HPV Vaccination: One Small Jab for Girls, One Giant Leap to Cervical Cancer Elimination

In 2008, Professor Harald zur Hausen received the Nobel Prize for his discovery that persistent infection with high-risk strains of the human papillomavirus (HPV) is the necessary cause of cervical cancer, an important cause of morbidity and mortality globally, but more so in low and lower middle income countries (LMICs). His discovery paved the way for development of prophylactic vaccines as well as tests to detect the infectious agent. A decade later, in 2018, the World Health Organization (WHO) announced an initiative for the elimination of cervical cancer, and the global strategy was formally launched on November 17, 2020, endorsed by 194 countries, India among them.

Elimination of a cancer! Not just any cancer but cervical cancer. The source of extreme physical misery, emotional strife and financial hardship. The second most common cancer among women in India, with approximately one lakh new cases every year and half as many deaths, one quarter of the global burden. The years of life lost with cervical cancer are more than with other cancers as these women are relatively younger, with active family and social responsibilities. As an oncologist, I have witnessed their suffering..women diagnosed in stage 4 who had developed urinary fistulas, where the odour would precede their entry into the consulting room, women who hesitated to mention the postmenopausal bleeding till the daughter-in-law noticed the stain on their saris, women with extreme sciatic and lumbar pain, obstruction to their ureters and renal failure… Then there were the luckier ones who got diagnosed at an earlier stage that was curable, but only with radical surgery or chemo- and radiation therapy… aggressive surgeries that take their toll, prolonged treatment schedules for radiation that deprive the caregivers of education or work, expensive chemo- and immunotherapy… And then, there were cases with recurrences despite our best efforts, requiring even more difficult exenteration procedures, stomas, etc. Yes, we could cure, we could provide symptom relief, even hormone replacement and other supportive care, but at a cost – physical, emotional, financial.

What made it even more tragic was the fact that this suffering was preventable. Since the 1940s, secondary prevention by regular Pap smear screening had been set up in the West, enabling detection of not just cancer but also its precancerous stages. The natural history of cervical cancer has been well documented for over a century. It has a long precancerous phase of 10-15 years termed cervical intraepithelial neoplasia (CIN) which can be detected by microscopic examination of cells collected on a slide by brushing the cervix. In this stage it is easily treated by simple day-care procedures that do not require removal of the uterus. In India and other LMICs we lacked the infrastructure and trained manpower to implement screening of all women over age 30 years even once in a lifetime, let alone the recommended 3-yearly intervals. Even in good tertiary centres, the laboratory placed a limit on the number of women that could be screened in a day. Outreach camps were conducted at regular intervals by gynaecologists and pathologists around the country trying to help the underprivileged, but these were merely a drop in the ocean. Even today, despite a national programme for screening with visual inspection (VIA), the screening coverage does not exceed 5%, and bringing women who test positive into the hospital for a confirmatory biopsy and treatment has extremely poor compliance.