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Context:

Cervical cancer continues to be a major public health challenge in India, particularly in rural and underserved regions. Despite being largely preventable and slow-growing, it remains one of the leading causes of cancer deaths among Indian women.

What is Cervical Cancer?

Cervical cancer is a type of cancer that develops in the cervix, the lower part of the uterus that connects the uterus to the vagina. It occurs when normal cervical cells undergo abnormal changes and begin to grow uncontrollably.

The disease is caused almost entirely by persistent infection with high-risk types of Human Papillomavirus (HPV), a very common sexually transmitted virus. While most HPV infections clear naturally, long-term infection with certain strains can lead to cancer. 

Global and Indian burden of Cervical Cancer:

• Cervical cancer ranks as the fourth most common cancer among women worldwide. In 2022, an estimated 660,000 new cases and around 350,000 deaths were reported globally. Nearly 94% of these deaths occurred in low- and middle-income countries, highlighting stark disparities in access to prevention, screening, and treatment services. 

• Regions such as sub-Saharan Africa, Central America, and South-East Asia experience the highest incidence and mortality rates. These patterns are closely linked to unequal health infrastructure, limited vaccine coverage, and broader socio-economic challenges including poverty and gender inequality. 

• India records roughly 127,000 new cases of cervical cancer annually, with about 80,000 deaths each year, making it a significant contributor to global cervical cancer mortality. 

• India contributes a major proportion of cervical cancer cases and deaths in the South-East Asia Region (SEARO) of the World Health Organization, with its share often accounting for over 60% of the regional burden.  

Cervical Cancer and HIV

Women living with HIV face a substantially higher risk of developing cervical cancer due to compromised immune function. Evidence shows they are about six times more likely to develop the disease than women without HIV, and approximately 5% of global cervical cancer cases are attributable to HIV infection.

Because cervical cancer often affects women in their productive and reproductive years, it has wider social consequences. Nearly one-fifth of children who lose a mother to cancer do so as a result of cervical cancer, underscoring its intergenerational impact. 

Disease Progression:

Almost all cases of cervical cancer are caused by persistent infection with oncogenic strains of human papillomavirus (HPV), a very common sexually transmitted infection. While most HPV infections are cleared naturally by the immune system, long-term infection with high-risk types can lead to abnormal cellular changes in the cervix.

If left untreated, these precancerous lesions can progress to invasive cancer over 15–20 years. In women with weakened immunity, such as those with untreated HIV, progression can be much faster, sometimes occurring within 5–10 years.

Several factors influence the likelihood of progression, including:

• Type of HPV infection
• Immune status
• Co-existing sexually transmitted infections
• High number of pregnancies
• Early age at first pregnancy
• Long-term hormonal contraceptive use
• Tobacco consumption 

Prevention:

Preventing cervical cancer requires a life-course approach that integrates awareness, vaccination, regular screening, and timely treatment.

HPV vaccination: HPV vaccination for girls aged 9–14 years is highly effective in preventing HPV infection and related cancers. As of 2025, several HPV vaccines are available globally, all of which protect against HPV types 16 and 18, responsible for most cervical cancer cases.

Vaccination schedules vary by country and immune status. While some countries also vaccinate boys to reduce community transmission and prevent HPV-related cancers in men, universal coverage among adolescent girls remains the priority.

Additional preventive measures include avoiding tobacco use, consistent condom use, and voluntary male circumcision.

Cervical screening and management of precancer: Regular screening is essential for detecting precancerous changes before they progress to cancer. Women are advised to begin screening at 30 years of age, while women living with HIV should start earlier, usually at 25 years.

High-performance tests, particularly HPV-DNA testing, are recommended at 5–10 year intervals. Self-sampling has emerged as a reliable and acceptable option, especially for women facing access, privacy, or social barriers.

When screening results are positive, early treatment of precancerous lesions can effectively prevent cervical cancer. Common treatment options include thermal ablation, cryotherapy, loop excision procedures (LEEP/LEETZ), and cone biopsy, where required. These procedures are generally quick, safe, and minimally uncomfortable. 

Early Detection and treatment of invasive cancer: Cervical cancer is highly curable when detected early. Awareness of symptoms and prompt medical consultation are crucial. Warning signs may include abnormal vaginal bleeding, persistent pelvic or back pain, unusual discharge, unexplained weight loss, or swelling of the legs.

Diagnosis involves clinical evaluation, imaging, and histopathological testing, followed by stage-appropriate treatment such as surgery, radiotherapy, chemotherapy, and supportive or palliative care.

Effective outcomes depend on clear referral pathways and multidisciplinary care, ensuring timely diagnosis, guideline-based treatment, and holistic support addressing physical, psychological, and social needs. 

Why Cervical Cancer remains a rural health crisis in India?

• Low screening coverage: Although national screening programmes exist, actual coverage in rural areas remains poor. Many women are screened late or not at all, leading to diagnosis at advanced stages, when treatment is more complex, expensive, and less effective. 

• Overdependence on VIA and weak follow-up: Rural screening largely relies on Visual Inspection with Acetic Acid (VIA), a subjective test that requires strong referral systems to be effective. However, weak follow-up mechanisms, poor counselling, and delays in confirmatory testing result in high loss-to-follow-up after a positive screen. 

• Limited access to diagnostic: Advanced diagnostics such as HPV-DNA testing, colposcopy, and biopsy, as well as cancer treatment facilities, are concentrated in urban centres. Rural women often face long travel distances, high out-of-pocket costs, unreliable transport, and loss of daily wages, discouraging timely care. 

• Human resource gaps: Frontline workers like ASHAs and ANMs are central to outreach but are overburdened and undertrained for cancer prevention tasks. The lack of specialised skills at the primary care level weakens screening quality, counselling, and continuity of care. 

• Low HPV vaccination uptake: Despite strong global evidence, HPV vaccination has not been systematically scaled up across rural India. Gaps in awareness, supply, and integration with existing health programmes limit its preventive impact. 

• Socio-cultural and gender barriers: Low health literacy, stigma around gynaecological examinations, fear and misinformation, lack of family support, and restricted decision-making power further reduce rural women’s participation in screening and treatment. 

Challenges in addressing cervical cancer in rural India:

High burden with disproportionate rural impact: India accounts for nearly one-fourth of global cervical cancer deaths. In 2022, the country recorded about 1.27 lakh new cases and nearly 80,000 deaths. Rural women face a significantly higher risk because over 60–70% of cases are detected at advanced stages, compared to earlier-stage detection in urban areas. 

Extremely low screening coverage: Despite national programmes, screening remains limited. Population-based surveys and programme data indicate that less than half of eligible women have ever been screened, with some estimates placing routine screening coverage as low as 1.9% among women aged 30–49 years. This directly contributes to delayed diagnosis and high mortality. 

Overreliance on VIA with weak follow-up: Most rural screening relies on Visual Inspection with Acetic Acid (VIA). While cost-effective, VIA is operator-dependent and subjective, requiring strong referral systems.
Fact: Studies show that a large proportion of women who test positive on VIA do not receive confirmatory colposcopy or treatment, mainly due to distance, cost, and poor counselling. 

Limited access to diagnostic and treatment facilities: Advanced diagnostics such as HPV-DNA testing, colposcopy, biopsy, radiotherapy, and chemotherapy are concentrated in urban tertiary hospitals. Rural women often travel 50–200 km for confirmatory diagnosis or treatment, leading to high out-of-pocket expenditure and loss of daily wages. 

Capacity gaps: ASHAs and ANMs are the backbone of outreach, but cancer prevention has been added to their roles without proportional training or time allocation. National Health Mission reviews have highlighted skill gaps in counselling, sample handling, and follow-up, weakening continuity of care. 

Low HPV vaccination uptake: Although HPV vaccination is globally recognised as a game-changer, systematic nationwide rollout remains limited in India, especially in rural areas. Lack of awareness, misinformation, and weak school-based delivery systems restrict coverage, reducing long-term prevention impact. 

Government initiatives to address Cervical Cancer in India:

National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS): Under the NPCDCS, cervical cancer screening has been integrated into population-based screening for non-communicable diseases. Women aged 30–65 years are screened primarily using Visual Inspection with Acetic Acid (VIA) at the primary care level, with referral linkages to higher facilities for diagnosis and treatment. 

Ayushman Arogya Mandirs (Health and Wellness Centres): Upgraded primary healthcare facilities, now known as Ayushman Arogya Mandirs, serve as the frontline for cervical cancer prevention. These centres provide:

• Free cervical cancer screening
• Community-level counselling and awareness
• Referral services for positive cases

As of mid-2025, over 100 million women had been screened under the population-based NCD programme, though rural gaps persist.

National Health Mission (NHM) support: The National Health Mission provides financial and operational support to states for:

• Training frontline health workers
• IEC (Information, Education, Communication) activities
• Organising screening camps, especially on National Cancer Awareness Day and World Cancer Day 

Pradhan Mantri Jan Arogya Yojana (PM-JAY): Under PM-JAY, eligible beneficiaries receive cashless treatment for cervical cancer at secondary and tertiary hospitals. This reduces catastrophic health expenditure for poor households requiring surgery, chemotherapy, or radiotherapy. 

Global initiatives to eliminate Cervical Cancer:

WHO global strategy for Cervical Cancer elimination: In 2020, the World Health Organization launched the Global Strategy to Accelerate the Elimination of Cervical Cancer, marking the first coordinated global effort to eliminate a cancer.

It is built around the 90–70–90 targets by 2030:

• 90% of girls fully vaccinated with HPV vaccine by age 15
• 70% of women screened using a high-performance test by ages 35 and 45
• 90% of women with precancer or invasive cancer treated

Achieving these targets could prevent over 60 million deaths globally by the end of the century. 

UN Joint Global Programme on Cervical Cancer: Multiple UN agencies including WHO, UNICEF, UNFPA, and UN Women collaborate under a joint global programme to:

• Integrate cervical cancer control with reproductive and adolescent health
• Address gender, equity, and human rights dimensions
• Strengthen national health systems

This approach recognises cervical cancer as both a health and gender equity issue. 

Australia is on track to eliminate cervical cancer by the 2030s due to near-universal HPV vaccination and HPV-based screening.

Rwanda achieved over 90% HPV vaccination coverage through strong political commitment and school-based delivery.

Bhutan combined HPV vaccination with organised screening, demonstrating success in a low-resource setting.

Way Forward:

• Transition to HPV - DNA based screening: India must gradually move from VIA-based screening to high-performance HPV-DNA testing, including self-sampling options. Evidence shows HPV-DNA testing is more accurate, reduces repeat visits, and lowers long-term treatment costs. Integrating this into the NPCDCS can significantly improve rural coverage. 

• Universalise HPV vaccination: A nationwide rollout of HPV vaccination for girls aged 9–14 years through schools and community platforms is critical. Linking vaccination with Rashtriya Bal Swasthya Karyakram (RBSK) and adolescent health services can ensure early and equitable protection. 

• Decentralise diagnostic and treatment services: District hospitals should be equipped with colposcopy, biopsy, and day-care treatment facilities. Mobile screening units and hub-and-spoke oncology models can reduce travel burden and out-of-pocket expenses for rural women. 

• Invest in frontline workforce capacity: ASHAs and ANMs need structured training, incentives, and protected time for cancer prevention tasks. Task-sharing with trained nurses and use of tele-mentoring models can enhance quality without overburdening frontline workers. 

• Address socio-cultural and gender barriers: Community engagement through self-help groups, Panchayati Raj Institutions, and local women leaders can improve trust and uptake. Ensuring privacy, female providers, and culturally sensitive counselling will reduce stigma. 

Conclusion:

Cervical cancer remains a major yet preventable health challenge, particularly in rural and low-resource settings. Its continued high burden reflects gaps in vaccination, screening, timely diagnosis, and equitable access to treatment rather than limitations of medical knowledge. Aligning national efforts with global strategies—especially universal HPV vaccination, high-quality screening, and strengthened referral systems—can transform cervical cancer from a leading cause of death into a disease of the past.

Source: Down to Earth