**Abstract**

Cervical cancer is a major cancer affecting 5.3 million women annually, worldwide, and is responsible for about 2.7 million deaths per year. More than 85% of the incident cases occur in developing countries. Cervical cancer is a totally preventable cancer, if diagnosed in the precancer stages and treated effectively. HPV vaccination has been introduced in many countries. Effective screening and treatment programs are available in many health settings. Posttreatment histopathological follow-up is done for 3–5 years. Cure from precancer condition and prevention of invasive cervical cancer are thus attained. But the main hurdle in achieving the above ambitious goal is the lacunae and deficiencies in conversion of knowledge into practice by the women who are otherwise well informed about the prevention of cervical cancer, as result of massive inputs in the field of health education. Thus, the screening participation and compliance to precancer treatment remain low. This barrier in translational knowledge should be overcome efficiently. **The author, from his vast experience in planning and implementing one of the largest cervical cancer screening programs in India, has conceptualized** "the STAR model P6 principles of Raj" for successful conversion of "knowledge into practice."

**Keywords:** cervical cancer, screening, treatment, low participation, translational knowledge to practice

### **1. Introduction**

Cervical cancer is the fourth common cancer among women in the world, and it accounts for about 530,000 new cases and 270,000 deaths annually, as reported in 2012. About 85% of these cases occur in developing countries. It represents 12% of incident cancers in women and 7.5% deaths due to cancer in women.

In a developing country like India, about 122,000 new cases of cervical cancer and about 67,400 deaths due cervical cancer are reported, every year, as per data of 2017. It is the second most frequent cancer among women of reproductive age group.

India also has the highest age standardized incidence of cervical cancer in South Asia at 22, compared to 19.2 in Bangladesh, 13 in Sri Lanka, and 2.8 in Iran [1, 2].

### **2. The role of HPV**

HPV is a necessary cause for cervical cancer [3].

More than 115 types of HPV are present and 18 are high-risk carcinogenic types for cervical cancer. Other than this, HPV-16 is the most common high risk in cervical cancer [4].

Primary prevention involves a risk reduction approach through behavioral intervention for sexual and healthcare-seeking behavior or through mass immuni-

*HPV and Cervical Cancer Control Programs: Effective Translation of Knowledge into Practice*

screening test, prompt diagnostic investigations, appropriate treatment, and

The objective of cervical screening/secondary prevention is to prevent invasive cervical cancer from developing by detecting and treating women with CIN2/3 lesions, and the effectiveness is determined by reduction in incidence and mortality. The critical components of a screening program are an acceptable good-quality

There is a strong support from nonexperimental studies in developed countries such as Denmark and Finland that the incidence and mortality of cervical cancer

Ensuring high levels of participation and sufficient healthcare infrastructure and human resources are important for a screening program to succeed [18]. It is also important for screening to be guided by equity considerations for those who are more vulnerable or with lesser access to healthcare services because of social,

Recent screening recommendations for specific age groups as per the American

• At the age of 21–29 years: Cytology (Pap smear) alone every 3 years.

• At the age of >65 years: No screening recommended if adequate prior

• A quadrivalent vaccine which protects against subtypes 16 and 18 plus

quadrivalent plus subtypes 31, 33, 45, 52, and 58 (which cause about 15% of

• The HPV vaccine is ideally recommended to vaccinate boys and girls at age

1.Population-level impact and herd effects following the introduction of human

*From the abstract:* We did a systematic review and meta-analysis of the populationlevel impact of vaccinating girls and women against human papillomavirus on HPV infections, anogenital wart diagnoses, and cervical intraepithelial neoplasia grade 2+ (CIN2+). Our results show compelling evidence of the substantial impact of HPV

• A 9-valent vaccine which protects against the same subtypes as the

• At the age of 30–65 years: Human papillomavirus virus (HPV) and cytology

Cancer Society (ACS) screening guidelines are as follows: [1, 2].

contesting every 5 years or cytology alone every 3 years.

screening has been negative and high risk is not present.

• A bivalent vaccine which protects against subtypes 16 and 18.

HPV Vaccines that aims to prevent cervical cancer are:

11–12 years, but vaccination can begins at age 9.

• At the age of 21 years: Screening is recommended.

zation against high-risk HPV [15].

*DOI: http://dx.doi.org/10.5772/intechopen.91313*

posttreatment follow-up [16].

6 and 11.

**107**

cervical cancers).

**6. The effect of HPV vaccination**

papillomavirus vaccination programs

can be reduced by screening [17].

economic, or demographic factors [19].

In cervical cancer cases, HPV prevalence was in the range of 87.8 to 96.67%, in a study in India. In women without cervical cancer, HPV prevalence varied from 7.5 to 16.9%.

The worldwide prevalence of HPV infection, in normal woman, is between 9% and 13%.

### **3. HPV infection worldwide**

HPV is associated with 50,000 new cases of cervical cancer and 250,000 associated cervical cancer deaths, worldwide, each year [5]. It also causes vulvar, vaginal, anal, and penile cancers and precancerous lesions of vulva/vagina, genital warts, and respiratory papilomatosis [5–7]. HPV infections are asymptomatic, and generally, individuals are not aware of being infected, thus facilitating the spread easily and unknowingly [5].

At least 50% of men and women will acquire genital HPV infection during their lifetime [8].

All sexually active women are infected with HPV at least once during their lifetime, and the highest prevalence is seen soon after the onset of sexual activities [9, 10].

A majority of episodes of type-specific HPV infection resolve spontaneously within 2 years, but this may be followed by an infection with a new type [7].

HPV transmission exclusively occurs following skin-to-skin contact with an infected partner. Sexual intercourse is not necessary, and the virus can be transmitted through sexual foreplay [5].

HPV can only replicate in the stratified squamous epithelium. HPV infection is the most common sexually transmitted diseases [11]. The major risk factor for HPV infection is sexual behavior, including early age of onset of sexual activity, multiple sexual partners, and coinfection with HIV [12].

Although the determinants of risk for persistent infection and progression to invasive diseases are not fully understood, persistence appears to be related to HPV type and concurrent infection with multiple virus types [12].

The prevalence and distribution of HPV types in the general population as well as in cervical neoplasia vary with geographic region and by the grade of disease [13].

### **4. Screening for cervical cancer**

Secondary prevention involves screening for precancerous lesions and treating them. The three screening modalities are cytology, visual inspection, and HPV test.

### **5. Prevention of cervical cancer**

HPV is necessary for the development of cervical cancer. Therefore, preventing HPV infection can prevent cervical cancer. This can be achieved by complete abstinence from sexual activity or by a vaccine [14].

*HPV and Cervical Cancer Control Programs: Effective Translation of Knowledge into Practice DOI: http://dx.doi.org/10.5772/intechopen.91313*

Primary prevention involves a risk reduction approach through behavioral intervention for sexual and healthcare-seeking behavior or through mass immunization against high-risk HPV [15].

The objective of cervical screening/secondary prevention is to prevent invasive cervical cancer from developing by detecting and treating women with CIN2/3 lesions, and the effectiveness is determined by reduction in incidence and mortality.

The critical components of a screening program are an acceptable good-quality screening test, prompt diagnostic investigations, appropriate treatment, and posttreatment follow-up [16].

There is a strong support from nonexperimental studies in developed countries such as Denmark and Finland that the incidence and mortality of cervical cancer can be reduced by screening [17].

Ensuring high levels of participation and sufficient healthcare infrastructure and human resources are important for a screening program to succeed [18]. It is also important for screening to be guided by equity considerations for those who are more vulnerable or with lesser access to healthcare services because of social, economic, or demographic factors [19].

Recent screening recommendations for specific age groups as per the American Cancer Society (ACS) screening guidelines are as follows: [1, 2].


HPV Vaccines that aims to prevent cervical cancer are:


### **6. The effect of HPV vaccination**

1.Population-level impact and herd effects following the introduction of human papillomavirus vaccination programs

*From the abstract:* We did a systematic review and meta-analysis of the populationlevel impact of vaccinating girls and women against human papillomavirus on HPV infections, anogenital wart diagnoses, and cervical intraepithelial neoplasia grade 2+ (CIN2+). Our results show compelling evidence of the substantial impact of HPV

**2. The role of HPV**

*Human Papillomavirus*

cervical cancer [4].

**3. HPV infection worldwide**

spread easily and unknowingly [5].

transmitted through sexual foreplay [5].

**4. Screening for cervical cancer**

**5. Prevention of cervical cancer**

abstinence from sexual activity or by a vaccine [14].

multiple sexual partners, and coinfection with HIV [12].

type and concurrent infection with multiple virus types [12].

7.5 to 16.9%.

lifetime [8].

[9, 10].

**106**

and 13%.

HPV is a necessary cause for cervical cancer [3].

More than 115 types of HPV are present and 18 are high-risk carcinogenic types

In cervical cancer cases, HPV prevalence was in the range of 87.8 to 96.67%, in a study in India. In women without cervical cancer, HPV prevalence varied from

The worldwide prevalence of HPV infection, in normal woman, is between 9%

HPV is associated with 50,000 new cases of cervical cancer and 250,000 associated cervical cancer deaths, worldwide, each year [5]. It also causes vulvar, vaginal, anal, and penile cancers and precancerous lesions of vulva/vagina, genital warts, and respiratory papilomatosis [5–7]. HPV infections are asymptomatic, and generally, individuals are not aware of being infected, thus facilitating the

At least 50% of men and women will acquire genital HPV infection during their

All sexually active women are infected with HPV at least once during their lifetime, and the highest prevalence is seen soon after the onset of sexual activities

A majority of episodes of type-specific HPV infection resolve spontaneously within 2 years, but this may be followed by an infection with a new type [7]. HPV transmission exclusively occurs following skin-to-skin contact with an

HPV can only replicate in the stratified squamous epithelium. HPV infection is the most common sexually transmitted diseases [11]. The major risk factor for HPV infection is sexual behavior, including early age of onset of sexual activity,

Although the determinants of risk for persistent infection and progression to invasive diseases are not fully understood, persistence appears to be related to HPV

The prevalence and distribution of HPV types in the general population as well as in cervical neoplasia vary with geographic region and by the grade of disease [13].

Secondary prevention involves screening for precancerous lesions and treating them. The three screening modalities are cytology, visual inspection, and HPV test.

HPV is necessary for the development of cervical cancer. Therefore, preventing

HPV infection can prevent cervical cancer. This can be achieved by complete

infected partner. Sexual intercourse is not necessary, and the virus can be

for cervical cancer. Other than this, HPV-16 is the most common high risk in

vaccination programs on HPV infections and CIN2+ among girls and women, and on anogenital warts diagnoses among girls, women, boys, and men, programs with multi-cohort vaccination and high vaccination coverage had a greater direct impact and herd effects.

mortality due to cervical cancer by 35%, in a period of 7 years—2000 to 2007,

*HPV and Cervical Cancer Control Programs: Effective Translation of Knowledge into Practice*

was done at the Christian Fellowship Community Health Centre Society,

with the International Agency for Research on Cancer (IARC), WHO.

He has served as the principal investigator for the first 3 years, and the project

Ambilikkai, Dindigul district, Tamil Nadu, India, and was in technical collaboration

Proof of concept (POC)—The Lancet Publication 2007, the author's paper.

Rengaswamy Sankaranarayanan, Pulikkottil Okkuru Esmy, Rajamanickam

Cervical cancer is the most common cancer among women in developing countries. We assessed the effect of screening using visual inspection with 4% acetic acid (VIA) on cervical cancer incidence and mortality in a cluster-randomized con-

Of the 114 study clusters in Dindigul district, India, 57 were randomized to one round of VIA by trained nurses and 57 to a control group. Healthy women aged 30– 59 years were eligible for the study. Screen-positive women had colposcopy, directed biopsies, and, where appropriate, cryotherapy by nurses during the screening visit. Those with larger precancerous lesions or invasive cancers were

Cervical cancer incidence and mortality in the study groups were analyzed and compared using Cox regression taking the cluster design into account, and analysis was by intention to treat. The primary outcome measures were cervical cancer

Of the 49,311 eligible women in the intervention group, 31,343 (636%) were screened during 2000–2003; 30,958 control women received the standard care. Of the 3088 (99%) screened positive, 3052 had colposcopy and 2539 directed biopsy. Of the 1874 women with precancerous lesions in the intervention group, 72% received treatment. In the intervention group, 274,430 person years, 167 cervical cancer cases, and 83 cervical cancer deaths were accrued compared with 178,781 person years, 158 cases, and 92 deaths and in the control group during 2000–2006 (incidence hazard ratio 075 [95% CI 055–095] and mortality hazard ratio 065

referred for appropriate investigations and treatment.

Effect of visual screening on cervical cancer incidence and mortality in Tamil

strongly recommends the STAR model P-6 principles of Raj©.

**9. Background**

Nadu, India: a cluster-randomized trial. Lancet 2007; 370(9585):398-406.

*DOI: http://dx.doi.org/10.5772/intechopen.91313*

Quote:

Rajkumar, et al.

**10. Summary**

trolled trial in India.

incidence and mortality.

**12. Results**

[047–089]).

**109**

**11. Methods**

Ref: *Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis*

*Drolet M, Bénard É, Pérez N, Brisson M, on behalf of the HPV Vaccination Impact Study Group. The Lancet. Open access*

2.Human papillomavirus (HPV) vaccination significantly reduces the frequency of genital HPV 16 and 18 infections and cervical intraepithelial neoplasia grade 2+ (CIN2+) in young women and shows signs of herd effects with a reduced frequency of anogenital warts in both young women and men, a recent study showed.

As cited in infectious diseases.

9/16/2019 HPV vaccination programmes reduce HPV infection, precancerous lesions with potential crossover and herd effects | News for Doctor, N.

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