With India's first HPV vaccine set to roll out in 2023, experts hope women finally have a fighting chance against cervical cancer

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Back in 1987, when the Mumbai-based non-profit Cancer Patients Aid Association (CPAA) initiated a campaign to conduct the papanicolaou or Pap smear test, a screening procedure for cervical cancer, it met with stiff resistance, remembers its CEO Alka Sapru Bisen. "Women were reluctant to get it done... they didn't even want to be physically examined by a surgeon. We've come a long way since." But the fight against cervical cancer - an otherwise preventable disease, according to doctors - is still far from won in the country.

While the incidence and mortality rate of the disease has declined over the past three decades, a Lancet study released last December revealed that India still accounts for the highest number of cervical cancer cases in Asia. According to the study, of the 40 per cent of total deaths from cervical cancer, 23 per cent occurred in India, followed by China (17 per cent). Recent estimates from the HPV Information Centre, which compiles, processes, and disseminates country-specific information related to human papillomavirus (HPV), a virus that can cause cervical cancer, show that 511.4 million Indian women aged 15 years and above, are at the risk of contracting the disease. It remains the second highest cancer - after breast cancer - responsible for premature deaths in the country with 77,348 women (estimates of 2020) dying of it annually.

There is however hope now, in the form of a home-grown vaccine.

A vaginal swab is taken and the smear is tested for the cancer-causing HPV strain during a Pap smear test

For the last few months, Serum Institute of India - the force behind the AstraZeneca COVID vaccine - has been working to launch CERVAVAC, the country's first indigenously developed HPV vaccine. It is slated to roll out between July and September this year. "This is going to be the first step towards ensuring a cervical cancer-free future in the country," Bisen tells mid-day.

Cervical cancer develops in the cervix, which is the lower and narrow end of the uterus that connects to the vagina. According to Dr Sewanti Limaye, director of oncology and precision medicine, Sir HN Reliance Foundation Hospital, the main cause of cervical cancer is the human papillomavirus, which is a sexually
transmitted infection.

According to the Indian Council of Medical Research, HPV types 16, 18, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68, 73 and 82 are classified as carcinogenic to humans. Persistent HPV infection [especially HPV types 16 and 18] is known to cause the cervical cancers. It also causes a significant proportion of anogenital and head and neck cancers… Among HPV attributable cancers, 80 per cent are cervical cancer, ICMR stated in a research paper titled Epidemiology of human papillomavirus related cancers in India: Findings from the National Cancer Registry Programme, published last year.

Dr Sewanti Limaye, Dr Sonal Kumta and Dr Suresh Advani

"However, not all women who have HPV will develop cervical cancer," says Limaye, "There are other risk factors that increase a woman's likelihood of developing cervical cancer, including smoking; having a weakened immune system; a family history of the disease, multiple sexual partners and sexual intercourse at a young age."

Dr Suresh Advani, senior consultant-medical oncology, SL Raheja Hospital, Mahim, says that while breast cancer mortality is still the highest in India, the incidence of cervical cancer continues to be a cause for concern in poorer regions of the country. "In states like Bihar, Jharkhand, Assam, West Bengal and Uttar Pradesh, cervical cancer is still the reason for highest mortality [among women]," says Advani, "One of the primary reasons is poor genital hygiene among men and women, and a lack of awareness about it. Water shortage in these regions is often linked to the fight against the disease." There are also cultural and social barriers, making it difficult for women to access healthcare services, particularly for reproductive health issues.

Symptoms of cervical cancer may not be noticeable in the early stages of the disease, which is why regular cervical cancer screening, says Limaye, is important. "But, as the cancer progresses, symptoms include abnormal vaginal bleeding, such as bleeding between periods, or after intercourse, after menopause; pain during sexual intercourse; unusual vaginal discharge; pelvic pain or pain during urination, and changes in menstrual cycles," says Limaye.

An awareness session, as part of the Eliminate Cervical Cancer Campaign, led by Cancer Patients Aid Association (CPAA) in rural Maharashtra

The problem is that most women continue to defer screening and testing. "Cervix is an organ that is absolutely exposed, making it very easy for doctors to examine," says Dr Sonal Kumta, senior consultant obstetrics and gynaecology, Fortis Hospital, Mulund. "But, culturally there continue to be reservations around physical examination and the Pap smear test. Patients will still not come for a regular, annual check-up, ignoring all the symptoms and instead choosing to opt for over-the-counter medicines. This leads to delayed diagnosis and treatment."

The granddaughter of a 78-year-old Mumbaikar, who was diagnosed with cervical cancer in March 2022, shares that her grandmother had not just ignored vaginal bleeding, but refused to tell anyone in the family about it. "We realised something was wrong, when her loo visits didn't seem normal… she would urinate very frequently. Early March last year, she complained of painful urination, and even developed fever. We assumed she had a urinary infection, and decided to visit a doctor," says the Mumbai resident, who did not wish to be identified for the story. Tests showed blood in the elderly woman's urine samples, after which she was directed to a gynaecologist, who following an examination and series of tests, concluded that she had Stage 3 cervical cancer. The family was directed to Tata Memorial Hospital in Parel, where she was advised five chemo and 30 radiation sessions, both external and internal, over a period of five weeks. While she is now fit as a fiddle, her granddaughter admits that this could have gone another way, considering her age. "When she first started experiencing abnormal bleeding, she put it down to her indulging in spicy food. It never occurred to us that she could have had cancer."

The HPV vaccine, says Limaye, is highly effective at preventing the infection. "The vaccine is recommended for girls and boys between the ages of nine and 14, but can also be given to people up to age 45… By vaccinating children at a young age, before they become sexually active and are exposed to HPV, India can greatly reduce the risk of HPV infection and cervical cancer," she says. Dr Kumta adds that while the ideal group is adolescents, older people who are sexually active, can also take the vaccine. "Even if you may have got an HPV infection, it could protect you against other strains of the virus."

CPAA CEO Alka Sapru Bisen (in red) and Dr Dhananjaya Sarnath, executive director, research studies, at the non-profit's Mahalaxmi lab where samples are screened for HPV infection. Pic/Anurag Ahire

Until now, HPV vaccines available in the market were manufactured by foreign firms - Gardasil, marketed by Merck, and Cervarix, marketed by Glaxo Smith Kline - and cost anywhere between Rs 2,000 to Rs 4,000 per dose. With a three-dose recommendation, the total vaccination cost would total Rs 10,000, making it unaffordable for most.

Bengaluru-based author and brand consultant Shalaka Kulkarni, 30, who has already taken the first two doses of the Gardasil vaccine (each shot cost Rs 4,000), says she first learnt about the vaccine from a gynaecologist friend. "On both the occasions that I took the vaccine, I didn't experience any side-effects or soreness." Kulkarni who has one last dose left, has been trying to convert friends and peers. "The more you talk about it, the more people are going to become aware."

With the HPV vax yet to make it into the country's national immunisation programme, the CPAA three years ago, decided to lead a campaign to fight the infection, and help stem the growing burden of cervical cancer in India. "Annual screening of healthy individuals is very much part of the work that we do." While cervical cancer screening has been part of the initiative for 35 years, the CPAA team also began HPV screening among healthy individuals in vulnerable groups in 2020. "These include sex workers, rag pickers and manual labourers… we have been also been reaching out to other NGOs," she says, adding, "We have our own lab [in Mumbai], so we do the processing here under the guidance of Dr Dhananjaya Sarnath, who leads this programme for us." Every screening camp, says Bisen, is preceded by an awareness session. This has helped catch HPV strains early among the vulnerable group. They also provide free HPV vaccination for eligible school-going girls in municipal schools and those belonging to the lower-strata in rural Maharashtra. "The vaccine guarantees 90 per cent absentia from cervical cancer, and is the best step forward," she feels. Consent is taken from the parents before the inoculation drive - this includes co-opting them in the fight against cancer, and addressing the stigma and shame associated with it. Bisen, who has carried out a similar drive in a few municipal schools in Mumbai, admits that the urban population is still reluctant.

Bengaluru-based author and brand consultant Shalaka Kulkarni recently took the first two doses of the Gardasil vaccine, which cost her around Rs 4,000 per shot

CPAA has vaccinated over 22,000 young girls and women, in the last three years, 80 per cent of them in their early teens. "We've covered several rural pockets, including Solapur, Chikhli, Buldhana, Panvel, and Usgaon." Since the vaccines available in the market are expensive, Bisen admits that the drive required rigorous funding. "As of now, the Aditya Birla Group has been supporting our initiative as part of its CSR project… a cheaper vaccine will allow us to take our campaign far and wide. We will be able to inoculate more people, and help work towards preventing the disease."

When it rolls out, Serum Institute of India's CERVAVAC is expected to cost, anywhere between R200-R400. Bisen believes that the government will eventually make it part of the national vaccination policy. In 2018, the World Health Organisation called for a global action towards elimination of cervical cancer (a threshold of 4 per 100,000 women-year) and set 90-70-90 targets to be achieved by 2030. "The indigenous vaccine will make this goal possible."

23 per cent
Percentage of cervical cancer deaths that occurred in India out of the 40 per cent total deaths from the disease, according to a study published last December in Lancet

How you can prevent hpv infection

HPV vaccination: The HPV vaccine is highly effective at preventing HPV infection, which is the main cause of cervical cancer. It is recommended for girls and boys between the ages of 9 and 14, but can be given to anyone up to age 45.

Regular cervical cancer screening: Regular screening for cervical cancer can detect precancerous changes in the cervix, which can be treated before they develop into cancer. The recommended screening method available with all gynaecs is the Pap test, which is typically recommended every three years for women aged
21 to 65.

Safer sex practices: Practicing safer sex, by using condoms and refraining from multiple sexual partners, can reduce the risk of HPV transmission and cervical cancer.

Lifestyle changes: Maintaining a healthy lifestyle, not smoking, eating nutritious food and focussing on genital health can also reduce the risk of cervical cancer.
Dr Sewanti Limaye, director of oncology and precision medicine, Sir HN Reliance Foundation Hospital

Symptoms of advanced disease

. Abnormal vaginal bleeding (between periods, after intercourse, after menopause)
. Pain during sexual intercourse
. Unusual vaginal discharge Pelvic pain or pain during urination

Can men take the vaccine?

According to the Center for Disease Control and Prevention, men can get HPV by having vaginal, anal, or oral sex with someone who has the virus. It also spreads through close skin-to-skin touching during sex. HPV can spread even when a person with the infection has no signs or symptoms. "Symptoms can appear years after you have sex with someone who has the infection. This makes it hard to know when you first got it." Among men, it can lead to penile, anal and oropharyngeal cancers. There is currently no approved test for HPV in men, but getting vaccinated with the HPV vaccine and using condoms can lower the risk.