Suneeta Krishnan, PhD

With the advent of the Papanicolaou (Pap) test and population-based screening, along with the development of the human papillomavirus (HPV) vaccine, cervical cancer has become a largely preventable disease for many. However, in India, cervical cancer is a leading cause of cancer mortality.

To better understand why this highly preventable disease remains such a prevalent killer in India, The ASCO Post spoke with Suneeta Krishnan, PhD, a social epidemiologist at RTI International who has done extensive studies on this important issue. Last year, Dr. ­Krishnan was named India Country Director of RTI Global India, an RTI’s wholly owned subsidiary based in New Delhi.

Impact of Social Inequalities on Women’s Health

Please tell the readers a bit about your background and your current work.

I’m a social epidemiologist, and my research focuses on the ways in which social inequalities shaped by economics and gender impact women’s health over the course of their lives. Over the years, my research has utilized methodologies from the public health epidemiology discipline and medical anthropology. So I do what’s called mixed-methods research.

For the first decade of my career, my research was largely focused on the ways in which gender and economic inequality manifest in adverse reproductive and sexual health outcomes among young women, primarily in India. I looked at unintended pregnancies, HIV [human immunodeficiency virus], and other sexually transmitted infections. Over the past 5 years, my world has expanded into research looking at how social inequalities impact women’s health in noncommunicable diseases such as cervical and breast cancers.

Leading Cause of Death in Women in India

Cervical cancer is a leading cause of cancer death in women in India. Please tell the readers a bit about the incidence rate and the disease’s epidemiology.

India bears about 25% of the global burden of cervical cancer. The age-standardized incidence rates of cervical cancer are also among the highest in the world. For example, the age-standardized incidence rate of cervical cancer in India is 22 per 100,000 women, compared with the global rate of 14 per 100,000 women. Even within South Asia, India has the highest incidence of cervical cancer. Annually, we have about 120,000 new cases of cervical cancer, and approximately 70,000 women die each year of the disease.

The very high mortality rates are due to lack of a national comprehensive prevention program combined with a lack of awareness about the signs and symptoms of cervical cancer at the community level. We also find that women from disadvantaged backgrounds and those in rural areas from lower-income households are much more likely to be diagnosed with advanced disease. On top of that, there is a lot of stigma and fear associated with gynecologic symptoms, which delays care-seeking. In my previous research on sexual and reproductive health, we noticed there’s a culture of silence around gynecologic health issues. All these factors lead to the high mortality rates.

Review Methodology

Please describe the purpose and methodology of your review.

We did a review that was motivated by an increased interest in addressing the challenge of cervical cancer in India. There are states in southern India that have made considerable progress in moving toward the United Nations Millennium Development Goals, which included reductions in maternal and infant mortality. By addressing those issues, noncommunicable diseases such as cervical cancer are coming to the forefront as a public health issue.

Back in 2006, the southern state of Tamil Nadu with World Bank funding initiated a pilot program to promote screening of four noncommunicable diseases including cervical and breast cancers. That program has now been scaled across the state. For similar reasons, the neighboring state of Karnataka is also considering launching a similar program and approached the World Bank for funding. In the context of planning that program, the World Bank commissioned our review, basically to bring together the evidence, both from research and existing programs in India, to support the planning of a cervical cancer prevention program.

India has been the site of several large-scale randomized controlled trials that have compared various cervical cancer screening approaches, including visual inspection with acetic acid, HPV vaccination testing, and cytology.

— Suneeta Krishnan, PhD

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Our review utilized two methods. One was a desk review of the literature that described research on cervical cancer prevention in India, including HPV vaccination and various methods to screen for cervical cancer. It’s important to note that India has been the site of several large-scale randomized controlled trials that have compared various cervical cancer screening approaches, including visual inspection with acetic acid, HPV testing, and cytology.

In addition to that, we wanted to document programmatic experiences of implementing cervical cancer screening in India. And to that end, we developed a case study on the state of Tamil Nadu. We examined efforts undertaken by the municipal corporation of the capital city of Chennai as well as the state government. Thus, the review synthesized the research literature as well as insights from programmatic experiences.

Public Awareness in Tamil Nadu

Since lack of awareness is a major barrier in the effort to prevent cervical cancer, are there any public awareness campaigns to address this issue?

One of the challenges in cervical cancer prevention is that advocacy for the need for prevention is fragmented. Although there are well-intentioned awareness drives that have been implemented at the local level, primarily by civil society organizations, they tend to be fairly small scale. Overall, awareness initiatives are not driven by evidence-based strategies. There hasn’t been a lot of research on the best way to increase awareness, so you have a variety of awareness programs whose efectiveness is unknown.

Tamil Nadu is the only state that has established a large-scale public health cervical cancer screening and treatment program, which includes a major awareness drive. Research that I’ve been doing over the past 6 months or so, with funding from the American Cancer Society, suggests that cervical cancer awareness has increased in Tamil Nadu in recent years. Physicians have reported that women, especially in urban areas, are aware of the signs and symptoms of cervical and breast cancers and are seeking out screening. The Tamil Nadu government commissioned an evaluation of the program—the results of that evaluation should provide insights on the outcomes of the large-scale, well-planned public campaigns implemented by the state. But this has been isolated to Tamil Nadu; there has not been a similar kind of concerted, large-scale effort to increase awareness in other parts of India.

Vaccination Programs

The introduction of HPV vaccination would seem a logical step to prevent many cervical cancers. Are there ongoing vaccination programs?

There has been a lot of pushback on HPV vaccination in India, but we’re seeing the beginning of change. In fact, I’ve just submitted an abstract in which I suggest the tide is turning on HPV vaccination. In India, the pushback has largely come from women’s health activists, who have questioned public investments in purchasing the vaccines from Big Pharma as opposed to using those limited resources to invest in the health-care system and increase the availability to cervical cancer screening and treatment services. It has become an either-or argument, pitting HPV vaccination (primary prevention) against screening (secondary prevention) in the competition for funding.

However, some public health researchers, including me, believe we need to promote comprehensive cancer prevention services. States are already beginning to invest in screening and treatment of NCDs, including cervical cancer. There are ways to raise additional funds for vaccination. India, which is classified as a lower middle–income country, has a partnership with Gavi, the Vaccine Alliance, which has supported HPV vaccination in many lower-income countries. In 2016, the government of India and GAVI entered into a partnership to expand the country’s provision of a host of new vaccines; GAVI has indicated that it can also support India to introduce the HPV vaccine.

India has a very strong childhood vaccination program. The country eradicated small pox and polio. Under the National Health Mission, the Indian government has launched a national child health program targeting children from birth to 18 years of age. Health teams visit all government schools to screen children for a range of health problems and can easily be mobilized to introduce the HPV vaccine. A school-focused effort can be supported by community campaigns.

We are now seeing HPV vaccination campaigns as well as screening initiatives introduced in neighboring countries such as Bangladesh and Nepal, on a pilot basis. Interestingly, the Indian state of New Delhi has just announced it will initiate an HPV vaccination program for girls in the sixth grade in government schools. As yet, the federal government has not reached a decision about rolling out the HPV vaccine nationally through the Universal Immunization Program.

Emphasis on Gender Equality

Please share a last thought on this important issue.

We’re at a very exciting point in global health issues. The World Health Organization has launched a new strategy on women’s, children’s, and adolescent’s health, with a strong emphasis on gender equality. There is global recognition of how important women’s and girl’s health is to the advancement of all countries. And this global recognition will offer a lot of opportunities to advance comprehensive cervical cancer prevention through vaccination, screening, and treatment, especially in underserved populations around the globe. ■

Disclosure: Dr. Krishnan reported no potential conflicts of interest.