This week’s edition of HealthTroopers, we interviewed Dr. Roopa Hariprasad, Gynecologist and Scientist at the Indian Council of Medical Research (ICMR) – National Institute of Cancer Prevention Research (NICPR). Dr. Roopa Hariprasad is involved in community-based screening and early detection of oral, cervical and breast cancers. We chatted with her to discuss the current status of cancer screening programs in India – what lessons can be learnt and how we can reduce the burden of cancer by improving screening methods.
Can you give our readers a brief description of your background and your current role at the National Institute of Cancer Prevention Research?
I am a Gynecologist by training and have worked in gynecological cancer research at the Institute Rotary Cancer Hospital, the cancer wing of All India Institute of Medical Sciences, Delhi. At ICMR-NICPR, I head the Division of Clinical Oncology. We run a Health Promotion Clinic, where we offer population-based cancer screening services in cervical, breast and oral in addition to other non-communicable diseases like hypertension and diabetes.
Tell us about ECHO and how it is being used?
Being a cancer prevention and research institute, we contribute to the Operational Framework of Management of Common Cancers, a set of guidelines released by the Ministry of Health and Family Welfare in August 2016 on population based cancer screening of three common cancers (oral, breast and cervical cancer). While engaging in this task, we got to know of the vast gap that exists in knowledge and skills required for cancer screening among the health care providers. So, we thought we could offer to share our knowledge to up-skill the existing work force in the government sector in cancer screening. Now it was impossible for us to do so only through contact training, which is highly resource dependent and time consuming. So, this is when Project ECHO (Extension for Community Healthcare Outcomes) came to our rescue, to leverage technology in the form of a web-based online knowledge sharing portal. ECHO is an online knowledge-sharing platform, which believes in moving knowledge (across health systems, cities, nations and continents) rather than moving patients or doctors. Through ECHO, we’re able to train various cadres of health care providers without either the trainers or trainees having to leave their work/ home space, thus reducing cost, time and efforts drastically. We use the ECHO platform to train health care providers from remote places who are interested to gain knowledge on cancer screening. It can be easily accessed on a desktop or laptop computer, tablet, or smartphone with broadband or wireless Internet connectivity.
Please also discuss capacity building of health care providers in cancer training using technology based learning?
Population based cancer prevention and screening is relatively new to our country. While the health care providers in the public health system are actively involved in maternal and child health activities, their training in prevention and early detection of cancer is limited. That is why it becomes imperative that we provide adequate training, before cancer screening is implemented in the country. Having offered technical support to the Ministry of Health and Family Welfare and having implemented a successful cancer screening Clinic on campus, we are confident that we can fill the gap in training in the government sector. But, traditional contact-training may not be feasible for various reasons, including time and resource constraints. This clearly necessitates the use of technology for training at this scale. This not only reduces cost involved in training, but also saves time and efforts. We use the ECHO model to impart knowledge on cancer prevention and screening. That is how we are now offering tailored certificate courses for various cadres of healthcare professionals. Introductory level courses are offered to medical officers and community health workers, including staff nurses, auxiliary nurse midwife and Accredited Social Health Activists, who are the front line health workers in the community. Advanced level courses are offered to gynecologists and dental surgeons.
Can you please comment about the recent national cancer screening guidelines released in India?
Government of India released the Operational Framework for the Management of Common Cancers. It details how three of the most common cancers i.e. cervical, breast and oral can be prevented by early detection and the screening modalities recommended for a country like India. Cervical cancer will be screened using the visual inspection by acetic acid (VIA), breast by clinical breast examination (CBE) and oral cancer will be detected by oral visual examination (OVE).
According to these guidelines, every woman between the ages of 30-65 years will be screened for cervical, breast and oral cancer, while men in the same age group will be screened for oral cancer. If screened to be positive, they’ll be referred to a higher facility for further evaluation and management. The screen negatives will be educated about the warning signs of cancer and called for re-screening after 5 years or whenever they have these signs. In India, the population based cancer screening is being piloted in about 150 districts.
How is Population-based screening being rolled out in India?
Population-based cancer screening will be rolled out by training the existing staff in the required knowledge and skills. As per these guidelines, the Accredited Social Health Activists (ASHA) worker, who is the frontline health worker, will build awareness regarding cancer screening and motivate the community; the staff nurses and auxiliary nurse midwives (ANMs) will conduct the screening at the primary health centre (PHC) and sub-center level, respectively. The screen positives will be evaluated by the medical officer, who’ll then refer them if required to the higher facility for further management.
What kind of outreach does screening of women’s cancers in rural India have today?
As of now, no organized screening facilities exist. But, things are improving rapidly after the release of the Operational Framework for Management of Common Cancers. Once the training of existing staff is completed, every health facility in India will offer cancer screening services, thus making it available to every woman in India, including in rural and other far-reaching locations.
We have read several reports how certain states in India are better equipped to diagnose and treat patients. What is being done by the center to improve the discrepancy in healthcare infrastructure between different geographic regions?
Health disparity exists to a large extent between states, even today as health is a state subject in India. Having said that, several executive bodies of the Ministry of Health and Family Welfare, such as National Health Systems Resource Centre are tirelessly working to guide and engage health facilities and their staff to leverage the funds available to them to include cancer screening amenities. Many sub-centers are being equipped and adequately staffed to convert them into Health and Wellness Centers (HWCs), available to every citizen of India, offering various health services, including cancer screening.
How willing are women in the rural areas to be proactive about screening?
The term “cancer” still instills fear in the community, because of various myths that abound. Cancer is often associated with imminent death. A cancer diagnosis still brings around gloom, completely ignoring the fact that various treatment modalities are available for treating cancer, depending on the stage of diagnosis. The financial burden associated with cancer treatment often makes the women to not seek medical assistance. In addition, there are certain social stigmas that are associated with cancer. While many consider it a “curse”, few also believe that it may come in the way of their matrimony. To avoid such unpleasant experiences, women often tend to evade cancer screening. That is where our front line health workers come to the fore. This is done by educating their communities on the benefits of cancer screening and many a times they accompany the women to the screening camps, literally going that extra mile!
Give us an example of low cost technology that is being used to screen for breast and cervical cancers in women?
In a Low and Middle Income Country (LMIC) like India, we are bound to use low cost technology to implement a huge program like population based cancer screening, for it to be successful and sustainable. While the western world has moved or is slowly moving to HPV testing as a screening module, this cannot be even thought of due to high cost of these tests. Therefore, in India VIA is the proposed test for screening cervical cancer, as this uses inexpensive acetic acid for the test, without major compromise in the sensitivity and specificity of screening. Similarly, we use clinical breast examination (CBE) for screening breast cancer, as opposed to mammogram.
What are some of the newer technologies that have been tested and developed for screening of cervical cancer in women?
There are many hand held, low cost colposcopes being tried in the research setting to evaluate the screen positives in the community, to avoid the transportation of women to a health facility thereby reducing the lost to follow ups. But to the best of my knowledge, they have still not reached the community.
Do any of the central or state insurance schemes support screening and diagnosis?
Ayushman Bharat Yojana or Pradhan Mantri Jan Arogya Yojana (PMJAY) is a centrally sponsored scheme launched in 2018, under the Ayushman Bharat Mission of the Ministry of Health and Family Welfare in India. This scheme aims at making interventions in primary, secondary and tertiary care systems, covering both preventive and promotive health, to address healthcare holistically. It is an umbrella of two major health initiatives namely, Health and Wellness Centres and National Health Protection Scheme.
How can a platform like “HealthTroopers” potentially help in increasing awareness about present day practices in women’s cancers in India.
HealthTroopers can definitely play a major role in creating cancer awareness. They can do so by providing education on healthy life style, explaining the ill effects of tobacco and alcohol, and imparting the benefits of screening. I strongly believe that this will have a strong influence on the society whereby the cancer burden could be substantially decreased.
‘Prevention is better than cure’ The saying may be old but is very relevant in this new context!!
Thank you Dr. Hariprasad for your time. Your insights are greatly appreciated.
Disclaimer: Interviews are published unedited or with minimal changes.