Infrastructure

India is a big country with more than 1 billion population, 72% of whom reside in the rural areas. The model proposed to control cervical cancer in India is that Regional Cancer Centres (RCCs) take the initiative to develop the community centres (CC) for cervical cancer prevention in the town hospitals or in the district hospitals or in the centres, which are involved in Cancer Atlas project. These community centres can start cervical cancer preventive services in the rural areas by providing health education and easy access to screening, diagnostic and treatment facilities.

In India there are 25 regional cancer centres, 210 institutions having more than 345 teletherapy facilities across the country (Gupta et al. 2006). Altogether 105 centres participated in the programme of the development of the Cancer Atlas for India (Nandakumar et al. 2004). Most of the town hospitals, district hospitals and the centres involved in the Cancer Atlas project have pathology and surgical facilities, the human resources like surgeons, gynaecologists, pathologists, nursing staff and technicians are available and they are working for regular activities of the hospital. These existing infrastructure and human resources can be used for the development of community cancer services in hospitals. At present the staff is not trained in the techniques of health education, screening, colposcopy and the surgical procedures for preinvasive lesions and they can be trained in the centres that are actively involved in the cervical cancer prevention programme. In India the following centres have been actively involved in cervical cancer prevention programme (Sankaranarayanan et al. 2003a, ICPO-ICMR

Tata Memorial Centre, Mumbai, Maharashtra.

Nargis Dutt Memorial Cancer Hospital, Barshi, Maharashtra.

Chittaranjan National Cancer Institute, Kolkata, West Bengal.

Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan.

Christian Fellowship Community Health Centre, Ambillikai, Tamil Nadu.

Regional Cancer Centre, Thiruvanathapuram (Trivandrum), Kerala.

Institute of Cytology and Preventive Oncology, ICMR, New Delhi.

The responsibility for a cervical cancer control programme could be assigned to the regional cancer centres and to the gynaecologist or pathologists of the hospital. The regional cancer centre should develop the network of community centres for cervical cancer prevention. The human resources from these centres can be trained and resources can be provided.

Due to the support of the regional cancer centre TMC, NDMCH Barshi provided the preventive services for cervical cancer in 959 villages covering 0.7 million female population (346 villages of the registry area covering 0.2 million female population, 116 villages from the health education programme covering 0.1 million female population and 497 villages from the screening programme covering 0.4 million female population). The studies conducted at NDMCH, Barshi and the results reported here are useful guidelines for cervical cancer control in rural, India.

7.3 Method

The health education programme in Barshi provides a model. It consisted intensive health education on the risk factors of the disease and included preventive measures against the disease and providing easy access for diagnosis and treatment. One community centre can cover a female population of 200,000 in the nearby rural area.

Apart from the existing staff, four field staff members to educate the women and to motivate the symptomatic women to undergo diagnosis and treatment at a detection clinic or at community centre was need to be appointed. One field staff member can be made responsible for 50,000 female populations. For the implementation of the

A follow-up round can be implemented after six months in that zone, in the follow-up round we propose the method used by the Rural Cancer Registry Barshi of identifying the symptomatic cases and referring cases to NDMCH i.e. to bring the symptomatic cases from the village for diagnosis at the community centre. The second round (health education by video, group meeting and organizing the detection clinic at the PHC) can be organized after every three years. A similar programme for other zones can be organized.

The village leaders and husbands of the women should be informed in advance about the facilities that the organizer is providing. Consent to the examination must be obtained from the participating women. A woman participating in the detection clinic should have her report explained after the screening. Medicine as per the complaints of the participants to be provided for those women attending at CC or detection clinic. The VIA test has the potential to be a cervical cancer screening tool in the developing countries setup (Sankaranarayanan et al 2007b). The VIA screening criteria and treatment of precancerous lesion should be followed as mentioned in IARC manual (Sankaranarayanan and Wesley 2003d, Sellors and Sankaranarayanan 2003). The results of the VIA screening test and the colposcopy diagnosis are available immediately and women can be encouraged to undergo immediate treatment of cryotherapy if needed.

The advantage of the VIA test is that participants will get the screening results immediately and the loss to follow-up will be minimal. The screen negative women must be informed that the test is negative, but in case of future symptoms related to the disease a women should attend the community centre. If the test is positive and women underwent colposcopy guided biopsy the results should be informed to the women by house visit. The cases diagnosed as CIN I, CIN II and CIN III from the same village can be treated at the same time and village leaders/close relative should be requested to accompany women for treatment. The treatment in the group accompanied by a village leader or close relative will give the women moral support. The precaution to be taken after the treatment by cryotherapy/LEEP should be properly explained to the woman and her husband. It has been reported that cryotherapy procedure done by nurses under the supervision of a doctor is safe and acceptable to the participant in rural India (Sankaranarayanan et al. 2007a). The success rate with LEEP in women treated for the first time is around 90% (Sellors and Sankaranarayanan 2003). The screening programme should focus on detecting and treating the precancerous lesion in single or two visit strategies rather than detecting and treating invasive disease given our experience showing poor compliance with treatment. The number of visits to the hospital for invasive cervical cancer cases should be minimized.

The localised cases can be treated by surgery at CC. The advanced cervical cancer cases should be treated at the level of radiotherapy centre/at RCC. The RCC should provide the necessary facility to the patient attending for the treatment from CC. The field staff should be assigned the responsibility of taking the women to the radiotherapy center and provide moral support to the patient during the treatment. The field staff has to act as a bridge between the community centre and the community. The patient who is unwilling to undergo treatment should be motivated by the village leaders and they should be provided with social support either by a close relative or some accompanying person from the village.

The cervical cancer incidence and mortality can be monitored by establishing a cervical cancer registry with the help of field staff by using the rural cancer registry method or with the help of an existing cancer registration centre of cancer atlas project.

The method for cervical cancer control to be adopted is presented in Figure 19.