Cervical cancer screening & HPV vaccination: a comprehensive approach to cervical cancer control.

India with its highest share of global burden of cervical cancer has to implement a population based cervical cancer control program to reduce the number of deaths. There are new screening options available like visual inspection after acetic acid application (VIA) test, single visit approach to screening and treatment etc. Emergence of the two effective vaccines against human papillomavirus (HPV), the necessary cause of cervical cancer, has introduced a fresh lease of life to the cervical cancer control strategies. The current high cost of the vaccines is a major impediment to implement a vaccine-based primary prevention approach.

Cervical screening by visual inspection with acetic acid (VIA) is well accepted by women--results from a community-based study in rural India.

OBJECTIVE: Among the low cost alternative screening tests Visual Inspection after Acetic Acid Application (VIA) has been found to be most promising. The objective of the present study was to evaluate the safety and acceptability of VIA done by health workers among rural Indian women. We also evaluated the level of women's satisfaction with the screening program. METHODS:Women residing in a defined geographic area were offered cervical screening using VIA by trained health workers. Women testing positive were colposcoped by a medical officer at the same sitting. Based on the feedback from a few focus group discussions a structured questionnaire was designed to interview the women after screening. A total of 498 women were selected randomly from the screened women for interview by a social worker. Besides enquiring about any discomfort they faced during or within seven days after screening, the women were also asked to indicate their level of satisfaction with the service. Their opinions to improve the quality of service were also sought. RESULTS: Most women reported no pain or only slight discomfort during screening (94.2%). The most common complaint after screening was vaginal discharge (12%). A burning sensation in the vagina was experienced by some of the women (5.8%). These complaints were mild and short-lasting in majority of cases. Most of the women were satisfied with the screening service (94.6% selected the top three of a six-point response scale) and 97% said they would recommend the test to others. The most common reasons for dissatisfaction with screening were discomfort during or after screening, long waiting time and failure to get treatment for other medical problems. CONCLUSION: VIA by trained health workers followed by colposcopy at the same sitting is an acceptable screening algorithm for Indian women. A VIA based screening program has to be integrated to the existing primary health care facility in developing countries.

Grand challenges in global health and the practical prevention program? Asian focus on cancer prevention in females of the developing world.

In response to the request for 'Breakthrough Questions' for 'Grand Challenges in Global Health' recently published in Nature, the Asian Pacific Organization for Cancer Prevention should focus its attention on what projects are of the highest priority for integration with its Practical Prevention Program (PPP). The most common female cancers in most of the countries of Asia are carcinoma of the breast, followed by the uterine cervix. While the incidences of breast adenocarcinomas are still generally lower than in the Western world they are rapidly increasing, and squamous cell carcinomas of the cervix are a major problem. Clearly there are many areas which would reward research. One factor which appears of major relevance in the mammary gland case is the diet, and particularly the phytoestrogens included in 'tofu', along with physical exercise. The age at which these could be operating needs to be elucidated, with reference to timing of menarche and menopause, and also breast mammographic density, another predictor of likelihood of neoplasia. In the cervix, the predominant influence is well established to be persistent infection with a high risk 'oncogenic' type of human papilloma virus (HPV). Vaccines therefore hold much promise, but a better understanding of the mechanisms underlying spontaneous clearance of both infection and cervical intraepithelial neoplasia (CIN) of different grades is also essential for optimal intervention. The roles of smoking and antioxidant intake in particular deserve emphasis. In Asia, with the considerable variation evident in both breast and cervical cancer incidence rates, as well as in cultural and other environmental factors, we are in a very favourable position to meet two specific challenges: 1). elucidation of how diet in adolescence determines susceptibility to neoplasia of the mammary glands; and 2). determination of what governs persistence of HPV infection. Realisation of these pivotal research aims, with especial emphasis on the context of the PPP, is our shared goal.