination is sufficient if started < 14 years of age and 3 if started after 14 years of age, vaccination can be considered even up to the age of 45 but with poor results.
Cervical cancer is preventable with effective screening measures and is curable if detected early. Treatment options for invasive cervical cancer is stage-based where surgery is an option for early-stage disease and chemo-radiation for advanced stages of same. Regardless of the threat posed due to cervical cancer, ignorance, and less acceptability of screening as well as of vaccination is a big challenge in the prevention of the disease. The month of January is observed as Cervical cancer awareness month around the world. A multitude of efforts is being made to increase awareness and facilitate screening for early detection of cervical cancer. With a comprehensive approach to prevent, screen and treat, cervical cancer can be eliminated as a public health problem.
The writer is Senior Consultant- Surgical Oncology, HCG Cancer Centre Jaipur.