Preventive and Social Medicine: Dr. Rajamanickam Rajkumar Talks to IntechOpen About Current Issues in the Field

Dr. Rajamanickam Rajkumar, the editor of IntechOpen's book "Topics on Cervical Cancer With an Advocacy for Prevention" and author of one of the chapters titled "Community Based Cancer Screening – The 12 “ I ”s Strategy for Success", kindly accepted to give an interview talking about his career, studies and current issues regarding cervical cancer, in an attempt to push forward both research and advocacy on prevention methods. According to the US National Library of Medicine, cervical cancer is the third most common type of cancer in women world-wide. The World Health Organisation (WHO) states that the world has a population of 2,337 million women ages 15 years and older who are at risk of developing cervical cancer. Current estimates indicate that every year 529,828 women are diagnosed with cervical cancer and 275,128 die from the disease. Using crude incidence rates, cervical cancer ranks as the 2nd most frequent cancer among women between 15 and 44 years of age. After age-standardization, cervical cancer ranks as the 2nd most frequent cancer in women in the world.

In view of the above-mentioned gruesome statistics regarding cervical cancer, Dr. Rajkumar, a respected researcher in the field, gives us a thorough overview on methods of prevention and other useful information to fight cervical cancer among women.

Dr. R. Rajkumar on his career and professional accomplishements

IntechOpen: Tell us something about your activity as a researcher and your areas of interests.

Dr. Rajkumar: My mission is to "reach the unreached" through education, empowerment and application of Preventive and Social Medicine to attain holistic health among the "Underserved" and "Unserved". My vision is “ Cancer Prevention Empowered Primary Health Care Services ” for all the villages in India through sustainable community support, training and partnership. My areas of interest are prevention of cervical cancer and the establishment of community oncology services within medical colleges.

IntechOpen: Why did you decide to dedicate your career to educating and promoting issues addressing cervical cancer?

Dr. Rajkumar: In 1993, fresh from my postgraduation in Public Health I got the opportunity to work in a Christian Fellowship Community Health Center, Ambillikai, Dindigul Dt, Tamil Nadu, India. I was appalled to see a number of young women who came to this hospital with complaints and being diagnosed with cervical cancer. Most of these women were having advanced stages of this disease. In spite of all our efforts to treat the disease, they used to die leaving their young children orphaned. I developed collaborations with the International Association of Cancer Registries (IACR) and I established the first Rural Population Based Cancer Registry in 1996 (IACR Membership Number 585). In 2000, we published the Rural India accounts for a very high incidence rate for cervical cancer (66.4 / 100 000). In 2001 we started a screening program for cervical cancer, in collaboration with the IARC / WHO. We were able to screen more than 30 000 women, mainly because of our strategies which were affordable, accessible and acceptable. We were able to diagnose about 2000 cases of pre-cancers and all the women were treated. In 5 years more than 80% of the women were proved to be free of the disease by histological confirmation. This cost effective strategy of using VIA (Visual Inspection with AceticAcid) as screening tool and offering cryotherapy for pre-cancers proved to be the best approach for control and prevention of cervical cancer in low and limited resource settings. This vast experience is my source of inspiration in dedicating my career to the cause of the world-wide crusade against cervical cancer.

IntechOpen: How many publications in the field of Gynecology have you edited up until today?

Dr. Rajkumar: I have published 13 papers in international journals and I edited a book with IntechOpen.

About cervical cancer and prevention methods

IntechOpen: Can you describe the main stages of cervical cancer development.

Dr. Rajkumar: HPV infection leads to the development of pre-cancer lesions which may develop into invasive cancers.

IntechOpen: What are the main symptoms of cervical cancer and most common treatments for it?

Dr. Rajkumar: Early cervical cancers usually don't cause symptoms. More advanced cancers can cause one or more of these symptoms:

-Abnormal vaginal bleeding-Bleeding that occurs between regular menstrual periods-Bleeding after sexual intercourse, douching, or a pelvic exam-Menstrual periods that last longer and are heavier than before-Bleeding after menopause-Increased vaginal discharge-Pelvic pain-Pain during sex

Infections or other health problems may also cause these symptoms. Only a doctor can tell for sure.

Treatments:

Surgery is an option for women with Stage I or II cervical cancer. Depending on the extent of the disease the following surgeries are performed:-Radical trachelectomy: the surgeon removes the cervix, part of the vagina, and the lymph nodes in the pelvis.-Total hysterectomy: the surgeon removes the cervix and uterus.-Radical hysterectomy: the surgeon removes the cervix, some tissue around the cervix, the uterus, and part of the vagina.-Radiation therapy: this is an option for women with any stage of cervical cancer. Radiotherapy is offered in 2 forms:a) External radiation therapy: a large machine directs radiation at your pelvis or other tissues where the cancer has spread.b) Internal radiation therapy: a thin tube is placed inside the vagina. A radioactive substance is loaded into the tube.-Chemotherapy: for the treatment of cervical cancer, chemotherapy is usually combined with radiation therapy. For cancer that has spread to distant organs, chemotherapy alone may be used.

IntechOpen: What are the groups of population most at risk of developing from cervical cancer? What is the incidence of women currently suffering from cervical cancer in India?

Dr. Rajkumar: The incidence ranges from 10 per 100 000 to 64 per 1 000 000 in India. The risk factors for cervical cancer are:

• HPV infection• Lack of regular Pap tests• Smoking• Weakened immune system• Sexual history• Using birth control pills for a long time• Multiparity• DES (diethylstilbestrol)

IntechOpen: It is known that viruses, once contracted, can either trigger a certain disease or can remain latent for the rest of a life. Does that apply to HPV as well? Can we be carriers of the virus without ever developing the disease?

Dr. Rajkumar: Having an HPV infection or other risk factors does not mean that a woman will develop cervical cancer. Most women who are at risk for cervical cancer may never develop it.

IntechOpen: Can HPV be transmitted in more ways rather than just through sexual intercourse?

Dr. Rajkumar: Sexual Intercourse is the only known route of transmission of the virus. Although sharing tampons and pads among women in certain communities (rural or socioeconomically backward) can transmit the virus.

IntechOpen: What can we do to protect ourselves from contracting the HPV virus?

Dr. Rajkumar: Having protected intercourse using male condoms is the only effective way of protection from HPV transmission and cervical cancer. The role of vaccines is yet to be proved to be effective in low socioeconomic rural populations in India.

IntechOpen: According to some research, nutrition is an important factor in terms of prevention against HPV. What are your thoughts about that?                                                           

Dr. Rajkumar: In one of our published papers we concluded that malnutrion in rural women may contribute to the persistance of an HPV infection.

IntechOpen: Can HPV be transmitted from mother to child during pregnancy? If the mother is infected with HPV, can it affect the pregnancy or the normal development of the fetus?

Dr. Rajkumar: Yes. Mother to fetal transmission is possible during pregnancy.There are no known adverse effects from transmission.

Preventing cervical cancer

IntechOpen: HPV vaccination is only effective if administrated when the HPV virus has not been contracted yet. Is this statement true? Also, have the vaccines any side effects?

Dr. Rajkumar: Prophylatic vaccines are effective only in uninfected individuals. Therapeutic vaccines are available to clear an established HPV infection of the cervix. There are no proven side effects of the vaccine.

IntechOpen: Is the PAP smear test the best option for HPV screening? Also, in your opinion, in rural, underdeveloped areas, how can financial restrains be tackled in order to enable the local populations to undergo screening tests?

Dr. Rajkumar: PAP smear has shown to be the most afforadable screening test with comparable accuracy for large scale screening programmes. VIA is an alternate method which is affordable.

Empowering and educating rural women, educating their families and social support by income generating schemes will be fundamental to the success of rural screening programs. Health insurance schemes can also be implemented at community levels. The local governments can be approached for funds.

IntechOpen: How often should we undergo screening tests? How many times a year?

Dr. Rajkumar: Screening for HPV by regular PAP tests beginning at age 21, or within three years of the first time of a sexual intercourse — whichever happens first is the reccommendations of the CDC, USA. If PAP tests are normal, then repeat it every 3 years. Abnormal PAP smears need further investigations and appropriate interventions.

IntechOpen: What is Liquid-based cytology? What screening test do you recommend?

Dr. Rajkumar: It is a technique which refines the cervical cells collected for accurate reading and interpretation. Wherever possible liquid based cytology can be carried out.

IntechOpen: Should men get tested too? Also, should the male community be included in initiatives aimed at raising awareness on HPV since men can be carriers of the virus, often without being conscious of it?

Dr. Rajkumar: Some doctors will test men who fall into a high-risk category - men who have sex with men and those who have HIV may be tested for HPV. Evaluating the risk of HPV-related diseases of the anal canal and penis in men is becoming more and more common.

IntechOpen: A study suggests that prostaglandin in semen may fuel the growth of cervical and uterine tumours and that affected women may benefit from the use of condoms. Can you comment on that?

Dr. Rajkumar: Receptor targeted approach to treatment, especially COX inhibition, has been proposed in models of cervical cancer. By extension of this principle condoms can prevent the PG rich semen from enhancing growth of these cancers although it still has to be extensively investigated.

Future projects

IntechOpen: Are there any new, cervical cancer raising awareness projects you are about to embark on in the foreseeable future?

Dr. Rajkumar: Yes. I have 4 projects:

1. Uterine Cervix Cancer Screening Treatment Outreach Program – U CAN STOP (a community based project by medical students)2. Sexual & Menstrual Hygiene Education & Awareness for Screening for HPV to prevent CaCx – SMASH CaCx (a women empowerment project by high school students in villages)3. Society for Colposcopy and Cervical Pathology in South India - COLPOSI (Association of Doctors, Nurses & Social Workers for CxCa prevention and control)4. Telepathology project in collaboration with the Ohio State University Medical Center, USA

IntechOpen would like to thank Dr. Rajkumar for sharing his valuable knowledge in the field of cervical cancer. By promoting free education we are one step closer to the final goal of giving full, free of charge access to valuable information to be used in fighting numerous deadly diseases afflicting nations world-wide.

Sources:

US National Library of Medicine

WHO - World Health Organisation