This week, London School of Economics and Yale graduate Pooja Yerramilli returns to explore the role and need for multidisciplinary approaches to global health and cancer research.
It is no secret that over half of all cancer deaths in low and middle-income countries (LMICs) are preventable or avoidable. Primary and secondary prevention have long been advocated as cost-effective means for controlling cancer. And, as Kuguru, et. al. rightly point out, our moral imperative to prioritize prevention efforts stems in part from the fact that cancers that should be avertible or treatable often become terminal when reported in late stages. Indeed, the most prevalent cancers in India fall into this category. Lung and oral cancers are preventable by risk factor (tobacco), as is cervical cancer (HPV infection). Moreover, cervical and breast cancers may be “curable” through such treatments as surgery, if detected early. Yet these four cancers together constituted almost 40% of all cancer cases and approximately 36% of all cancer deaths in India in 2008. These trends are consistent with numerous reports from the Indian state of Andhra Pradesh, which reaffirm that 75-80% of cancer cases treated through the Rajeev Aarogyasri Scheme (RAS) are diagnosed in advanced stages and therefore face lower survival rates.
The need to focus attention on mass prevention seems obvious, begging the question: why haven’t LMICs already effectively done it? As part of my research on the financing of cancer care and control in Andhra Pradesh, I investigated this question.
A review of legislation in India suggests that the central government has in fact long prioritized cancer prevention. In 1975, the government established the National Cancer Control Programme (NCCP), and shifted the program’s focus toward primary and secondary prevention in 1984. However, my conversations with government officials and health care providers indicated that cancer prevention strategies are inadequate on paper and even more inadequate in practice, due to myriad economic, social, and political factors. These discussions revealed that we cannot merely say “cancer prevention” is the most cost-effective means of controlling cancer, but must develop and identify specific prevention strategies that are the most cost-effective in LMICs. As two key informants detailed, cervical cancer screening methods are a prime example of the need and promise of such interdisciplinary research.
Pap smears have long been accepted in many high-income countries as an effective screening method for pre-cancers. Unfortunately, according to several oncologists I interviewed, mass screening programs which include Pap smears are nonexistent in Andhra Pradesh. The inaccessibility of screening may in part be attributed to inadequate infrastructure as well as social, cultural, and economic barriers.
In India, Pap smears are commonly seen as overly invasive and embarrassing. A woman who seeks a Pap smear is presumed to engage in sexual activity, which in India, is rarely openly discussed. This stigma not only discourages women from seeking Pap smears, but also affects the design of preventative programs. As many oncologists suggested, prevention efforts in Andhra Pradesh remain piecemeal, and are largely funded by independent charitable organizations and individuals. Several physicians confirmed that when they conduct health camps, they target married women for Pap smears, thus operating within the cultural stigma and insistence that only this cohort is at risk for developing cervical cancer. And because women must simultaneously work, manage household chores, and look after children, they seldom visit health camps or clinics until they can no longer ignore their symptoms. Thus, despite the efforts of many hospitals to raise awareness of pre-cancerous symptoms, Pap smear delivery rates remain low. As one study confirms, non-compliance and community participation are of primary concern when designing cervical cancer screening programs.
Even if these health care providers’ efforts to target symptomatic women were successful, several oncologists agreed that their initiatives could not truly qualify as screening. Screening by definition must entail the investigation of both symptomatic and asymptomatic individuals. Yet, according to one physician, in a country as large as India, the scaling up of Pap smears to cover the entire population may be financially infeasible.
These limitations seem to suggest that comprehensive and consistent cervical cancer prevention efforts in Andhra Pradesh are simply futile. However, recent research may provide alternative solutions. Several studies have compared the effectiveness of Pap smears with those of the recently innovated visual inspection with acetic acid (VIA) method and HPV DNA test in communities in Andhra Pradesh (and other LMICs). HPV DNA tests in particular may not only be more sensitive and specific than Pap smears, but also may reduce reliance on infrastructure and specialists. Therefore, such methods as self-collected HPV DNA tests may prove most suitable to regions such as Andhra Pradesh, which have inconsistent health infrastructure and a population reluctant to seek invasive tests at clinics due to cultural taboos.
Research currently under way is investigating the cost-effectiveness of these cervical cancer screening methods, to determine which are most scalable in resource-limited settings. The vast infrastructural, social, cultural, and economic barriers to access seem daunting, but multidisciplinary research may minimize some of these challenges and thereby improve health care delivery. The collaboration of researchers across such disciplines as biomedical sciences and health economics may facilitate the development of novel disease control methods while we also tackle the long term and fundamental health systems challenges that preclude consistent access to services across the cancer care and control continuum.
Pooja Yerramilli is a Yale graduate and MSc. candidate at the London School of Hygiene and Tropical Medicine and the London School of Economics. She has been involved in cancer advocacy efforts for several years, and was an active participant in policy discussions regarding smoking behaviors and insurance coverage of smoking cessation treatments at Yale. She recently worked with the Indian Institute of Public Health to complete a research project on the Financing of Cancer Care and Control in India.