- Email: [email protected]
Strategies for reducing risk of cervical cancer in adolescents in developing countries – A view point
INJMS-56; No. of Pages 4 indian journal of medical specialities xxx (2015) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/injms
Review Article
Strategies for reducing risk of cervical cancer in adolescents in developing countries – A view point Neha Dahiya a,*, Anita S. Acharya b, Damodar Bachani c, Manish Kumar Goel d a
Junior Resident, Department of Community Medicine, Lady Hardinge Medical College & Associated Hospitals, New Delhi, India b Professor, Department of Community Medicine, Lady Hardinge Medical College & Associated Hospitals, New Delhi, India c Director Professor, Department of Community Medicine, Lady Hardinge Medical College & Associated Hospitals, New Delhi, India d Associate Professor, Department of Community Medicine, Lady Hardinge Medical College & Associated Hospitals, New Delhi, India
article info
abstract
Article history:
Cervical cancer is the fourth commonest cancer across the globe. Although various health
Received 18 August 2015
programs initiated to screen and treat this cancer in developed countries have reaped
Accepted 6 October 2015
benefits in terms of reduction in mortality, yet poor access to screening and to management
Available online xxx
services continues to account for the vast majority of deaths in women living in low and middle income countries. The present review highlights the various risk factors that
Keywords:
predispose adolescents to cervical cancer and the 'risk reduction' strategies that need to
Cervical cancer
be implemented for the benefit of 'next generation' women.
Adolescents
# 2015 Published by Elsevier B.V. on behalf of Indian Journal of Medical Specialities Trust.
HPV
1.
Introduction
Cervical cancer is a major public health problem in many developing countries and the absolute burden is expected to increase in future unless effective prevention measures are undertaken. Globally, cervical cancer is the fourth most common cancer in women with nearly 528,000 new cases reported in 2012.1 Nearly 85% of the global burden occurs in the less developed regions, where it accounts for almost 12% of all female cancers. High-risk regions, with estimated Age
Standardized Rate (ASRs) over 30 per 100,000 include Eastern Africa (42.7), Melanesia (33.3), Southern Africa (31.5) and Middle Africa (30.6). There were an estimated 266,000 deaths from cervical cancer worldwide in 2012, accounting for 7.5% of all female cancer deaths.1 Cervical cancer is one of the leading cancers among Indian women with estimated 123,000 new cases and 67,477 deaths in 2012.1 It has been seen that the persistent infection with one of the 15 oncogenic types of Human Papilloma Virus (HPV) is the cause of almost all cases of cervical cancer and its precursor, cervical intraepithelial
* Corresponding author at: Department of Community Medicine, Lady Hardinge Medical College & Associated Hospitals, New Delhi 110001, India. Tel.: +91 9968910438. E-mail address: [email protected] (N. Dahiya). http://dx.doi.org/10.1016/j.injms.2015.10.003 0976-2884/# 2015 Published by Elsevier B.V. on behalf of Indian Journal of Medical Specialities Trust.
Please cite this article in press as: Dahiya N, et al. Strategies for reducing risk of cervical cancer in adolescents in developing countries – A view point, Indian J Med Spec. (2015), http://dx.doi.org/10.1016/j.injms.2015.10.003
INJMS-56; No. of Pages 4
2
indian journal of medical specialities xxx (2015) xxx–xxx
neoplasia (CIN). HPV infection is very common in young women in their early phase of sexual activity. Persistent infections and precancerous stage are established, typically within 5–10 years, from less than 10% of new infections but fortunately, invasive cancer arises over many years, even decades, in a minority of women with precancerous lesions, with a peak risk at about 35–55 years of age.2 A significant proportion of CIN, if not detected and treated, progresses to invasive cervical carcinoma over a period of 10–20 years owing to the effect of other cofactors.3 Cervical cancer is a multi-etiology disease and there are several risk factors, which are associated with it, and in India, majority of affected women have these risks factors. Most HPV infections regress rapidly without causing clinically significant disease. Several studies have quoted that it is not very uncommon to find cervical cancer in women younger than 20. A study conducted in United States, which covered 92% of the population, showed that for women less than 40 years of age, 78% of cervical cancer cases involved women aged 30–39 years, 21% were among women aged 20–29 years, and the remaining 1% were diagnosed in women less than 20 years of age. This study also showed that between 1999 and 2008, there were 3063 cases of cervical cancer each year. On average, there were 14 cases per year among women aged 15–19, and 125 cases per year among women aged 20–24 years.4 The prevalence rate among adolescents is increasing, reflecting changes in sexual behavior associated with biological factors during adolescence. A survey conducted among college students in Delhi showed that sexual exposure is earlier than legal age of marriage.5 In another study, it was observed that nearly half (45%) of young women in India marry (begin cohabiting with their husband) before the legal age of marriage for women which is 18 years.6 This increases risk of infections including HIV infection due to the physical trauma associated with sexual activity, pregnancy, and illegal abortions, indicating that more attention is needed to educate adolescents, for prevention of HPV infection.6
2.
Risk factors for cervical cancer
Numerous studies indicate that the determinants of cervical cancer include persistent HPV infection (OR 36.97, p < 0.001), early age at first sexual exposure <12 years compared to <18 years (OR 3.5), multiple sexual partners (OR 5.5), interval between menarche and first sexual intercourse <6 years (OR 3.32–4.09), smoking (OR 3.36, p < 0.001), low education status, parity and low socio economic status, HIV and other sexually transmitted diseases, poor menstrual hygiene, and long-term oral contraceptive use.7–16
3.
Risk reduction strategies
Majority of these risk factors, which start at an early age, are modifiable and can be prevented through effective public health strategies. It is important to address these factors, particularly in vulnerable youths, through multiple approaches for reducing risk of cervical cancer at a later age.
3.1.
Health education and counseling
HEADSSS is a screening tool and interview instrument for assessing risks in adolescent's lives. The acronym stands for Home, Education/Employment, Activities, Drugs, Sexuality, Suicide, and Safety. This interview format is flexible and can be catered to all adolescents.17 It provides a systematic approach to interview adolescents which progresses from the least threatening topics to the most personal and sensitive subjects. Awareness about risk factors of cervical cancer is important to empower adolescent girls. This requires multi-media approach through mass media as well as interpersonal communication.
3.2.
Preventing sexually transmitted infections (STIs)
It is important to increase awareness about sexually transmitted diseases, their prevention by use of barrier methods and educating about ‘‘Safe sex’’ which is defined as sexual practices that do not involve the exchange of bodily fluids, including blood, semen, vaginal secretions, and saliva, to avoid AIDS and other sexually transmitted diseases. The practice entails sex without penetration or sex using condoms or other barrier measures with consistency and counseling adolescents for taking early treatment, if they have signs and symptoms of infection.
3.3.
Menstrual and personal hygiene
Hygiene in general and menstrual hygiene in particular play an important role in prevention of cervical cancer. An Indian study revealed that risk associated with the use of unclean cloth during menstruation was 2.5-fold higher for the development of CIN III and malignancy as compared to the use of clean cloth or sanitary napkins. The factor remained statistically significant even after adjustment for other factors such as age, age at marriage, promiscuity, and education, thus highlighting the importance of menstrual hygiene.18 Another study in Mali highlighted the use of home-made napkins as a statistically significant risk factor in the development of cervical cancer. Poor hygiene has been observed as a co factor for cervical cancer with prevalent HPV infection. The Ministry of Health and Family Welfare has launched a scheme for promotion of menstrual hygiene under adolescent health program for young girls in the age group of 10–19 years in rural areas where community based health education is given to promote menstrual health and sanitary napkins are provided under National Health Mission's brand 'Freedays'. These napkins are being sold at rate of INR 6 per pack of six napkins by Accredited Social Health Activists (ASHA).19 This scheme can be extended to cover urban areas as well.
3.4.
HPV vaccination
Since HPV vaccine is an effective prophylactic measure, vaccinating girls and women before sexual debut and therefore before exposure to HPV infection provides an excellent opportunity to decrease the incidence of cervical cancer over time. Both Cervarix and Gardasil vaccines work
Please cite this article in press as: Dahiya N, et al. Strategies for reducing risk of cervical cancer in adolescents in developing countries – A view point, Indian J Med Spec. (2015), http://dx.doi.org/10.1016/j.injms.2015.10.003
INJMS-56; No. of Pages 4 indian journal of medical specialities xxx (2015) xxx–xxx
best, if administered prior to exposure to HPV in girls 9–14 years of age and mounts better immune response.6 Cervarix protects against HPV 16 and 18 while Gardasil offers additional protection against 6 and 11 (which causes genital warts). The target population for HPV vaccination depends on the age at which individual first gets exposed to HPV and this varies among countries. To ensure that the recipients receive maximum protection, the target population should be young adolescents between 9 and 14 years of age who are considered to be sexually inactive. HPV vaccine produces a higher immune response in preteens than it does in older teens and young women.20 Gardasil, the quadrivalent vaccine, is also approved for boys. This vaccine helps prevent boys from getting infected with the types of HPV serotypes than can cause cancers of the throat, penis, and anus. The vaccine also prevents genital warts. When boys are vaccinated, they are less likely to spread HPV to their current and future partners.
3.5.
The following potential challenges can adversely affect cervical cancer control programs aimed at adolescents. 1. Rapport building with adolescents groups and their active involvement for any health related intervention. 2. Sociocultural issues associated with the HPV vaccine, as it targets a STI and primarily targets female adolescents and young women. 3. Cost, situational delivery, and complexity of HPV counseling. 4. Country's disease burden, health care infrastructure, capacity for initiating, and sustaining a intervention for adolescents. 5. Deep rooted cultural practices for early marriage of girls in spite of legislation.
5.
Key messages
1. Cervical cancer is the fourth commonest cancer across the globe. 2. Health education and counseling using HEADSSS systematic approach constitute an important prevention strategy. 3. Menstrual hygiene and personal hygiene play an important role in prevention of cervical cancer. 4. Vaccination is an effective measure to decrease the incidence of cervical cancer over time.
Age at marriage
Strictly enforcing laws to prevent child marriages in rural areas is critical, because girl's virginal status and physical immaturity, and unprotected coitus with their husbands increase the risk of HPV transmission secondary to laceration of hymen, vagina, or cervix. Multiple factors in their husbands including prior sexual behavior and polygamy can further increase their risk. To stop child marriages, policies and programs must educate communities to raise awareness regarding health risks of teenage marriage and pregnancy by engaging community and religious leaders and parents and empower girls through education and employment.21
3.7.
Challenges
School health program
Menstrual hygiene and HPV vaccination should be integral components of comprehensive school health program. These activities would require close coordination between health and education sectors at various levels. Vaccination schedules must be synchronized with school calendars. As drop out after primary level schooling is high, particularly among girls in some states, strategies should be devised to reach out to girls not attending schools or who have missed vaccinations days at school.
3.6.
4.
3
Curbing tobacco smoking
Tobacco contains known carcinogens such as polycyclic aromatic hydrocarbons that could potentially have a direct transformation effect on the cervix or could cause immunosuppression, allowing HPV infections to persist and progress to cancer.22 The primary purpose of smokefree laws and policies is to protect nonsmokers from secondhand smoke. However, smokefree laws can also motivate and help tobacco users quit and prevent initiation of tobacco use. Studies have shown that the implementation of smokefree laws and policies can increase cessation and reduce smoking prevalence among workers and the general population, and may also reduce smoking initiation among youth.
Conflicts of interest The authors have none to declare.
references
1. Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013[cited 2015 Jun 15]. Available from: http://globocan.iarc.fr. 2. Schiffman M, Castle P, Jeronimo J, Rodriguez A, Wacholder S. Human papillomavirus and cervical cancer. Lancet. 2007;370:890–907. 3. Bosch FX, Lorincz A, Munoz N, Meijer CJ, Shah KV. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol. 2002;55:244–265. 4. Benard VB, Watson M, Castle PE, Saraiya M. Cervical carcinoma rates among young females in the United States. Obstet Gynecol. 2012;120:1117–1123. 5. Bhatla N, Joseph E. Cervical cancer prevention & the role of human papillomavirus vaccines in India. Indian J Med Res. 2009;130:334–340. 6. Moore AM, Singh S, Ram U, Remez L, Audam S. Adolescent Marriage and Childbearing in India: Current Situation and Recent Trends. New York, New York: Guttmacher Institute; 2009.
Please cite this article in press as: Dahiya N, et al. Strategies for reducing risk of cervical cancer in adolescents in developing countries – A view point, Indian J Med Spec. (2015), http://dx.doi.org/10.1016/j.injms.2015.10.003
INJMS-56; No. of Pages 4
4
indian journal of medical specialities xxx (2015) xxx–xxx
7.
8.
9.
10.
11.
12.
13.
14.
April 31. Available from: https://www.guttmacher.org/pubs/ 2009/06/04/AdolescentMarriageIndia.pdf. Thulaseedharan JV, Malila N, Hakama M, et al. Socio demographic and reproductive risk factors for cervical cancer – a large prospective cohort study from rural India. Asian Pac J Cancer Prev. 2012;13:2991–2995. Franchesi S, Rajkumar T, Vaccarella S, et al. Human papillomavirus and risk factors for cervical cancer in Chennai, India: a case–control study. Int J Cancer. 2003;107:127–133. Sogukpinar N, Saydam BK, Can HO, et al. Assessment of cervical cancer risk in women between 15 and 49 years of age: case of Izmir. Asian Pac J Cancer Prev. 2013;14:2119–2125. Mukherjee BN, Sengupta S, Chaudhuri S, Biswas LN, Maiti P. A case–control study of reproductive risk factors associated with cervical cancer. Int J Cancer. 1994;59:476–482. Louie KS, de Sanjose S, Diaz M, et al. Early age at first sexual intercourse and early pregnancy are risk factors for cervical cancer in developing countries. Br J Cancer. 2009;100:11917. Mhaske M, Jawadekar SJ, Saundale SG. Study of association of some risk factors & cervical dysplasia/cancer among rural women. Natl J Community Med. 2011;2:209–215. Vallikad E, Krishnan S, Kumaraswamy. Studies, Strategies and Concepts for Women's Health in Women's Hands: A Community Approach for the Control of Cancer Cervix in Karnataka, India. Kidwai Mem. Instit. Onco.; 1998. Biswas LN, Manna B, Maiti PK, Sengupta S. Sexual risk factors for cervical cancer among rural Indian women: a case–control study. Int J Epidemiol. 1997;26:491–495.
15. Kahn JA, Rosenthal SL, Succop PA, Ho GY, Burk RD. Mediators of the association between age of first sexual intercourse and subsequent human papilloma virus infection. Pediatrics. 2002;109:E5. 16. Natphopsuk S, Settheetham-Ishida W, Sinawat S, Pientong C, Yuenyao P, Ishida T. Risk factors for cervical cancer in northeastern Thailand: detailed analyses of sexual and smoking behavior. Asian Pac J Cancer Prev. 2012;13:5489–5495. 17. Katzenellenbogen R. HEADSS: the review of systems for adolescents. Virtual Mentor. 2005;7:. 18. Juneja A, Sehgal A, Mitra AB, Pandey A. A survey on risk factors associated with cervical cancer. Indian J Cancer. 2003;40:15–22. 19. National Health Mission, MOHFW, Government of India. Scheme for Promotion of Menstrual Hygiene among Adolescent Girls in Rural India. [cited 2015 Sep 20]. Available from: http://nrhm.gov.in/nrhmcomponnets/ reproductive-child-health/adolescent-health/mhs.html? start=5. 20. Nigam A, Saxena P, Acharya A, Mishra A, Batra S. HPV vaccination in India: critical appraisal. ISRN Obstet Gynecol. 2014;2014:1–5. 21. Nour N. Child marriage: a silent health and human rights issue. Rev Obstet Gynecol. 2009;2:51–56. 22. IARC. Tobacco Smoking and Involuntary Smoking. Lyon, France: IARC; 2004 [cited 2015 Jun 15]. Available from: http:// monographs.iarc.fr/ENG/Monographs/vol83/mono83.pdf.
Please cite this article in press as: Dahiya N, et al. Strategies for reducing risk of cervical cancer in adolescents in developing countries – A view point, Indian J Med Spec. (2015), http://dx.doi.org/10.1016/j.injms.2015.10.003
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/injms
Review Article
Strategies for reducing risk of cervical cancer in adolescents in developing countries – A view point Neha Dahiya a,*, Anita S. Acharya b, Damodar Bachani c, Manish Kumar Goel d a
Junior Resident, Department of Community Medicine, Lady Hardinge Medical College & Associated Hospitals, New Delhi, India b Professor, Department of Community Medicine, Lady Hardinge Medical College & Associated Hospitals, New Delhi, India c Director Professor, Department of Community Medicine, Lady Hardinge Medical College & Associated Hospitals, New Delhi, India d Associate Professor, Department of Community Medicine, Lady Hardinge Medical College & Associated Hospitals, New Delhi, India
article info
abstract
Article history:
Cervical cancer is the fourth commonest cancer across the globe. Although various health
Received 18 August 2015
programs initiated to screen and treat this cancer in developed countries have reaped
Accepted 6 October 2015
benefits in terms of reduction in mortality, yet poor access to screening and to management
Available online xxx
services continues to account for the vast majority of deaths in women living in low and middle income countries. The present review highlights the various risk factors that
Keywords:
predispose adolescents to cervical cancer and the 'risk reduction' strategies that need to
Cervical cancer
be implemented for the benefit of 'next generation' women.
Adolescents
# 2015 Published by Elsevier B.V. on behalf of Indian Journal of Medical Specialities Trust.
HPV
1.
Introduction
Cervical cancer is a major public health problem in many developing countries and the absolute burden is expected to increase in future unless effective prevention measures are undertaken. Globally, cervical cancer is the fourth most common cancer in women with nearly 528,000 new cases reported in 2012.1 Nearly 85% of the global burden occurs in the less developed regions, where it accounts for almost 12% of all female cancers. High-risk regions, with estimated Age
Standardized Rate (ASRs) over 30 per 100,000 include Eastern Africa (42.7), Melanesia (33.3), Southern Africa (31.5) and Middle Africa (30.6). There were an estimated 266,000 deaths from cervical cancer worldwide in 2012, accounting for 7.5% of all female cancer deaths.1 Cervical cancer is one of the leading cancers among Indian women with estimated 123,000 new cases and 67,477 deaths in 2012.1 It has been seen that the persistent infection with one of the 15 oncogenic types of Human Papilloma Virus (HPV) is the cause of almost all cases of cervical cancer and its precursor, cervical intraepithelial
* Corresponding author at: Department of Community Medicine, Lady Hardinge Medical College & Associated Hospitals, New Delhi 110001, India. Tel.: +91 9968910438. E-mail address: [email protected] (N. Dahiya). http://dx.doi.org/10.1016/j.injms.2015.10.003 0976-2884/# 2015 Published by Elsevier B.V. on behalf of Indian Journal of Medical Specialities Trust.
Please cite this article in press as: Dahiya N, et al. Strategies for reducing risk of cervical cancer in adolescents in developing countries – A view point, Indian J Med Spec. (2015), http://dx.doi.org/10.1016/j.injms.2015.10.003
INJMS-56; No. of Pages 4
2
indian journal of medical specialities xxx (2015) xxx–xxx
neoplasia (CIN). HPV infection is very common in young women in their early phase of sexual activity. Persistent infections and precancerous stage are established, typically within 5–10 years, from less than 10% of new infections but fortunately, invasive cancer arises over many years, even decades, in a minority of women with precancerous lesions, with a peak risk at about 35–55 years of age.2 A significant proportion of CIN, if not detected and treated, progresses to invasive cervical carcinoma over a period of 10–20 years owing to the effect of other cofactors.3 Cervical cancer is a multi-etiology disease and there are several risk factors, which are associated with it, and in India, majority of affected women have these risks factors. Most HPV infections regress rapidly without causing clinically significant disease. Several studies have quoted that it is not very uncommon to find cervical cancer in women younger than 20. A study conducted in United States, which covered 92% of the population, showed that for women less than 40 years of age, 78% of cervical cancer cases involved women aged 30–39 years, 21% were among women aged 20–29 years, and the remaining 1% were diagnosed in women less than 20 years of age. This study also showed that between 1999 and 2008, there were 3063 cases of cervical cancer each year. On average, there were 14 cases per year among women aged 15–19, and 125 cases per year among women aged 20–24 years.4 The prevalence rate among adolescents is increasing, reflecting changes in sexual behavior associated with biological factors during adolescence. A survey conducted among college students in Delhi showed that sexual exposure is earlier than legal age of marriage.5 In another study, it was observed that nearly half (45%) of young women in India marry (begin cohabiting with their husband) before the legal age of marriage for women which is 18 years.6 This increases risk of infections including HIV infection due to the physical trauma associated with sexual activity, pregnancy, and illegal abortions, indicating that more attention is needed to educate adolescents, for prevention of HPV infection.6
2.
Risk factors for cervical cancer
Numerous studies indicate that the determinants of cervical cancer include persistent HPV infection (OR 36.97, p < 0.001), early age at first sexual exposure <12 years compared to <18 years (OR 3.5), multiple sexual partners (OR 5.5), interval between menarche and first sexual intercourse <6 years (OR 3.32–4.09), smoking (OR 3.36, p < 0.001), low education status, parity and low socio economic status, HIV and other sexually transmitted diseases, poor menstrual hygiene, and long-term oral contraceptive use.7–16
3.
Risk reduction strategies
Majority of these risk factors, which start at an early age, are modifiable and can be prevented through effective public health strategies. It is important to address these factors, particularly in vulnerable youths, through multiple approaches for reducing risk of cervical cancer at a later age.
3.1.
Health education and counseling
HEADSSS is a screening tool and interview instrument for assessing risks in adolescent's lives. The acronym stands for Home, Education/Employment, Activities, Drugs, Sexuality, Suicide, and Safety. This interview format is flexible and can be catered to all adolescents.17 It provides a systematic approach to interview adolescents which progresses from the least threatening topics to the most personal and sensitive subjects. Awareness about risk factors of cervical cancer is important to empower adolescent girls. This requires multi-media approach through mass media as well as interpersonal communication.
3.2.
Preventing sexually transmitted infections (STIs)
It is important to increase awareness about sexually transmitted diseases, their prevention by use of barrier methods and educating about ‘‘Safe sex’’ which is defined as sexual practices that do not involve the exchange of bodily fluids, including blood, semen, vaginal secretions, and saliva, to avoid AIDS and other sexually transmitted diseases. The practice entails sex without penetration or sex using condoms or other barrier measures with consistency and counseling adolescents for taking early treatment, if they have signs and symptoms of infection.
3.3.
Menstrual and personal hygiene
Hygiene in general and menstrual hygiene in particular play an important role in prevention of cervical cancer. An Indian study revealed that risk associated with the use of unclean cloth during menstruation was 2.5-fold higher for the development of CIN III and malignancy as compared to the use of clean cloth or sanitary napkins. The factor remained statistically significant even after adjustment for other factors such as age, age at marriage, promiscuity, and education, thus highlighting the importance of menstrual hygiene.18 Another study in Mali highlighted the use of home-made napkins as a statistically significant risk factor in the development of cervical cancer. Poor hygiene has been observed as a co factor for cervical cancer with prevalent HPV infection. The Ministry of Health and Family Welfare has launched a scheme for promotion of menstrual hygiene under adolescent health program for young girls in the age group of 10–19 years in rural areas where community based health education is given to promote menstrual health and sanitary napkins are provided under National Health Mission's brand 'Freedays'. These napkins are being sold at rate of INR 6 per pack of six napkins by Accredited Social Health Activists (ASHA).19 This scheme can be extended to cover urban areas as well.
3.4.
HPV vaccination
Since HPV vaccine is an effective prophylactic measure, vaccinating girls and women before sexual debut and therefore before exposure to HPV infection provides an excellent opportunity to decrease the incidence of cervical cancer over time. Both Cervarix and Gardasil vaccines work
Please cite this article in press as: Dahiya N, et al. Strategies for reducing risk of cervical cancer in adolescents in developing countries – A view point, Indian J Med Spec. (2015), http://dx.doi.org/10.1016/j.injms.2015.10.003
INJMS-56; No. of Pages 4 indian journal of medical specialities xxx (2015) xxx–xxx
best, if administered prior to exposure to HPV in girls 9–14 years of age and mounts better immune response.6 Cervarix protects against HPV 16 and 18 while Gardasil offers additional protection against 6 and 11 (which causes genital warts). The target population for HPV vaccination depends on the age at which individual first gets exposed to HPV and this varies among countries. To ensure that the recipients receive maximum protection, the target population should be young adolescents between 9 and 14 years of age who are considered to be sexually inactive. HPV vaccine produces a higher immune response in preteens than it does in older teens and young women.20 Gardasil, the quadrivalent vaccine, is also approved for boys. This vaccine helps prevent boys from getting infected with the types of HPV serotypes than can cause cancers of the throat, penis, and anus. The vaccine also prevents genital warts. When boys are vaccinated, they are less likely to spread HPV to their current and future partners.
3.5.
The following potential challenges can adversely affect cervical cancer control programs aimed at adolescents. 1. Rapport building with adolescents groups and their active involvement for any health related intervention. 2. Sociocultural issues associated with the HPV vaccine, as it targets a STI and primarily targets female adolescents and young women. 3. Cost, situational delivery, and complexity of HPV counseling. 4. Country's disease burden, health care infrastructure, capacity for initiating, and sustaining a intervention for adolescents. 5. Deep rooted cultural practices for early marriage of girls in spite of legislation.
5.
Key messages
1. Cervical cancer is the fourth commonest cancer across the globe. 2. Health education and counseling using HEADSSS systematic approach constitute an important prevention strategy. 3. Menstrual hygiene and personal hygiene play an important role in prevention of cervical cancer. 4. Vaccination is an effective measure to decrease the incidence of cervical cancer over time.
Age at marriage
Strictly enforcing laws to prevent child marriages in rural areas is critical, because girl's virginal status and physical immaturity, and unprotected coitus with their husbands increase the risk of HPV transmission secondary to laceration of hymen, vagina, or cervix. Multiple factors in their husbands including prior sexual behavior and polygamy can further increase their risk. To stop child marriages, policies and programs must educate communities to raise awareness regarding health risks of teenage marriage and pregnancy by engaging community and religious leaders and parents and empower girls through education and employment.21
3.7.
Challenges
School health program
Menstrual hygiene and HPV vaccination should be integral components of comprehensive school health program. These activities would require close coordination between health and education sectors at various levels. Vaccination schedules must be synchronized with school calendars. As drop out after primary level schooling is high, particularly among girls in some states, strategies should be devised to reach out to girls not attending schools or who have missed vaccinations days at school.
3.6.
4.
3
Curbing tobacco smoking
Tobacco contains known carcinogens such as polycyclic aromatic hydrocarbons that could potentially have a direct transformation effect on the cervix or could cause immunosuppression, allowing HPV infections to persist and progress to cancer.22 The primary purpose of smokefree laws and policies is to protect nonsmokers from secondhand smoke. However, smokefree laws can also motivate and help tobacco users quit and prevent initiation of tobacco use. Studies have shown that the implementation of smokefree laws and policies can increase cessation and reduce smoking prevalence among workers and the general population, and may also reduce smoking initiation among youth.
Conflicts of interest The authors have none to declare.
references
1. Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013[cited 2015 Jun 15]. Available from: http://globocan.iarc.fr. 2. Schiffman M, Castle P, Jeronimo J, Rodriguez A, Wacholder S. Human papillomavirus and cervical cancer. Lancet. 2007;370:890–907. 3. Bosch FX, Lorincz A, Munoz N, Meijer CJ, Shah KV. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol. 2002;55:244–265. 4. Benard VB, Watson M, Castle PE, Saraiya M. Cervical carcinoma rates among young females in the United States. Obstet Gynecol. 2012;120:1117–1123. 5. Bhatla N, Joseph E. Cervical cancer prevention & the role of human papillomavirus vaccines in India. Indian J Med Res. 2009;130:334–340. 6. Moore AM, Singh S, Ram U, Remez L, Audam S. Adolescent Marriage and Childbearing in India: Current Situation and Recent Trends. New York, New York: Guttmacher Institute; 2009.
Please cite this article in press as: Dahiya N, et al. Strategies for reducing risk of cervical cancer in adolescents in developing countries – A view point, Indian J Med Spec. (2015), http://dx.doi.org/10.1016/j.injms.2015.10.003
INJMS-56; No. of Pages 4
4
indian journal of medical specialities xxx (2015) xxx–xxx
7.
8.
9.
10.
11.
12.
13.
14.
April 31. Available from: https://www.guttmacher.org/pubs/ 2009/06/04/AdolescentMarriageIndia.pdf. Thulaseedharan JV, Malila N, Hakama M, et al. Socio demographic and reproductive risk factors for cervical cancer – a large prospective cohort study from rural India. Asian Pac J Cancer Prev. 2012;13:2991–2995. Franchesi S, Rajkumar T, Vaccarella S, et al. Human papillomavirus and risk factors for cervical cancer in Chennai, India: a case–control study. Int J Cancer. 2003;107:127–133. Sogukpinar N, Saydam BK, Can HO, et al. Assessment of cervical cancer risk in women between 15 and 49 years of age: case of Izmir. Asian Pac J Cancer Prev. 2013;14:2119–2125. Mukherjee BN, Sengupta S, Chaudhuri S, Biswas LN, Maiti P. A case–control study of reproductive risk factors associated with cervical cancer. Int J Cancer. 1994;59:476–482. Louie KS, de Sanjose S, Diaz M, et al. Early age at first sexual intercourse and early pregnancy are risk factors for cervical cancer in developing countries. Br J Cancer. 2009;100:11917. Mhaske M, Jawadekar SJ, Saundale SG. Study of association of some risk factors & cervical dysplasia/cancer among rural women. Natl J Community Med. 2011;2:209–215. Vallikad E, Krishnan S, Kumaraswamy. Studies, Strategies and Concepts for Women's Health in Women's Hands: A Community Approach for the Control of Cancer Cervix in Karnataka, India. Kidwai Mem. Instit. Onco.; 1998. Biswas LN, Manna B, Maiti PK, Sengupta S. Sexual risk factors for cervical cancer among rural Indian women: a case–control study. Int J Epidemiol. 1997;26:491–495.
15. Kahn JA, Rosenthal SL, Succop PA, Ho GY, Burk RD. Mediators of the association between age of first sexual intercourse and subsequent human papilloma virus infection. Pediatrics. 2002;109:E5. 16. Natphopsuk S, Settheetham-Ishida W, Sinawat S, Pientong C, Yuenyao P, Ishida T. Risk factors for cervical cancer in northeastern Thailand: detailed analyses of sexual and smoking behavior. Asian Pac J Cancer Prev. 2012;13:5489–5495. 17. Katzenellenbogen R. HEADSS: the review of systems for adolescents. Virtual Mentor. 2005;7:. 18. Juneja A, Sehgal A, Mitra AB, Pandey A. A survey on risk factors associated with cervical cancer. Indian J Cancer. 2003;40:15–22. 19. National Health Mission, MOHFW, Government of India. Scheme for Promotion of Menstrual Hygiene among Adolescent Girls in Rural India. [cited 2015 Sep 20]. Available from: http://nrhm.gov.in/nrhmcomponnets/ reproductive-child-health/adolescent-health/mhs.html? start=5. 20. Nigam A, Saxena P, Acharya A, Mishra A, Batra S. HPV vaccination in India: critical appraisal. ISRN Obstet Gynecol. 2014;2014:1–5. 21. Nour N. Child marriage: a silent health and human rights issue. Rev Obstet Gynecol. 2009;2:51–56. 22. IARC. Tobacco Smoking and Involuntary Smoking. Lyon, France: IARC; 2004 [cited 2015 Jun 15]. Available from: http:// monographs.iarc.fr/ENG/Monographs/vol83/mono83.pdf.
Please cite this article in press as: Dahiya N, et al. Strategies for reducing risk of cervical cancer in adolescents in developing countries – A view point, Indian J Med Spec. (2015), http://dx.doi.org/10.1016/j.injms.2015.10.003