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Cervical Cancer

Screen and Treat is an effective strategy for secondary prevention of cervical cancer especially in resource-constrained settings – Interview with Dr. Dipanwita Banerjee

January is Cervical Cancer Awareness Month. Read about cervical cancer screening and use of the HPV vaccine for prevention of disease.

Our guest is Dr. Dipanwita Banerjee, a Gynecologic Oncology Specialist at the Chittaranjan National Cancer Institute (CNCI) in Kolkata. In this interview, she sheds light on cervical cancer diagnosis and carves a path forward for Indian women to reduce the burden of cervical cancer.

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Thank you for being part of this initiative. Our readers would like to hear about your role at CNCI.

I joined as a Specialist in the Department of Gynecological Oncology at Chittaranjan National Cancer Institute in October 2012. I am involved in clinical, community based cancer detection, research and academic activities of the Department. Nearly 1000 new cases of various gynecological cancers register in the department every year. As a Specialist in the Department of Gynecological Oncology, CNCI, I am responsible for diagnostic workup of patients, making decisions on their management and performing surgeries when appropriate. I have keen interest in various research related activities in the field of gynecological cancers and have been working as a Principal investigator, Co Principal Investigator in various community based cervical cancer screening projects. I have been trained in cancer epidemiology and biostatistics from the International Agency for Research on Cancer, WHO, Lyon, France. I have also been trained in Good Clinical Practices and Ethics in Human Research. I am involved in teaching of the students and I participate in regular CMEs (Continuing Medical Education) held in the Department and the Institute.

What does the CNCI offer in terms of diagnostics, radiology and other oncology community awareness support in comparison to other hospitals in the area?

CNCI is the one of the National Cancer Institutes of India and is under the aegis of the Ministry of Health and Family Welfare, Government of India. The 220 bedded hospital has various disciplines and amenities to provide state-of-art oncology care. The work on second campus of the Institute is almost complete with an addition of 460 beds. The institute also has a preventive Oncology Division at Chandan Nagar, Hooghly district. The Department of Gynecological Oncology is involved in cervical cancer screening projects for last 2 decades and has successfully screened 55,000 women in last 8 years using the Visual Inspection with Acetic Acid method (VIA) and Human Papilloma Virus (HPV) DNA test. The institute is responsible for manpower training to successfully implement cervical cancer screening programs under the National Health Mission, Government of India.

Does the institute conduct cancer awareness and screening outreach programs? What tests do you run during screening? How do you ensure follow up?

The Department Of Gynecological Oncology, CNCI is working on cervical cancer prevention and management of both pre-cancers and cancers for the last 2 decades. Every month 15-20 cervical cancer screening camps utilizing 5% acetic acid for VIA and HPV DNA test are being conducted in the community as a service project funded by the Ministry of Health and Family Welfare, Government of India. For follow up, we do maintain a register and all data are recorded in epi info software version 6. All women who screen positive undergo further colposcopy, biopsy followed by treatment either at the community or at CNCI. Invasive cancer cases detected are referred to CNCI for appropriate management.

Are there any recommended guidelines for cervical cancer screening or do they vary between cities and hospitals?

World Health Organization (WHO) has prepared guidelines on screening for cervical cancers in low resource countries. The available PAP smear cytology or other non-cytological tests like VIA and HPV DNA test are being utilized for cervical cancer screening. The screening method may vary between the cities but the guidelines remain the same. The Federation of Obstetrics and Gynecological Societies of India (FOGSI) has also published a clinical practice guideline on cervical cancer screening which is more relevant to Indian settings.

VIA has been advocated as the test of choice in low resource settings but is also associated with high false-positive rates. What are your thoughts? How is cervical cancer screened for?

Yes it is true that VIA has high false positive rates, but for mass screening we need a test which is cheap, easy to perform, easy to train people and comes with immediate results, thus helping women to undergo further tests and also get treated at same time if required. Therefore, with a slight chance of over treatment, Screen and Treat is an effective strategy for secondary prevention of cervical cancer especially in resource-constrained settings where chance of dropout rate can be overruled by treating the woman at same visit. VIA is a useful method for treatment selection to identify those patients who can be treated by either cryotherapy or thermocoagulation at the community level.

Establishing a good quality screening program based on PAP smear cytology is difficult in an Indian scenario as we have limited numbers of trained cytopathologists in the country coupled with a significant inter-observer variation and a scarce number of laboratory services across the country. Whereas the future belongs to HPV DNA test, owing to high sensitivity and specificity for 13 high risk oncogenic HPV types, WHO is also recommending HPV DNA test as a primary test for cervical cancer screening if available and is working on an affordable test.

Do you recommend the HPV vaccine for your patient groups?

As a state government initiative, four states from India have already started administering a two dose HPV vaccine to schoolgirls between 10-14 years. The Indian Academy of Pediatrics has also incorporated the vaccine in its schedule.  At present the cost is a concern as parents have to buy the vaccine. The National Technical Advisory Group on Immunization has approved the vaccine but it will take a couple of years to be included into the immunization schedule.

I do recommend the vaccine and as a Principal Investigator at the CNCI site, have done an acceptability study on HPV vaccination on 555 girls. More than 98% girls have completed their second dose till date. The Serum Institute of India is working on an indigenous HPV vaccine and will soon be introduced as a multicentric Phase II/III clinical trial.

What are the different gynecological cancers that you see in your patient population? Do patients from urban and rural areas present tumors with different molecular subtypes? 

Every year, close to 8000 new cases are registered in the out-patient department of the Institute with follow up of another 35000 to 40000 patients. More than 80% of our patients are indigent and receive free treatment. All types of radical surgeries including radical vulvectomy with inguinofemoral lymphadenectomy are performed in our institute. As a part of a retrospective study, I observe a rising trend in endometrial cancers in the last 5 years. The data has not been analysed fully and will be available once it is published. The most common cancer we attend to at our institute is breast cancer and it is persistently rising all over India. There are very few referrals from the northeast region that suggests there is no obvious change seen in women attending the institute for treatment services. Both Population based Cancer Registry (PBCR) and HBCR (Hospital Based Cancer Registries) are functional at CNCI. The incidence of breast cancer is more frequent in urban population whereas cervical cancer is more frequently seen in remote areas of West Bengal. No difference has been noticed regarding the molecular subtypes in rural vs urban setting.

How about screening for biomarkers? 

Biomarkers are not used in breast cancer screening. Clinical breast examination, mammography, ultrasonography and MRI are being used as a screening tools depending on woman’s age, family history, BRCA positivity etc.

If there is one thing you would like to see incorporated in our health practices that could help improve diagnosis or treatment, what would it be?

For effective cancer control, awareness about vaccination in the society is of utmost importance. Media coverage, on billboards, radio and advertisements in social media will be helpful to create awareness about the fact that cervix cancer is preventable and can be cured if detected at pre-invasive or early invasive stage. Keeping a bowl of freshly prepared acetic acid to perform VIA in each gynecologist’s clinic and training them to detect acetowhite lesions and do colposcopy and biopsy would be highly effective to reduce the burden of cervical cancer.

Many thanks for your time. It has been a pleasure speaking with you.

Bio: Dr. Dipanwita Banerjee is a recipient of the prestigious John N Kapoor Travelling Fellowship on Gynecologic Oncology, Roswell Park Cancer Institute, Buffalo, New York. She is also a recipient of the Medal for proficiency in thesis work in the discipline of MS Gynecology and Obstetrics from IPGME&R, Kolkata. She has won many awards and presented papers in various national and international conferences including UICC World Cancer Congress 2014 and FIGO 2015.  Dr. Banerjee has worked as a Master trainer in cervical pre-cancer workshops in collaboration with the International Agency for Research on Cancer, WHO in India and abroad. She has 26 publications to her credit in various national and international peer reviewed journals including book reviews and book chapters. She is presently attached with various organizations in various capacities:  as an Executive Committee Member in Asia Oceania organization on genital infections and neoplasia, India; as Secretary, Oncology Committee, The Bengal Obstetrics and Gynecological Society; as Core committee member of FOGSI-FIGO Pratishruti Workshops on Cervical Cancer Prevention, 2017-18; as Member of Association of Gynecologic Oncologists of India (AGOI) and Member of Indian Society of Colposcopy and Cervical Pathology (ISCCP).

 

Disclaimer: Interviews are published unedited or with minimal changes.

 

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