The cervical cancer puzzle

There is a big push in India to vaccinate adolescent girls against human papillomavirus (HPV) which causes cervical cancer. HPV Information Centre, which puts down cervical cancer as the second leading cause of deaths among women in India. The vaccine, which comes at Rs 3,000 per jab, is a big business. Each child needs at least two doses. Market research shows that global HPV vaccine market is likely to grown to USD 3.5 billion by the end of 2025, up from USD 2.0 billion in 2016. The market finds additional prospects in young boys who, too, need to be vaccinated as they are reservoirs of the virus and could infect the girls.

Countries, however, are divided on this front.

But HPV vaccine is contentious

In India, the central government continues to debate whether the vaccine should be included in the universal immunisation programme despite recommendations of the National Technical Advisory Group on Immunisation, an advisory body constituted by the government itself. Trials carried out in India have been mired with controversy as they resulted in deaths of eight girls in 2008. A PIL was filed in the Supreme Court and it is quite likely that the government would be able to take a decision on the inclusion of this vaccine in the immunisation programme only after the verdict.

Recently, a person used a false name and affiliation to Karolinska Institutet in Sweden to publish a paper in Indian Journal of Medical Ethics, saying that HPV vaccine was the reason for recent increase in the number of cases of cervical cancer in parts of Sweden. According to media reports, the paper has been retracted and Karolinska Institutet has clarified that this person does not work for them.

Dip in cervical cancer cases 

There is another conundrum. If we go by data, there is evidence that between 2006 and 2016, there has been a decrease in cancers caused by infectious agents such as cervical cancer despite an overall increase in cancer cases across the globe. These findings have been published in the journal JAMA Oncology on June 2. This trend has also been seen in India where cervical cancer was, historically, the most predominant of cancers.

A study published in 2009 in Indian Journal of Medical Research shows that in urban population-based cancer registries such as those in Bengaluru, Bhopal, Chennai, Delhi and Mumbai, there has been a significant decrease in cervical cancer. For example, the data shows that in urban areas like Chennai, the reduction in age adjusted rate was from 42.3 per 100,000 population in 1982-83 to 22.3 in 2004-05.

This happened without using HPV vaccine.

But if this is the case, should we even go in for vaccination? At the recently organised 1st Conference on Environmental and Occupational Determinants of Cancer: Intervention for Primary Prevention, this question was asked to the panelists who justified vaccination saying that reduction is seen only in urban areas and vaccination is important to protect people in the rural areas. This is supported by the fact, which the paper in Indian Journal of Medical Research also showed, that in rural areas such as Barshi, the decline was merely from 23.5 (in 1988-89) to 22.8 (in 2004-05).

But the problem is that the vaccine offers protection only from two strains of HPV. Other than the virus, other risk factors include early marriage, multiple pregnancies, poor genital hygiene of both men and women, poor healthcare facilities, lack of testing facilities, poor diet and smoking.

These risk factors are modifiable and instead of depending on vaccine, improving the environment might be a better strategy. If these worked in, what are now, the urban areas in India, they would surely work across the country. As of now, most of the uptake of the vaccine is in urban areas, where it is not needed.

Health India