Perspective Chapter: Cervical Cancer Elimination by 2030—The W.H.O Goal: Neo Challenges and Next Gen Solutions “TIT for TAT”—The Community Competency Model of Raj ©

Abstract

Cervical Cancer is the fourth most common cancer among women, worldwide. It accounts for 600,000 new cases per year, and 340,000 deaths globally (WHO 2020 data). It causes a lot of maladies and suffering for women, in the age group of 30–60 years, especially in the poor community of developing countries. Cervical cancer is a great public health problem and is a cause of grave concern for the health system in Low-Middle-Income Countries—LMIC. But cervical cancer is amenable for early detection and successful treatment of precancer stages. Human Papilloma Virus—HPV vaccines offer a high level of primordial prevention, against cervical cancer. Therefore, the World Health Organization, in 2018, has called for “Elimination of Cervical Cancer by 2030.” The objective is to reduce the incidence rate of cervical cancer to below 4/100,000, by the year 2030. This leads to many “Neo Challenges” and also opens the door for “Next Gen Solutions”. The author, with vast experiences in his Cervical Cancer Screening Projects of IARC/ WHO, at Tamil Nadu, India, during 2000–2007, advocates a strategy called “TIT for TAT—The Community Competency model of Raj©.”

1. Introduction

Cervical Cancer accounts for about 600,000 incident cases and 340,000 cause specific deaths, per year, worldwide, according to IARC/WHO, for the year 2020 [1]

Cervical Cancer ranks 7th among the most common cancers in general and among women, it is ranking as the 4th highest, worldwide, as per the data available with the WHO, for the year 2020 [2].

As far as Mortality is concerned, it is the 9th most common cancer-causing deaths among all cancers and the 4th leading among cancers in women, during 2020 [3].

2. Methodology

2.1 Efforts towards elimination of cervical cancer: the favorable features of the disease

The Human Papilloma Virus—HPV, is the known causal factor for the Cervical Cancer. HPV consists of more than 180 strains. But only a few are oncogenic. The HPV 16, 18 are the high-risk oncogenic strains. When a woman enters sexual life, she is exposed to the HPV infections. But these infections undergo self-clearance, due to the good immunity that may exist in the woman. In some cases, the HPV infection persists for a long time, even up to 10 years. If there are oncogenic strains like the HPV 16, 18, the cervical cells undergo a pathological process called dysplasia or Cervical Intra epithelial Neoplasia—CIN. These are the Pre cancer lesions. At this stage, the disease is detectable by the application of screening tests.

The screening tests which are available:

1. Visual Inspection with—Acetic acid VIA, Lugol’s Iodine VILI

2. Pap smear test

3. HPV tests (DNA—Hybrid capture—Genotyping)

These tests have acceptable levels of Sensitivity and Specificity to detect CIN lesions.

2.2 Precancer lesions: diagnosis and management protocols

2.2.1 See & treat

The Health care provider, who does the screening, subjects the woman to VIA testing. If the VIA test is positive, then the woman is treated by Cryotherapy/Thermal ablation/Cold coagulation/Laser/Cold knife conization/LEEP or LLETZ.

2.2.2 See: test & treat

The woman is subjected to VIA testing. If the result is positive, another screening test is applied, by means of Pap smear or HPV testing. Even if one of these tests is positive, the woman undergoes Precancer treatment, by modalities listed above.

2.3 The 3 eligibility criteria for elimination, are fulfilled by cervical cancer

2.3.1 Criteria 1: effective vaccines

The HPV Vaccines which are available in the Health care system are the Bivalent, Quadravalent and Nonovalent vaccines. They are prophylactic vaccines given to Girls between the age group 9–15 years, in doses as recommended by their Health care providers. The protective value of these vaccines are claimed to be more than 70%.

2.3.2 Criteria 2: early diagnosis at precancer stages

Various screening methods are available for the early diagnosis of Cervical Cancer, especially in the Precancer stages. The methods are VIA, Pap smear and HPV tests. These tests have high accuracy with acceptable levels of Sensitivity and Specificity. Further confirmation is done by Colposcopy and Cervical Biopsies. Hence, sure methods for diagnosis of pre cancer stages are available and the effective treatment of these lesions, prevent the stages of invasive Cervical Cancer. This is an important criterion for fulfilling the eligibility of Cervical cancer, for Elimination.

2.3.3 Criteria 3: effective treatment for cervical precancer

The various treatment modalities available for the treatment of cervical precancer lesions:

1. Cryotherapy

2. Cold coagulation

3. Thermal ablation—electric cautery

4. Laser ablation

5. Cold knife conization

6. Loop Electrosurgical Excision Procedure—LEEP/Large Loop Electrosurgical Excision of Transformation Zone—LLETZ

All the above methods are very efficient for the treatment of Cervical precancers, resulting in Cure rates, up to 80–90%.

3. The WHO declares cervical cancer Elimination by 2030

3.1 Milestones

1. May, 2018—The Director General of WHO, gave a call at WHA for “Elimination of Cervical Cancer by 2030” [4].

2. November 2020, The WHO launched the Global strategy to “Accelerate the Elimination of Cervical Cancer”.

3. Signatory countries should achieve an Incidence rate of < 4 per 100,000 women per year, by 2030.

4. The IARC/WHO provides all the support needed to achieve this goal by 2030.

3.2 The targets set by WHO, for cervical cancer elimination by 2030

3.2.1 HPV vaccination

90% of girls to be fully vaccinated with the HPV vaccine by the age of 15 years [4].

3.2.2 Cervical cancer screening

70% of women to be screened by VIA/Pap smear /HPV tests, by the age of 35 years, and again by the age of 45 years.

3.2.3 Precancer and cancer treatment

90% of women with precancer lesions, to be treated. 90% of women with invasive cancer to be treated and offered Palliative care.

3.2.4 Challenges for cervical cancer screening, in low- and middle-income countries

1. Low levels of Awareness.

2. Lack of Knowledge.

3. Indifferent and negative Attitude.

4. Poor Health seeking Behavior.

5. Very poor levels of Translation of Knowledge into Practice.

6. Screening—Acceptability, Availability, Affordability.

7. Pre cancer Treatment—the availability and problems in utilization.

8. Socio Economic barriers.

9. Cultural and Political barriers.

4. Discussion

Cervical Cancer Elimination by 2030

Neo Challenges and Next Gen Solutions

“TIT for TAT”

The Community Competency Model of Raj ©

“TIT”

Trained manpower—Indigenous resources—Translational research—TIT

“TAT”

Targets achievement—Action plan—Transformational research—TAT

The author recommends

“TIT” as the Next Gen solutions

“TAT” as the Neo challenges

The Community Competency Model of Raj ©, for achieving Cervical Cancer Elimination by 2030.

These recommendations are based on the “Proof of Concept ”, Cervical Cancer Screening project of IARC/WHO, at Christian Fellowship Community Health Center, Ambilikai, Dindigul district, Tamil Nadu, India, during 2000–2007. The Author was the Principal Investigator of this project, which achieved a reduction in the Cervical Cancer Incidence by 25% and mortality due to Cervical Cancer by 35%, in a period of 5 years [5].

Brief description of the model “TIT for TAT”:

NEXT GEN SOLUTIONS—“TIT”

“TIT”

T = Trained manpower

I = Indigenous resources

T = Translational research

NEO CHALLENGES—“TAT”

“TAT”

T = Target achievement

A = Action plan

T = Transformational research

4.1 Next gen solutions = “TIT”

4.1.1 T = Trained manpower

It is very important and prudent, to have the entire team, trained in their role, from authorized persons/organizations, and get certified, which are approved and accepted by the implementing authorities. Assessment exams are to be conducted at the start, concurrent and terminal levels to assure Internal Quality Control and Quality Assurance.

4.1.1.1 Doctors

To be trained in Colposcopy, Cryotherapy and LEEP/LLETZ, procedures. The author had his trainings with the fellowship from IARC/WHO, at RCSI—Dublin, RCOG—London, SCCPS—Singapore and served as a Hon. Consultant to the Cervical Cancer Screening Program of The Ohio State University Medical Center.

4.1.1.2 Nurses/female health workers

To be trained in Visual Inspection methods with Acetic acid—VIA, Lugol’s Iodine—VILI Pap smear techniques, Endocervical curettage, Colposcopy guided Biopsy techniques, Cervical cells collection for HPV testing, technical assistance during treatment procedures and Counseling methods. Maintenance of clinical instruments, equipment, sterilization, autoclaving and laundry, which are very important tasks for the nurses.

4.1.1.3 Lab technicians

To be trained in Cervical Pathology and HPV testing procedures. The Medical Records staff needs to be trained in appropriate computer applications, Data management, data analysis, interpretation and publishing techniques.

4.1.1.4 Health educators/counselor

The participation of women for the Cervical Cancer Programs and compliance with the treatment and follow-up procedures, largely depends upon the level of Knowledge, Attitude and Practice. Even though, they may have adequate knowledge regarding Cervical Cancer and its prevention, the proportion of women who will translate “Knowledge into Practice” is relatively small.

4.1.1.5 Knowledge—present/practice—absent

The main barriers to achieving the above ambitious goal, are the lacunae and deficiencies in the conversion of knowledge into practice, by the women, who are otherwise well informed about the prevention of Cervical Cancer, as a 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, by the virtue of his vast experiences, in planning and implementing one of the largest cervical cancer screening programs in India, has conceptualized “The STAR P6 Health Education Model of Raj© (6), for successful conversion of “Knowledge into Practice”.

The STAR P6 Health Education Model of Raj© (Figure 1) [6].

Figure 1.

The STAR P6 Health Education Model of Raj© [6].

4.1.1.6 The “P 6” concepts

The STAR approach can be better explained under 6 aspects of the program:

1. Projection

2. Perception

3. Promotion

4. Performance

5. Perseverance

6. Pursuit

The sole motive of the STAR approach is to encourage young women and girls for the HPV Vaccination and Screening of Cervical Cancer, applying the above mentioned 6 criteria, which involves a series of programmed and tailored steps in Health Education.

Figure 2.

Spectacles with lens attached—Indigenous Cervix scope.

4.1.2 I = Indigenous

4.1.2.1 Indigenous resources

The stability and sustainability of the Cervical Cancer Screening programs largely depend upon the Availability and Affordability of Resources. Instead of depending on distant and foreign resources which may be very costly and unaffordable, it is always prudent to develop locally available and affordable Indigenous resources, which would be functional and effective, even in limited and low resource settings. Some of the examples, that the Author has used in his WHO project are listed below:

1. Puppet shows and Role plays instead of Electronic media, especially in the hilly, mountainous, tribal areas, which are non-motorable and where electricity is not available. The programs are conducted with the help of Generators which are diesel fuelled.

2. Colposcopes are binocular and locally made, rather than sophisticated, hi-tech digital Colposcopes. Spectacles with a magnifying lens, were tried for examination of the Cervix, and it was satisfactory and successful (Figure 2).

3. Cryotherapy equipment which are locally made and uses Carbon di Oxide or Nitrous Oxide, under high pressure, targeted with a Gun, for freezing the cervical dysplasia lesions (Figure 3).

4. Silver nitrate crystals for hemostasis after Cervical biopsy, as a substitute to Monsel’s paste, which is not available in many places and also is very costly for the limited budget programs.

5. Development of Pathology Laboratory, exclusively for the screening program, with a well-trained technician, in Cervical Pathology.

4.1.3 T = Translational research

The flow of knowledge, skills, technology, training, manpower, money and materials from a resource-rich organization, to resource poor and resource needed organization, is envisaged in Translational Research.

The author mobilized resources from Ireland, UK, France, Singapore and USA, to get trained in Cervical Cancer Screening and treatment procedures. Experts from these countries, came to the project sites of the Author, in Tamil Nadu, India, to conduct workshops and Community Based Screening programs in the villages.

Thus the 3 concepts of “TIT”—Trained manpower—Indigenous resources—Translational research, were the Neo Gen solutions.

Figure 3.

Indigenous Colposcope and Cryotherapy Gun.

4.2 Neo challenges = “TAT”

4.2.1 T = Targets achievement

The WHO has set the Goal of Cervical Cancer Elimination by 2030. More than 190 countries are signatories to this declaration and have committed to the achievement of the Targets, set as follows:

1. The first is for 90% of girls to be fully vaccinated against the human papillomavirus (HPV) by the age of 15 years.

2. The second is to ensure that 70% of women are screened using a high-performance test by the age of 35, and again by age 45.

3. The final target is that, 90% of women with pre-cancer receive treatment and for 90% of women with invasive cancer to have proper treatment and palliative care.

4.2.2 A = Action plan

4.2.2.1 For the successful implementation of “Cervical Health Evolution Cascade—CHEC”

1. Every 30,000 population, should have a “Community Health Center—CHC”. This should be accessible to all, and equipped with basic equipment, instruments, essential drugs for Primary Health Care.

2. Each CHC should have 2 Female Community Health Nurses—CHN.

3. From every 5000 population, 2 Female Community Health Volunteers—CHV, should be identified and well trained in the practical aspects of Cervical Cancer screening and treatment (Figure 4).

Figure 4.

Cervical Health Evolution Cascade—CHEC.

4.2.3 T = Transformational research

“Start from what you know, Build on what you have and Achieve on what you should” ….Raj—the Author

The Health Care System tilts towards the Prevention of Diseases and Promotion of Health from the Curative and Remedial care (Figure 5).

Figure 5.

The tilted balance for “Transformational Research”.

5. Conclusion

The main focus of this chapter is “Papilomaviridae Infections and Cervical Cancer—The Neo Challenges and Next Gen Solutions.” The take home message is that HPV prevalence varies among region to region, communities to communities. The strains which infect the women are also multiple, varying in different countries and communities. The oncogenic strains of HPV are highly prevalent in Africa, Asia and American regions. Therefore, Cervical Cancer has a high incidence in these continents. The WHO has initiated a Goal—Elimination of Cervical Cancer by 2030.

The Neo challenges faced are listed under the phrase “TAT”

(Target—Action plan—Transformation).

T—Targets are the 90-70-90 of WHO. 90% of the girls in age group 9–15 to be fully immunised against HPV. 70% of the eligible women to undergo Screening for Cervical Cancer. 90% of the Precancers to be treated and palliative care to be offered for Cervical Cancer patients.

A—Action plan to create Primary Health Care infrastructure, in the communities through their full participation, contribution and ownership

T-Transformational Research, which shifts the paradigm of Health Services from Treatment based to Prevention focused, by use of Appropriate Technology for Health.

The Next Gen solutions are listed under the phrase “TIT”.

(Trained manpower—Indigenous resources—Translational research).

T—Trained manpower emphasizes on adequate training for the locally available and permanently employed Doctors, Nurses, Lab technicians, Health educators, Counselors and other paramedical staff of the programs, rather than relying on the specialists and temporary staff from external sources.

I—Indigenous resources, equipment, instruments and technology, are the accessible, affordable and available infrastructures for the efficient functioning of the programs, on a long-term basis.

T—Transformational research is based on shifting of the paradigm of Health care services from Treatment mode to Prevention mode.

Therefore, for the achievement of the WHO Goal of “Elimination of Cervical Cancer by 2030”, the author, strongly recommends the TIT for TAT—The Community Competency Model of Raj© which effectively addresses the “Papilloma viridae infections and Cervical Cancer—The Neo Challenges and Next Gen solutions”, both at regional and Global levels.

Acknowledgments

The author records his boundless love to Mary Ethalya Thiarathi, granddaughter, a baby angel of 2 years, for allowing him to write this chapter amidst so much pampering and playing. My sincere thanks to my family Ms. Celin Rani, Er. Rixon Raj, Dr. Rijula Raj, Er. Pavith Raj, for their excellent care and support, during my long hours of work, for editing this book and compiling this chapter.

The author is pleased to serve as Chief Editor, for his 7th book in this series, with the InTech Open Access Publishers. Their combination has the credentials of contributing to the “Advances in Academics and Revolution in Research”, in the most pertinent, high priority fields of, “Cervical Cancer Prevention and HPV Vaccination”, thus serving the Science and Society at Supreme levels.

We thank the Almighty, for keeping us safe and healthy, in these difficult times of war and pandemics, to serve for the community, in thoughts, words and deeds.

Conflict of interest

“The authors declare no conflict of interest.”