HPV Screening for Cervical Cancer in Rural India saves women’s lives

The following is a press release from The International Agency for Research on Cancer

The International Agency for Research on Cancer (IARC) is part of the World Health Organization.
IARC’s mission is to coordinate and conduct research on the causes of human cancer, the mechanisms of carcinogenesis, and to develop scientific strategies for cancer prevention and control. The Agency is involved in both epidemiological and laboratory research and disseminates scientific information through publications, meetings, courses, and fellowships.
Cervical cancer is a major global public health problem affecting socioeconomically deprived populations. It is the most
common cancer among women in low-resource countries where 85% of the global cervical cancer burden of
approximately 493 000 cases and 273 000 deaths are found annually. While HPV vaccines have been launched
recently to prevent infection by the two major types of HPV causing cervical cancer, cervical cancer prevention will still
need to rely on early detection of cervical cancer precursors by screening for several years before the full impact from
affordable and efficient immunization programmes can be felt. “Cervical cancer deaths need to be prevented urgently in
the developing world to reduce disparities and improve women’s health” said Dr Christopher Wild, IARC Director. For
several decades now, it has been known that the wide-spread use of Pap smear test for screening has successfully and
substantially reduced cervical cancer deaths in developed countries. “However, Pap smear screening has not been
uniformly successful in preventing cervical cancer deaths in many parts of the world, particularly in low- and medium-
resource countries, due to several challenges in providing good quality testing and following up women testing positive”,
Dr Wild added.

Recognising the need for a more practical and effective approach to screening and early detection of cervical cancer in
developing countries, Dr Rengaswamy Sankaranarayanan, Head of the Screening Group at IARC, with Dr Bhagwan
Nene and colleagues from the Nargis Dutt Memorial Cancer Hospital (NDMCH), Barshi, India and Dr Surendra Shastri
and colleagues from the Tata Memorial Centre (TMC), Mumbai, India undertook a large randomised controlled trial in
the remote district of Osmanabad in Maharashtra State, India. 131 806 healthy women aged 30-59 were invited to take
part in the study and 32,000 – 34,000 women were randomly allotted to receive either a single round of screening by
HPV testing or visual inspection with 4% acetic acid (VIA) or Pap smear and compared cervical cancer cases and
deaths with those of the 31,500 women allotted to the usual care and health education. Women found positive on any of
the screening tests were investigated with colposcopy and biopsies and those with cervical pre-cancer and cancer
received appropriate treatment.

In this perspective, “the joint effort by the IARC, NDMCH and TMC scientists assumes enormous public health
importance in demonstrating the objectivity, utility and the comparative effectiveness of different screening approaches
in cervical cancer prevention in low- and medium-resource countries” said Dr Rajan Badwe, Director of the TMC.

This is the largest randomised controlled trial of the three screening methods for cervical cancer in a low-resource
setting, carried out in rural India from 2000 to the present. Dr Sankaranarayanan and colleagues found that HPV testing
was more objective and prevented more advanced cervical cancers and cancer deaths, compared with an unscreened
group of women, than the Pap test or visual screening. Fewer subsequent cancers were diagnosed among the HPV test
negative women than among Pap or visual screen negative women. “The significant reduction in advanced cancers and
cervical cancer deaths following a single HPV testing is due to the possibility that HPV screening detected more
precancerous lesions with a high potential of becoming cancer than those detected by visual screening or Pap smear”
said Dr Sankaranarayanan.

“These results emanate from a rigorous study, designed to provide strong scientific evidence, and have benefitted from
substantial community level cooperation, ethical committees inputs and a systematic registration of cervical cancer
cases in the Osmanabad district” said Dr B. Nene, Director of the NDMCH.

Complete data were available for 131,746 women for whom cervical cancer incidence and mortality were analysed. The
results showed 127 cervical cancers cases, 39 advanced cancers and 34 cervical cancer deaths in the HPV screened
group; 152 cervical cancer cases, 58 advanced cancers, and 54 deaths in the Pap smear group; 157 cervical cancer
cases, 86 advanced cancers and 56 deaths in the visual screening group compared with 118 cervical cancers, 82
advanced cancers and 64 deaths in the unscreened control group of women. These results show no significant
reduction in advanced cancers or cervical cancer deaths following VIA or cytology screening, while a significant
reduction in advanced cervical cancers and deaths followed a single round of HPV testing in this low-resource setting.
“The study shows a number of important findings with wide-ranging implications for all countries in the world, including
developed countries” said Dr Wild.

The parallel development of fast, accurate and affordable HPV tests, suitable for use in developing countries, makes
HPV testing a feasible screening approach in low-resource settings and should go hand in hand with further
developments in affordable and effective vaccines to prevent infection by the two major types of HPV responsible for
cervical cancer development. “Although HPV testing will avoid the variation and subjectivity in test interpretation and
minimize efforts required in quality assurance, high participation for screening and treatment of precancers and cancers
are critical to successful screening programmes leading to reduce disease burden in all settings” added Dr Surendra
Shastri, head of preventive oncology at the TMC.

Recommendations
It is of the utmost importance to set up organized screening programs in low-resource populations to reduce the current
high burden of cervical cancer in the near future, parallel to immunization programs when affordable HPV vaccination is
available. For HPV screening to be feasible, low cost, HPV testing should be made available as rapidly as possible.*

Acknowledgements
This study was conducted with active collaboration from the Nargis Dutt Memorial Cancer Hospital (NDMCH), Barshi
and Tata Memorial Centre, Mumbai. The study was supported by a generous grant from the Bill & Melinda Gates
Foundation through the Alliance for Cervical Cancer Prevention (ACCP), a group of five international organizations with
a shared goal of working to prevent cervical cancer in developing countries.

*See: Affordable Solutions to Cervical Cancer Threat

Article reference: N Engl J Med 2009;360:1385-94

For more information, please contact
Dr Sankaranarayanan, Head, IARC Screening Group, at sankar@iarc.fr
Nicolas Gaudin, IARC Communications at com@iarc.fr
The International Agency for Research on Cancer (IARC) is part of the World Health Organization. Its mission is to
coordinate and conduct research on the causes of human cancer, the mechanisms of carcinogenesis, and to develop
scientific strategies for cancer control. The Agency is involved in both epidemiological and laboratory research and
disseminates scientific information through publications, meetings, courses, and fellowships.
If you wish your name to be removed from our press release e-mailing list, please write to com@iarc.fr.

World Health Organization
International Agency for Research on Cancer Organisation mondiale de la Santé Centre international de Recherche sur le Cancer
150, cours Albert-Thomas 69372 Lyon Cedex 08 (France)
Telephone: 33 472 738 485     Facsimile: 33 472 738 311     http://www.iarc.fr

PG

Author: H. Sandra Chevalier-Batik

I started the Inconvenient Woman Blog in 2007, and am the product of a long line of inconvenient women. The matriarchal line is French-Canadian, Roman Catholic, with a very feisty Irish great-grandmother thrown in for sheer bloody mindedness. I am a research analyst and author who has made her living studying technical data, and developing articles, training materials, books and web content. Tracking through statistical data, and oblique cross-references to find the relevant connections that identifies a problem, or explains a path of action, is my passion. I love clearly delineating the magic questions of knowledge: Who, What, Why, When, Where and for How Much, Paid to Whom. My life lessons: listen carefully, question with boldness, and personally verify the answers. I look at America through the appreciative eyes of an immigrant, and an amateur historian; the popular and political culture is a ceaseless fascination. I have no impressive initials after my name. I’m merely an observer and a chronicler, an inconvenient woman who asks questions, and sometimes encourages others to look at things differently.