-By Dr Suman Singh
Cervical cancer is caused by the human papilloma virus, it begins in the cervix which is the lower part of the uterus. Here there is uncontrolled growth of the cells which displaces normal healthy tissue causing abnormal intermenstrual/post coital bleeding and discharge. Ultimately it spreads to the surrounding structures leading to morbidity and death.
How big is the problem?
Every 9 minutes one Indian woman loses her battle to cervical cancer. India accounts for approximately 20%of HPV related cancers worldwide. Mortality rate of HPV related cancers is 60%.
Who is at risk of cervical cancer?
Young age at first intercourse, those with greater number of sexual partners ,those whose partners have had multiple partners, those who smoke, have poor hygiene, who had induced abortions and those who have used birth control pills over a long period of time. Around 31 % of women are HPV positive within the first year of sexual intercourse and 50% within 3 years.
What are the signs of cervical cancer?
Early cervical cancer usually has no signs which are why screening is so important. Those who are symptomatic will have vaginal spotting or bleeding after sexual intercourse, in between menstrual cycles or after menopause and they may also have foul smelling discharge which does not go away even after treatment.
How is cervical cancer diagnosed?
The most common screening test is the Pap smear test where the doctor will collect a sample of the cells from the cervix and send it for examination. Unfortunately less than 5% of women are regularly getting themselves screened in India. Cervical cancer is the second most common cause of death in women after breast cancer and most affected individuals are unaware that they are infected, hence may unknowingly spread the virus.
What is HPV?
It is a small non enveloped ds DNA virus which affects the squamous epithelial cells. More than hundred types are identified of which 30 to 40 infect the genital area of women and men. The low risk types causing genital warts are HPV 6 and 11 and the higher risk oncogenic types causing cancer are HPV 16,18 ,31,33,45,52,58.These 9 serotypes may cause 55 million cases of HPV cancers and disease in India. HPV causes more than cervical cancer. These high risk serotypes are responsible for 98%of cervical cancer, 95%of vulvar cancer, 77% of vaginal cancer and 73% of anal cancer.
How common is HPV infection?
It is quite common.80% of women acquired an HPV infection in their lifetime. Over 80% of HPV infections are transient, asymptomatic and resolve spontaneously so for every one million women infected with HPV, 1600 develop invasive cervical cancer if left untreated. Since cervical cancer takes around 10 to 15 years to develop it is important to vaccinate young adults in their teens and early life in order to prevent the disease later .In women apart from cervical cancer it causes anal cancer, vulval cancer, oro-pharyngeal cancer, vaginal cancer, anogenital warts and recurrent respiratory papillomatosis.
HPV affects only women or men also?
As per global study 6.5 out of 10 men have an HPV infection. Men are highly susceptible and have a low rate of seroconversion following HPV Infection. It causes oro-pharyngeal, anal, penile cancers, anogenital warts and recurrent respiratory papillomatosis in men.
Need for prevention of cervical cancer?
Vaccines produced by recombinant DNA technology help in creating neutralizing antibodies thereby improving the natural immunity and clearance of the HPV virus. The vaccine efficacy is 100% against genital warts and vulval and vaginal pre cancers and 90% against cervical cancer when taken correctly. Impressive declines were detected within four years after vaccine availability in various countries like Australia, United States, and Denmark etc.
What is the recommendation for Vaccination?
Young girls less than 14 years of age need only two doses of the vaccine at 0 and 6 months. Above 14 years of age 3 doses of the vaccine are required at 0, 2 and 6 months interval. All three doses should be given within a one year period .It is an intramuscular injection in the deltoid region, the second dose should be administered at least one month after the first dose and the third dose should be administered at least three months after the second dose. Vaccination is not given in pregnancy but it's perfectly safe and encouraged to be taken post-delivery during breast feeding. There is no need for booster dose and three doses give lifelong protection. Cervical cancer vaccine has been included in the National Immunization Program of India for less than 15 years of age in 2023.
Is it WHO recommended?
Apart from WHO, many esteemed health bodies all over the world have strongly advocated use of vaccine and it has been recommended by American College of Obstetrics and Gynecology, American Cancer Society, Royal College of Obstetricians and Gynecologists, Canadian National Advisory Committee, Canadian Pediatric Society, Board of Health Denmark, Joint committee on vaccination and immunization UK, Australian technical advisory group on immunization and New Zealand immunization technical forum. FDA and CDC have also strongly recommended the vaccine and it has been licensed as safe and effective and included in the immunization program of more than 100 countries world over. In India it is strongly recommended by the Federation of Obstetrics and Gynecological society of India, Indian Academy of Pediatrics and the Association of Physicians of India.
It is recommended for use between 9 to 45 years, in the older women it protects against new infections and boosts the otherwise waning suboptimal natural immunity.
Contraindications?
Hypersensitivity to the active substances or to any of the excipients (yeast/ latex allergy), pregnancy and severe acute illness.
What is new?
The Gardasil 9 is a nona valent vaccine which is effective against nine strains as compared to the previous quadrivalent vaccine which was effective against four strains and therefore is more effective. It’s a gender neutral vaccine which can reduce HPV related cancers by 99-100% in both men and women if the overall coverage in both genders is 80%.It is considered to be a high impact vaccine as it can avert one death for every 50 people vaccinated.9 Valent HPV may be used to continue or complete the vaccination series in patients who started with 4 valent or 2 valent HPV vaccine. The dosing schedule is the same as the quadrivalent vaccine.
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