Epidemiology of Cervical cancer

Dr Soni Rani
Department Of Community Medicine
Katihar Medical College
Epidemiology Of
Cervical Cancer

PRESENTATION OUTLINE
 Introduction ( Anatomy/ Definition)
 Risk factors of cervical cancer
 Epidemiology/ problem statement
 Signs and symptoms of cervical cancer
 Screening tests
 Diagnosis of cervical cancer
 Staging
 Prevention of cervical cancer.
 NCCP/NPDCS/NCRP
 Conclusion

CERVIX- ANATOMY
 The cervix or cervix
uteri (Latin: neck of
Uterus) is the lower part
of the uterus in
the human female
reproductive system.
 In a non-pregnant
woman, the cervix is
usually 2 to 3 cm long (1
inch) and roughly
cylindrical in shape.
 The narrow,
central cervical
canal runs along its

CERVIX- ANATOMY
 The opening into the
uterus is called
the internal os, and the
opening into the vagina
is called the external os.
 The lower part of the
cervix, known as the
vaginal portion of the
cervix (or ectocervix),
bulges into the top of the
vagina.
 The cervix has been
documented
anatomically since at
least the time

CERVICAL CANCER- DEFINITION
 Cancer that forms in tissues of the cervix
(the organ connecting the uterus and
vagina) is known as cervical cancer.
 It is usually a slow-growing cancer that may
not have symptoms but can be found with
regular Pap tests .
 Cervical cancer is almost always caused by
human papillomavirus (HPV) infection.

RISK FACTORS OF CERVICAL CANCER

MODIFIABLE RISK FACTORS
NON-M0DIFIABLE RISK
FACTORS
 Early marriage
 Early child birth
 Having too many
children
 Multiple sexual partner
 Un-protected sex
 Smoking
 Oral contraceptive pills
 Mental stress
 Decrease immunity
(AIDS)
 Family history /
hereditary
 Socio- economic status
 Decrease Immunity (
Congenital)

 HPV (human papillomavirus) - a sexually
transmitted virus. There are more than 130 different
types of HPVs, at least 18 of which can cause
cervical cancer.
 Many sexual partners or becoming sexually
active early - cervical cancer-causing HPV types are
nearly always transmitted as a result of sexual
contact with an infected individual.
 Women who have had many sexual partners
generally have a higher risk of becoming infected with
HPV, which raises their risk of developing cervical
cancer.

 Smoking - increases the risk of developing many cancers,
including cervical cancer.
 A weakened immune system - such as in people
with AIDS, or transplant recipients taking
immunosuppressive medications.
 Long-term mental stress - women who experience high
levels of stress over a sustained period may be less able to
fight off HPV.
 A study from the American Academy of Pediatrics in 2016
supported this. Principal investigator Dr. Anna-Barbara
Moscicki said: "Women who reported self-destructive
coping strategies, like drinking, smoking cigarettes or
taking drugs when stressed, were more likely to

 Giving birth at a very young age - women
who give birth before the age of 17 are
significantly more likely to develop cervical
cancer compared with women who have their
first baby after the age of 25.
 Several pregnancies - women who have had
at least three children in separate pregnancies
are more likely to develop cervical cancer
compared to women who have never had
children.
 Contraceptive pill - long-term use of some
common contraceptive pills slightly raises a
woman's risk.

 Other sexually transmitted diseases
(STD) - women who become infected
with chlamydia, gonorrhea, or syphilis have a
higher risk of developing cervical cancer.
 Socio-economic status - studies in several
countries have revealed that women with low
SES have significantly higher rates of
cervical cancer.

HPV DISEASE SPECTRUM
 HPV is a member of the family
Papillomaviridae.
 They are small, non-enveloped deoxyribonucleic
acid (DNA) viruses.
 Over 130 serotypes of HPV have been
discovered, of which 15–20 are oncogenic.
 The lag period between the oncogenic HPV
infection and the invasive cervical cancer is 15–
20 years.
 Based on the association with cervical cancer,
genital HPVs are further grouped into high-risk
types, probable high-risk types and low-risk
types.

 Worldwide, high-risk type HPV-16 and 18 contribute
over 70% of all cervical cancer cases (the most
prevalent being HPV-16 in at least 50–60% and HPV-
18 in at least 10–12%).
 Similarly, in Indian women, the most common
prevalent genotypes are HPV-16 and 18.
 Non-oncogenic HPV serotypes-6 and 11 contribute
over 90% of benign genital infections such as genital
warts.
 Oncogenic HPV serotypes have also been
implicated in the causation of anal, vulvar, vaginal,
penile and oropharyngeal cancers.

 HPVs infect the basal epithelium and are
grouped as cutaneous and mucosal types.
 HPV cervical infection results in cervical
morphological lesions ranging from normal
(cytologically normal women) to development of
different stages of high-grade precancerous
lesions cervical intraepithelial neoplasia:
 Cervical intraepithelial neoplasia (CIN)-1, CIN-2,
CIN-3/Carcinoma in-situ) and, subsequently,
invasive cervical cancer (ICC)

CERVICAL CANCER- INCIDENCE
 Cervical cancer is the fourth most
common cancer in women, and the
seventh overall, with an estimated
528,000 new cases in 2012.
 As with liver cancer, a large majority
(around 85%) of the global burden
occurs in the less developed regions,
where it accounts for almost 12% of all
female cancers.

CERVICAL CANCER- INCIDENCE
 High-risk regions, with
estimated ASRs over 30
per 100,000, include
Eastern Africa (42.7),
Melanesia (33.3),
Southern (31.5) and
Middle (30.6) Africa.
 Rates are lowest in
Australia/New Zealand
(5.5) and Western Asia
(4.4).
 Cervical cancer remains
the most common
cancer in women in

ANNUAL NUMBER OF NEW CASES OF CERVICAL CANCER BY AGE
GROUP IN DEVELOPING AND DEVELOPED REGIONS(ESTIMATES FOR
2012)
Data Source- GLOBOCAN 2012

COMPARISON OF THE TEN MOST FREQUENT CANCERS IN WOMEN AGED
15-44 YEARS BY WORLD DEVELOPING AND DEVELOPED REGIONS (FOR
2012)
Data Source- GLOBOCAN 2012

CERVICAL CANCER- MORTALITY
 There were an estimated 266,000 deaths
from cervical cancer worldwide in 2012,
accounting for 7.5% of all female cancer
deaths.
 Almost nine out of ten (87%) cervical
cancer deaths occur in the less developed
regions.

CERVICAL CANCER- MORTALITY
 Mortality varies 18-
fold between the
different regions of
the world,
 less than 2 per
100,000 in Western
Asia, Western
Europe and
Australia/New
Zealand to more
than 20 per 100,000
in Melanesia (20.6),
Middle (22.2) and

COMPARISON OF THE TEN MOST FREQUENT CANCER DEATHS IN WOMEN
IN THE WORLD COMPARED TO DEVELOPING AND DEVELOPED REGIONS
(FOR 2012)

BURDEN OF CERVICAL CANCER- INDIA
 In India, cervical
cancer contributes
to approximately 6–
29% of all cancers
in women.
 The ASR is highest
23.07/100,000 in
Mizoram( Aizawl
city) state and the
lowest is
4.91/100,000 in
Dibrugarh district.

 India has a population of approximately 365.71
million women above 15 years of age, who
are at risk of developing cervical cancer.
 The current estimates indicate approximately
132,000 new cases diagnosed and 74,000
deaths annually in India, accounting to nearly
1/3rd of the global cervical cancer deaths.
(Reference- WHO/ICO Information Centre on
HPV and Cervical Cancer (Available
from:http://www.who.int/hpvcentre.)

 At any given time, about 6.6% of women in
the general population are estimated to
harbor cervical HPV infection.
 HPV serotypes 16 and 18 account for nearly
76.7% of cervical cancer in India.
 Warts have been reported in 2–25% of
sexually transmitted disease clinic attendees
in India; however, there is no data on the
burden of anogenital warts in the general
community.

BURDEN OF CANCER- BIHAR
 Vaishali followed by Bhojpur, Begusarai,
Muzaffarpur and Patna districts have the
highest incidence of cancer in the state.
 Mahavir Cancer Sansthan (MCS) has come
out with a new research saying over 50, 000
deaths are caused by cancer every year in
Bihar, while over 80,000 new cancer
patients come up every year in the state.

SIGNS AND SYMPTOMS OF CERVICAL CA
 Mostly asymptomatic.
 When present, common symptoms of cervical
cancer may include:
 Vaginal bleeding: This includes bleeding
between periods, after sexual intercourse or
post-menopausal bleeding.
 Unusual vaginal discharge: A watery, pink or
foul-smelling discharge is common.
 Pelvic pain: Pain during intercourse or at
other times may be a sign of abnormal changes
to the cervix.

SIGNS AND SYMPTOMS OF CERVICAL CA
 Cervical cancer may spread (metastasize)
within the pelvis, to the lymph nodes or
elsewhere in the body.
 Signs of advanced cervical cancer include:
 Weight loss
 Fatigue
 Back pain
 Leg pain or swelling
 Leakage of urine or feces from the vagina
 Bone fractures

 Screening of cervical cancer
 Staging
 NCCP/NPDCS/NCRP
 Conclusion

SCREENING OF CERVICAL CANCER
 Cervical screening is the process of
detecting and removing abnormal tissue
or cells in the cervix before cervical
cancer develops.
 By aiming to detect and treat
cervical neoplasia early on, cervical
screening aims at secondary
prevention of cervical cancer.

CERVICAL CANCER SCREENING
 Cervix is amenable to screening by a number
of methods
1. visual inspection with acetic acid (VIA),
2. magnified VIA (VIAM)
3. visual inspection with Lugol's iodine
(VILI),
4. the Papanicolaou test (also Known as
PAP test),
5. and HPV DNA testing.

VIA STRENGTH AND LIMITATIONS
Screening tests Strength Limitations
Acetic acid applied
to cervix to identify
cancerous and
precancerous cells
•Require less
training (5-15 days)
than others.
•Cheaper than PAP
and HPV testing
•Potential for
immediate
treatment ( Screen
and Treat)
•Variable sensitivity
and specificity for
CIN.
•Possibility of
overtreatment .
•Acetic acid must
be prepared directly
before screening.
• inappropriate for
older women( more
than 50 years)
because of change
in cervix position.

VIAM STRENGTH AND LIMITATIONS
•Acetic acid applied
to cervix.
•Viewed under low
magnification.
•Require less
training (5-15 days)
than others.
•Cheaper than PAP
and HPV testing
•Potential for
immediate treatment
( Screen and Treat)
•Same as VIA.
•Magnification does
not improve
performance more
than naked eye.

VILI STRENGTH AND LIMITATIONS
•LUGOL IODNE
applied to cervix to
identify cancerous
and precancerous
cells
•Process is often
added by
magnification tools.
•Require less training
(5-15 days) than
others.
•Cheaper than PAP
and HPV testing
•Potential for
immediate treatment (
Screen and Treat)
•Has a one month
shelf life.
•Variable sensitivity
and specificity for CIN
2+.
•Possibility of
overtreatment ..

PAP TEST
 The Pap test
is recommended for all women
between the ages of 21 and 65
years old.
 can be done in a doctor’s office
or clinic.
 During the Pap test, the doctor
will collect a few cells and
mucus from the cervix and the
area around it.
 The cells are then placed on a
slide or in a bottle of liquid and
sent to a laboratory.

HOW TO PREPARE FOR PAP TEST?
 You should not schedule
your Pap test for a time
when you are having your
period.
 If you are going to have a
Pap test in the next two
days—
 You should not douche
(rinse the vagina with
water or another fluid).
 You should not use a
tampon.
 You should not have sex.
 You should not use a birth

HPV TESTING
 The HPV test checks for the
virus, not cell changes.
 The test can be done at the
same time as the Pap test, with
the same swab or a second
swab.
 You won’t notice a difference in
your exam if you have both
tests.
 A Pap test plus an HPV test
(called co-testing) is the
preferred way to find
early cervical cancers or pre-
cancers in women 30 and older.

WHEN TO START AND FREQUENCY OF
SCREENING
When to start Screening Age- 21 Years
Frequ
ency
of
scree
ning
PAP
TEST
21-29 YEARS EVERY 3 YEAR
Frequ
ency
of
scree
ning
PAP+
HPV(
Co-
testing
)
21-29 YEARS Not recquired
When to stop Age more than 65
years with adequate

STRENGTH AND LIMITATIONS OF PAP TEST
Sample of cells
taken from
transformation one
of cervix.
Slide has to be
prepared and sent
to lab for
cytological
examination.
High specificity. Relatively low
sensitivity.
Require lab and
technicians.
Lag in result
may contribute to
loss of follow up
and delayed
treatment.
Require long
duration of training
of cytotechnicians

STRENGTH AND LIMITATIONS OF HPV TEST
Screening
tests
Strength Limitations
Sample of cells
taken from cervix
by provider or
women herself.
Send to lab for
analysis by trained
technician.
High specificity
and high
sensitivity for HPV.
Require minimal
training
Women can self
collect sample.
Has to be
followed by test for
dysplasia.
Require lab and
technicians.
Lag in result
may contribute to
loss of follow up
and delayed
treatment.
Costlier as

STUDIES PROVIDING ACCURACY OF
CERVICAL SCREENING TESTS
VIA IAM VILI PAP
SMEAR
HPV
TESTING
SE
N
SP
E
SE
N
SP
E
SE
N
SP
E
SE
N
SP
E
SE
N
SP
E
SHASHTRI
ET AL
59.7 88.4 69.7 87.3 75.4 84.3 57.4 98.6 62.0 93.5
SANKARN
ARAYAN
ET AL
71.2 89.1 - - 76.9 86.3 70.0 98.6 69.1 93.6
GREVITT
ET AL
31.5
6
87.4
5
- - - - 78.2
4
85.8
8
100 90.6
SUMMARY 67.6 84.3 65.3 85.7 78.2 87.1 62.1 93.5 77.8 91.5

DIAGNOSIS OF CERVICAL CANCER
 If the Pap test showed some abnormal
cells, and the HPV test is also positive,
the doctor may suggest 1 or more of the
following diagnostic tests:
 Colposcopy
 Biopsy
 Pelvic examination
 X-Ray

 CT Scan ( CAT Scan)
 PET/PET-CT Scan
 Cystoscopy
 MRI
 Proctoscopy
 Laproscopy

COLPOSCOPY
 The colposcope is
not inserted into the
woman’s body and
the examination is
not painful, can be
done in the doctor's
office, and has no
side effects.
 It can be done on
pregnant women
also.

BIOPSY
 Other tests can
suggest that cancer is
present, but only a
biopsy can make a
definite diagnosis.
 If the lesion is small,
the doctor may remove
all of it during the
biopsy.
 There are several
types of biopsies:

TYPE OF BIOPSY- ECC
 One common method uses an instrument to
pinch off small pieces of cervical tissue.
 endocervical curettage (ECC) has been
done to check an area inside the opening of
the cervix,.
 the doctor scrapes a small amount of tissue
from inside the cervical opening.

TYPE OF BIOPSY- LEEP/CONE BIOPSY
 A loop electrosurgical excision procedure
(LEEP) uses an electrical current passed
through a thin wire hook.
 The hook removes tissue for examination in the
laboratory.
 A LEEP may also be used to remove a
precancer or an early-stage cancer.
 Conization (a cone biopsy) removes a cone-
shaped piece of tissue from the cervix.
 Conization may be done as treatment to remove
a precancer or an early-stage cancer.

 Pelvic examination. The specialist may re-
examine the pelvic area while the patient is
under anesthetic to see if the cancer has
spread to any organs near the cervix,
including the uterus, vagina, bladder, or
rectum.
 X-ray.
 intravenous urography

 Computed tomography (CT or CAT) scan.
 A CT scan can also be used to measure the
tumor’s size.
 Sometimes, a special dye called a contrast
medium is given before the scan to provide
better detail on the image.
 This dye can be injected into a patient’s vein
or given as a pill to swallow.

 Magnetic resonance imaging (MRI). MRI
can also be used to measure the tumor’s
size.
 Positron emission tomography (PET) or
PET-CT scan. A PET scan is usually
combined with a CT scan , called a PET-CT
scan
 A PET scan is a way to create pictures of
organs and tissues inside the body.

 Cystoscopy. A cystoscopy is used to
determine whether cancer has spread to the
bladder.
 Proctoscopy (also called
sigmoidoscopy). A proctoscopy is used to
see if the cancer has spread to the rectum.
 Laparoscopy. A laparoscopy is a procedure
that allows the doctor to see the spread of
cancer within abdominal cavity.

STAGING OF CERVICAL CANCER
FIGO (INTERNATIONAL FEDERATION OF GYNECOLOGY AND OBSTETRICS) STAGING
SYSTEM
 Stage I. Cancer is confined to the cervix.
 Stage II. Cancer is present in the cervix and
upper portion of the vagina.
 Stage III. Cancer has moved to the lower
portion of the vagina or internally to the pelvic
side wall.
 Stage IV. Cancer has spread to nearby organs,
such as the bladder or rectum, or it has spread
to other areas of the body, such as the lungs,
liver or bones.

STAGING OF CERVICAL CANCER
AJCC (AMERICAN JOINT COMMITTEE ON CANCER) TNM STAGING
SYSTEM
 The extent of the main tumor (T)
 Whether the cancer has spread to nearby
lymph nodes (N)
 Whether the cancer has spread
(metastasized) to distant parts of the body
(M)

PREVENTION OF CERVICAL CANCER
 Majority of the women become infected with
HPV at some point in their lives, soon after the
onset of sexual activity.
 The lifetime risk for genital HPV is 50–80% and
genital warts is approximately 5%.
 In women who undergo routine screening, the
risk of having an abnormal Papanicolou (Pap)
smear is 35%, CIN 20% and ICC is <1%
approximately.
 Both HPV Vaccination ( Primary Prevention) and
Screening ( Secondary prevention) is important
for prevention of cervical cancer.

WHY VACCINATION IS THE BEST FORM OF
PREVENTION
 There is no clear evidence that barrier methods
of contraception, most notably use of condoms,
confer a protection against HPV infection.
 Secondly, except for genital warts, the infection
is asymptomatic.
 Adherence to routine screening by the
susceptible female population through periodic
Pap smears even in developed countries has
been unsatisfactory.
 In developing countries like India, large-scale
routine screening is difficult to achieve.

DEVELOPMENT OF HPV VACCINE HISTORY
 Recombinant DNA technology is used to
express the L1 major capsid protein of HPV
in yeasts (Saccharomyces cerevisiae), which
self-assemble to form empty shells
resembling a virus, called virus-like
particles (VLPs).
 The VLPs have the same outer L1 protein
coat as HPV but contain no genetic material.
 The vaccine uses these VLPs as antigens to
induce a strong protective immune response.

TYPES OF HPV VACCINE
 Two vaccines licensed globally are available in
India; a quadrivalent vaccine (Gardasil™
marketed by Merck) and a bivalent vaccine
(Cervarix™ marketed by Glaxo Smith Kline).
 Clinical trials with both vaccines have used
efficacy against CIN-2/3 and
adenocarcinoma in situ (AIS) caused by HPV.
 These vaccines do not protect against the
serotype with which infection has already
occurred before vaccination.

GARDASIL
 Gardasil™ is a mixture of
L1 proteins of HPV
serotypes 16, 18, 6 and 11
with aluminum-containing
adjuvant.
 Clinical trials with three
doses at 0, 2 and 6 months
in more than 16,000
women aged 16–26 years
from five continents,
including Asia, have
shown 100% efficacy .
 This vaccine confers
protection against both

CERVARIX
 Cervarix™ is a mixture of L1
proteins of HPV serotypes
16 and 18 with AS04 as an
adjuvant.
 Clinical trials with three
doses at 0, 1 and 6 months
in more than 18,000 women
globally has shown 90%
efficacy against type 16/18-
related CIN-2/3 and AIS .
 Follow-up studies in a
subset of participants over
4–5 years showed no
evidence of waning
immunity.
 This vaccine confers

EFFICACY OF VACCINES
 Participants who were already positive to any
vaccine HPV types before vaccination
acquired protection against disease caused
by other vaccine types.
 Additionally, 99–100% efficacy was reported
against vaccine-type related genital warts,
vaginal intraepithelial neoplasia and vulvar
intraepithelial neoplasia.

EFFICACY OF VACCINES
 Immunogenicity studies in females aged 9–
15 years showed antibody titers non-inferior
to those aged 16–26 years.
 In a combined analysis of all participants
over 3 years and a subset through 5 years,
efficacy against vaccine-HPV type disease
was 95.8% and efficacy against vaccine-
type-related CIN or external genital lesions
was 100%.
 Longer follow-up studies are under way.

DOSAGE AND SCHEDULE
 The vaccine dose is 0.5 mL given
intramuscularly, either in the deltoid muscle or in
the antero-lateral thigh.
 It is available as a sterile suspension for
injection in a single-dose vial or a prefilled
syringe.
 HPV vaccines can be given simultaneously with
other vaccines such as Hepatitis B and Tdap.
 At present, there is no data to support the use of
boosters.

DOSAGE AND SCHEDULE
 The recommended age for initiation of
vaccination is 9–12 years.
 Catch-up vaccination is permitted up to the age
of 26 years.
 A total of three doses at 0, 2 and 6 months are
recommended with Gardasil™ or 0, 1 and 6
months with Cervarix™ (minimum interval of 4
weeks between the first and the second dose,
12 weeks between the second and third dose
and 24 weeks between the first and third dose).

DOSAGE AND SCHEDULE
 If the HPV vaccine schedule is interrupted,
the vaccine series need not to be restarted.
 If the series is interrupted after the first dose,
the second dose should be administered as
soon as possible, with an interval of at least
12 weeks between the second and third
doses.
 If only the third dose is delayed, it should be
administered as soon as possible.

SIDE EFFECT AND CONTRAINDICATIONS
 The most common adverse reactions are local
reactions like pain (mild to moderate) in 83%,
swelling with erythema in 25% and systemic
adverse effects such as fever in 4% of the
vaccinees.
 No serious vaccine-related adverse events have
been reported.
 The HPV vaccine is currently not licensed for
use in female patients younger than 9 years or
older than 26 years or for use in male patients.

 It is contraindicated in people with a history
of immediate hypersensitivity to yeast or to
any vaccine component.
 The vaccine should be deferred in patients
with moderate or severe acute illnesses.
 The vaccine may be administered in a sitting
or lying down position and the patient should
be observed for 15 min post-vaccination for
syncope.

 The vaccine is not recommended for use in
pregnant women.
 Although it has not been causally associated
with adverse outcomes of pregnancy, data are
limited.
 Any exposure to the vaccine during pregnancy
must be immediately reported.
 Lactating women and immunosuppressed
female patients can receive the vaccine.
 The efficacy and the degree of immune
response could be poor in the
immunosuppressed group.

HPV VACCINATION IN MALE
 HPV vaccine is not licensed for use among
males in India.
 Efficacy studies among males are under way.
 Australia is the first country to approve the
quadrivalent HPV vaccine in males (between
9 and 15 years old), and the vaccine was
approved for administration to males
between the ages of 9 and 26 years in other
developed nations.

IAP RECOMMENDATIONS
 The Indian Academy of Pediatrics Committee on
Immunisation (IAPCOI) recommends offering
HPV vaccine to all females who can afford the
vaccine (Category 2 of IAP categorisation of
vaccines).
 The Advisory Committee on Immunization
Practices currently recommends routine
vaccination of females aged 11–12 years with
three doses of the HPV vaccine.
 Vaccination can be given to females as young
as 9 years as well as in those aged 13–26 years
who have not previously completed
vaccination.

CONCERN AND SAFETY
 The primary obstacle to HPV vaccination is
financial.
 Because of the high cost of the present
vaccines, the affordability and accessibility of
these vaccines is a major concern for a mass
vaccination program in developing countries
like India.

CONCERN AND SAFETY
 One study in India has been conducted by the State
governments in collaboration with the Indian Council
of Medical Research (ICMR) and PATH for
operational feasibility .
 The other was a clinical trial to investigate the
immunogenic efficacy of two doses (6 months apart)
compared with the conventional three doses (0–2–6
months) of Gardasil.
 There were allegations in the media of vaccine-
caused death of four girls in north India, and the
Union Government suspended both studies and
initiated enquiry into the safety of both vaccines.

CONCERN AND SAFETY
 The causes of death have been scrutinized
by the State Government and reported to
ICMR and DCGI; all were satisfied that no
deaths were related to the vaccine.
 The vaccines continue to remain as a
licensed product approved by the DCGA.
 To date, no deaths have been causally
associated with HPV vaccination in India or
elsewhere.

LACUNAE AND FUTURE
 More research is needed regarding duration of
protection induced by these vaccines, need
for boosters, effect on prevalence and
incidence of HPV types included in the
vaccine.
 The efficacy in female patients older than 26
years and in male patients, the role of routine
HPV vaccine in males for prevention of genital
warts and emergence of other rarer HPV types
after the current common types are controlled
has to be studied in detail.

LACUNAE AND FUTURE
 The effect on cervical cancer screening practices,
safe sex behavior and further economic analysis
are a few questions to be answered in the future.
 As prophylactic, vaccines will be effective pre-
exposure to virus and, hence, the target population
for vaccination will be 9–10-year-old pre-pubertal
girls, but this will raise cultural and social issues.
 There is an urgent need to conduct epidemiological
studies in countries like India on the long-term
efficacy, logistics and economics of universal HPV
vaccination in eligible females.

NATIONAL CANCER CONTROL PROGRAMME
NCCP-1984
NPDCS-2010
NPCDCS-
2011 MDCCPNCRP/ICM
R

 The National Cancer Control Programme for
India was formulated in 1984 with four major
goals:
1. Primary prevention of tobacco related
cancers.
2. Early detection of cancers of easily
accessible sites
3. Augmentation of treatment facilities, and
4. Establishment of equitable, pain control and
palliative care network throughout the
country.

 National programme for prevention and
control of Diabetes, cardiovascular disease
and stroke (NPDCS) was initiated in 2010.
 National cancer control programme (NCCP) has
been integrated with NPDCS to formulate a
national programme for control of cancer,
Diabetes, cardiovascular disease and stroke
(NPCDCS) in 2011.
 The focus of NPCDCS is on promotion of
healthy lifestyle, early diagnosis and
management.

EXISTING SCHEMES UNDER NPCDCS
 Financial Assistance to Voluntary
Organizations
 District Cancer Control Scheme
 Cobalt Therapy Installation
 Development of Oncology Wings in Govt.
Medical College Hospitals

MODIFIED DISTRICT CANCER CONTROL PROGRAMME
 Modified District Cancer Control Programme
has been initiated in four states namely Uttar
Pradesh, Bihar, Tamil Nadu & West Bengal.
 This will be a Survey , in which about 12 lakh
women in the age group 20–65 years are being
contacted.
 Health education about general ailments, cancer
prevention and early detection besides ‘Self
Breast Examination’ will be imparted.
 The project will be completed in about a year’s
time.

NATIONAL CANCER REGISTRY PROGRAMME( NCRP)
 The NCRP commenced by the ICMR in
December 1981
 NCRP is now working on the objectives of
collection of authentic data on cancer
occurrence, and helping national programme
for control of cancer, Diabetes,
cardiovascular disease and stroke
(NPCDCS)
 NCRP began with a population based cancer
registries (PBCRs) at Bangalore, Chennai,
Mumbai and hospital-based cancer registries
(HBCRs) at Chandigarh, Dibrugarh, and
Thiruvananthapuram.

NATIONAL CANCER REGISTRY PROGRAMME( NCRP)
 NCRP, it has been now been extended to cover
other common noncommunicable diseases
under the National Centre for Disease
Informatics and Research (NCDIR) under the
ICMR in March 2011.
 The broad and overall objectives of the NCDIR
is to sustain and develop a national research
data-base on cancer, diabetes, CVD and Stroke
 The current thrust areas of NCDIR are cancer
registries, patterns of care and survival
studies (POCSS) and development of software
applications programmes.

NATIONAL CANCER AWARENESS DAY
 Cancer Awareness day was first observed on 7–
11–2001.
 Hon’ble Min. of State, Ministry of
Communications Shri Tapan Sikdar at Vigyan
Bhawan on the same day, released a
commemorative stamp on Cancer and first day
cover portraying Madame Curie.
 A newspaper advertisement on National Cancer
Awareness Day was also released in prominent
dailies across the country.

 Screening tests
 Staging
 NCCP/NPDCS/NCRP
 Conclusion
 references

CONCLUSION
 HPV vaccination is for primary prevention
(serotype-specific with limited cross-protection)
of carcinoma cervix.
 A cost-effective second-generation HPV vaccine
is needed for developing countries to address
various issues specific to the region.
 However, till such time, secondary prevention
through periodic cervical cancer screening
should be in place to use the existing
infrastructure and cost-effective screening
methods such as Pap smear and HPV DNA
tests.

CONCLUSION
 There is no risk of getting an HPV infection
from the vaccine as the vaccine does not
contain live virus.
 HPV vaccination and regular cervical
screening is the most effective way to
prevent cervical cancer.

REFERENCES
1. World Health Organization. HPV IARC monograph
summary. Lancet Oncol. 2005;6:204.
2. Dunne EF, Markowitz LE. Genital human Papillomavirus
infection. Clin Infect Dis. 2006;43:624–9.
3. Carter JJ, Koutsky LA, Hughes JP, Lee SK, Kuypers J, Kiviat N, et
al. Comparison of human papillomavirus types 16, 18, and 6 capsid
antibody responses following incident infection. J Infect
Dis. 2000;181:1911–9.
4. Myers ER, McCrory DC, Nanda K, Bastian L, Matchar DB.
Mathematical model for the natural history of human papillomavirus
infection and cervical carcinogenesis. Am J
Epidemiol. 2000;151:1158–71
5. Bosch FX, de Sanjosé SS. Human papillomavirus and cervical
cancer - burden and assessment of causality. J Natl Cancer Inst
Monogr. 2003;31:3–13.
6. Munoz N, Castellsague X, de Gonzalez AB, Gissmann L. HPV in

REFERENCES
7. American College of Obstetricians and Gynecologists. HPV
Vaccine - ACOG Recommendations. [Last Accessed on 2008,
April 28]. Available
from: http://www.acog.org/departments/dept_notice.cfm?recno=
7andbulletin=3945 .
8. Saslow D, Castle PE, Cox JT, Davey DD, Einstein MH, Ferris
DG, et al. Gynaecologic Cancer Advisory Group. American
Cancer Society guideline for human papillomavirus (HPV)
vaccine use to prevent cervical cancer and its precursors. CA
Cancer J Clin. 2007;57:7–28.
9. Choudhury P, John TJ. Human papilloma virus vaccines and
current controversy. Indian Pediatr. 2010;47:724–5.
10. Choudhury P, Yewale V. Human papilloma virus vaccines and
current controversy-reply. Indian Pediatr. 2011;48:248–9.

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