(Focus-India)
This interview was published in www.oncofocus.com on 21st January 2020
January is designated for raising awareness on Cervical cancer. We interviewed Dr. Rahul Roy Chowdhury, a leading Oncologist, to understand the current practice, challenges, and future trends in Cervical cancer screening and management.
Dr. Rahul Roy Chowdhury has been practicing as a Gynecological Oncologist for several years, following his training in the United Kingdom as a Gynecologist and an Oncologist. Along with his practice, he is involved in multiple clinical trials and is keenly interested in research activities.
Dr. Rahul Roy Chowdhary is part of Verifothesis, our in-house research panel. Join Verifothesisto contribute to the evolution of the healthcare paradigm.
The biggest problem India has is that it has not been able to establish screening in the country as a universal program, where women in the reproductive age group are offered screening mandatorily. Hence, screening is ‘patchy’ and driven by individual physicians/ hospitals, rather than the government.
We understand that cervical cancer is one of the most common gynecological malignancies around the world. So, for someone to get an early diagnosis, what should be the early signs and symptoms that a woman should look for?
Dr. Rahul: Unfortunately, there are no early signs and symptoms for Cervical cancer. By the time the signs and symptoms appear, the disease is already in an advanced stage. Thus, a continuous screening program is required so that the disease can be diagnosed even when a patient does not show any signs and symptoms.
So, in terms of screening, what are the criteria and how is it done?
Dr. Rahul: We suggest screening for anyone who is above 30 years of age and sexually active. We know that cervical cancer is mainly caused by the Human Papilloma Virus (HPV). Though 1 in 5 women will acquire HPV, 90% of these women will get rid of the virus because of their robust immune system. However, there are some women who can’t get rid of HPV and in these women, the persistent HPV infection may result in the development of cervical cancer.
Thus, the detection of HPV DNA alerts us that a particular woman might be at risk of developing cervical cancer. If no HPV is detected, then the chance of that person acquiring cervical cancer in the next five years is very low. If the HPV test is positive then we will do a PAP-test [a cytology test], to check if the cells obtained from the uterine cervix [mouth of the womb] have transformed to pre-cancerous/cancerous stage. These two tests are the screening tests and doing them together is referred to as ‘co-testing.
What are your suggestions to increase the early diagnosis of cervical cancer?
Dr. Rahul: The recommended screening age in India is 30 years and above (till 65 years), which is the most cost-effective strategy when compared to other resource-rich countries. Various statistical modeling shows that starting screening at earlier age leads to higher detection of abnormal test results without an increased diagnosis of precancer or in other words the test results are ‘false positive’. This would also mean that there would be a requirement of more healthcare personnel to obtain smears and more trained cytopathologists to analyze the smears.
The biggest problem India has is that it has not been able to establish screening in the country as a universal program, where women in the reproductive age group are offered screening mandatorily. Hence, screening is ‘patchy’ and driven by individual physicians/ hospitals, rather than the government.
It seems a better approach than, we can, instead, focus on preventing cervical cancer by giving vaccines to the girls between the age of 9 to 12. A lot of countries, like the UK and Australia, are adopting this approach. In fact, Australia may become the first cervical cancer-free country in the world as they are not only vaccinating their girls but also boys (due to the sexually transmitted nature of the HPV infection).
In India, Punjab, Delhi, and Sikkim have started HPV vaccination free of cost. India has an established extended Programme of Immunisation, and the vaccination approach at present times seems more feasible. However, please note that even after the HPV vaccine you require screening at the age of 30 because the vaccine only covers four virus strains at the moment, whereas you know cancer can be caused by other HPV strains.
Cervical cancer is likely when there is persistence of HPV which may be a linked to the poor nutritional and immunity status of these women.
Who are at risk of developing cervical cancer?
Dr. Rahul: Women with a history of early intercourse/ early / child marriages, multiple partners, poor socio-economic backgrounds are at an increased risk – of having cervical cancer. It is unfortunate that most of the textbooks stigmatize these personal choices of women. These choices can increase the risk because it exposes women to a higher volume and duration of HPV. Cervical cancer is likely when there is the persistence of HPV which may be linked to the poor nutritional and immunity status of these women.
What are the major types of cervical cancer?
Dr. Rahul: When you do a biopsy the commonest type of cervical cancer that you come across is a squamous cell type. Then, there is also a glandular cell type - also called adenocarcinoma. Then there is a combination of both - audio and squamous. But, the majority that we come across is squamous cell carcinoma.
What is the prognosis? What are the common treatment options?
Dr. Rahul: You can divide the treatment options depending upon the early and late stages. If it is in the early stage, then you can go for radical surgery – try and remove the uterus and cervix, the surrounding tissue along with the lymph glands. However, when you cannot do surgery because the cancer is in a late stage, then, radiotherapy is the preferred treatment option. This is normally termed concurrent chemo-radiotherapy, where a small dose of chemotherapy is used to boost the power of radiation and make it more effective. If cancer comes back after the primary treatment, then chemotherapy is used. All these treatment decisions in an institute are taken by a group of oncologists [a multi-disciplinary team] – gynecological oncologists, radiation oncologists, medical oncologists, oncopathologists, and radiologists – loosely termed the ‘tumor board’.
I think every woman must go and take the opportunity to get screened for cervical cancer. You must also vaccinate your daughters.
Do you foresee any interesting trends in terms of cervical cancer space?
Dr. Rahul: There is a lot of work going on in the cervical cancer space. First of all, perhaps, because of the general trend of improvement in health in India, the cervical cancer rate is dipping. Secondly, a lot of drugs have been tested and one of the drugs, bevacizumab, which is a monoclonal antibody, is being used in a recurrent setting and has a good response rate. Previously, we used the same set of drugs that we used for ovarian cancer and that didn't seem to work very well. Now, adding bevacizumab to this set of chemotherapy seems to help in a recurrent setting. There are many other novel drugs which are under investigation in international clinical trials as well as treatment methods that are at present being investigated. There is also a better understanding of the behavior of Human Papillomavirus interaction with the host and a greater depth of knowledge in virus genomics which will hopefully allow us to translate the information into clinical practice in the future.
In terms of epidemiology, according to a report published by WHO, unfortunately, every year we have roughly about ninety-six thousand new cases and approximately sixty thousand deaths.
Doctor, what is the takeaway message for our readers?
Dr. Rahul: I think every woman must go and take the opportunity to get screened for cervical cancer. You must also vaccinate your daughters.
It was an insightful discussion. Thank you for your time and your valuable inputs. I am sure that this interview will help in increasing awareness!
Dr. Rahul: Thank you!