India: Cervical Cancer Screening
Updated: Sep 2, 2019
Nimmi Ramanujam, PhD, Director
The goal of my trip to India in May 2015 was to learn about cervical cancer screening from various stakeholders, and how technology interventions can benefit current programs. The Tamil Nadu government has been recognized as having implemented the most comprehensive cervical cancer-screening program in India. What is so interesting about prevention programs for cervical cancer is that it is so highly dependent on the geographical location and the resources available to tackle it. In India, and especially Tamil Nadu, the government has taken the initiative to use Visual Inspection with Acetic acid (VIA) as the primary mode of screening in the general female population in contrast to cytology (Pap smear), which is used in the western world. The argument made against the use of the Pap smear is the need for infrastructure and human resources, to process and read the slides, respectively. VIA on the other hand simply involves looking at the cervix under acetic acid staining and it is truly emblematic of point of care in that the patient does not need to wait for a result. If women are VIA positive, then they are referred to a tertiary center where they would get a biopsy to confirm the presence of disease and followed up with the appropriate type of therapy.
My first stop in Chennai was at the Adayar Cancer Institute where I collaborate with Dr. Malliga the head of preventive oncology. Dr. Malliga has a program where she is the primary colposcopist at the cancer Institute but has a group of sisters she has trained who take mobile screening vans to outlying and remote villages to perform VIA on the general female population. They essentially work as a team of two (one sister and one medical officer) to perform VIA in a school setting and a large number of women are recruited to undergo the procedure as well as education on cervical cancer. Women who are positive are referred to the closest hospital that offers the appropriate services. This is an excellent example of the scale up model that Tamil Nadu has established. But with every good deed, there are new challenges and the ones faced by Dr. Malliga and her challenges are twofold: First, only a portion of the women who are screened as VIA positive actually go to secondary or tertiary care. Attrition after screening is not atypical and this poses a challenge in raising the standards of cancer prevention. Second, because VIA is subjective and does not have high quality assurance, women who are referred as VIA positive to secondary or tertiary care often do not have disease and not only create a bottleneck in the hub (tertiary center) but also may distrust the health system if there is discordance between initial and final findings. Dr. Malliga expressed that she believes that the screening programs have been effective in achieving scale but the impact is yet to be full reached. During our discussions it was clear that a technology that could take pictures and was easy to use and that would allow for teleconnectivity would enable her to provide immediate feedback on VIA conducted at the point of care and also provide virtual mentoring and quality assurance.
I also had the privilege of visiting the state of Tamil Nadu health government’s office where I met both the administrators of the program as well as the colposcopist who provided the large-scale training needed for the community health providers. They asked great questions particularly in regards to why our transvaginal digital colposcope (TVDC) would actually be beneficial over a simple magnifying glass that the sisters use to view the cervix. This was an excellent question and generated a testable hypothesis that we should definitely explore in the field - what value does our colposcope add in the field given that it will never be as cheap as the magnifier? I think we would need to compare whether a health worker trained with the TVDC would in fact triage patients more effectively compared to standard VIA.
One of the highlights of my visit to Chennai was a meeting with Dr. Shanta, the chairperson of the cancer institute. She lives in a beautiful but modest home right within the Cancer Institute. Oh a piece of important trivia, she is the niece of Nobel laureate S. Chandrashekar and the grandniece of the Nobel laureate C.V. Raman. She was definitely a young at heart 87 year old who had spent many years as a gynecologic surgeon and oncologist and an incredibly insightful individual who is forward thinking and truly committed to providing the best healthcare to the truly marginalized. Shanta and the sisters who do VIA at the camps in the rural villages. Dr. Shanta worked with me to setup a mock gynecological exam so we could test out the device! The sisters were excited to try our TVDC and I was pleased that it was fairly straightforward for them to operate the device and the phone to which it was attached. I left the device with them for the weekend and they had lots of constructive input on refining the device for their use. One of the interesting pieces of feedback that I had not anticipated was their need for a tablet rather than a small phone. They wanted to record patient health history information, view images and be able navigate and choose information that they could do more easily on a tablet than on a phone. Sterilization of something that is inserted into the vagina was also considered important and they did not want a throw away sleeve but rather something like the speculum where you could change the sleeve and re-use it again after sterilization.
The final part of my visit took me to the HealthCare Innovation Technology Center (HTIC), which is a joint initiative between the Indian Institute of Technology, Madras and the Dept. of Biotechnology where integration of engineers, clinicians, government and industry under one umbrella has been created to spur the translation of innovative health care technologies to serve the local population. Their dynamic leader, Dr. Mohan shared some of the work that they are already doing in this space. Particularly noteworthy was the design and development of a surgical unit to enable accessibility to high quality cataract surgery to rural India. Pilot project of 486 surgeries have been successfully completed in collaboration with Sankara Nethralaya. What is distinct about the HTIC is the local capacity and intelligence that they are building to create technologies for Indians by Indians.
I was lucky to be able to have great companions during my visit to India. Jeff Moe, from the Duke Global Health Institute traveled with me to Chennai and came to the Cancer Institute and took many pictures of the TVDC in action and helped me with a variety of logistical challenges that inevitably came up throughout the day! Suneeta Krishnan who is the India project director for the Research Triangle Institute (RTI) helped arrange the meetings with the state health government’s office and with HTIC and has tremendous insight into the local challenges associated with cervical cancer screening in India. Her efforts on the ground to address this important health challenge have enabled her to create partnerships and collaborations to really mobilize the different stakeholders to improve the current ecosystem such that screening and treatment of cervical pre-cancers and cancers can become more affordable and accessible to as many women as possible.