Cancer has become one of the ten leading causes of death in India. Data from population-based registries under National Cancer Registry Programme indicate that
the leading sites of cancer in women are cervix, breast and oral cavity.

Cancer Cervix
Cervical cancer is the third most common cancer in the world, with 2.3 million prevalent cases and 5,10,000 incident cases each year. Annually, 2,88,000 women die of cervical cancer, and 80% of these deaths occur in low resource countries.

In view of the well-defined natural history and long detectable preclinical phase, the cancer of uterine cervix gets priority in terms of control program through mass screening. An important reason for higher cervical cancer incidence in developing countries is lack of effective screening programs aimed at detecting precancerous conditions before they progress to invasive cancer.

The World Health Organization recommended that in low resource settings, the aim should be to screen every woman once in her lifetime; at 40 years. Frequency of screening should be increased to ‘once every 10 years’ and then ‘once every 5 years’ for women 35-64 years of age. The tests used for screening (cytology, HPV testing, VIA/VILI) and the various screening guidelines are shown in table 1, 2.

Table 1: Sensitivity and specificity of various tests



Table 2: Screening Guidelines (2011)



Current status of cervical cancer screening in India
In the absence of organized screening program, routine screening of asymptomatic women is almost non-existent in India. A consensus on cervical cancer screening was developed in collaboration with WHO in 2006 (NCCP).

The National Cancer Control Programme (NCCP) formulated and funded by the Ministry of Health, Government of India has proposed a plan to screen women using VIA at the PHC and a single visit approach at the District hospital (DH), wherein the treatment based on colposcopy is done in the same visit. Women who are positive for VIA, are referred to the DH, where a repeat VIA, Pap smear, colposcopy, and punch biopsy are done on an out patient basis. If VIA is negative, they come for repeat screening after 5 years. Women with no evidence of invasive disease come for repeat Pap smear and colposcopy after one year. In case of an invasive disease referral for a tertiary care centre is done. (Fig. 1)

Cancer Breast
It is the second most prevalent cancer in Indian women. As 85% patients have no identifiable risk factor other than age, every woman must be considered at risk and universal screening is recommended. Evidence suggests that such screening is associated with a significant decrease in mortality. The sensitivity of Breast self examination is around 48%, Clinical breast examination is 57%-70%, and mammography is 77%-80%.The guidelines for breast cancer screening are shown in table 3.

Ovarian Cancer
It is the second most common gynecological cancer. The incidence of ovarian cancer increases with age, from 1.4 cases per 100,000 in women younger than age 40 to 45.0 cases per 100,000 in women older than 60 years. Ovarian cancer is the most lethal of all the gynecologic cancers, killing more women each year than cervical and endometrial cancers combined.

Fig. 1: Suggested scheme at various levels for a population based screening programme for cervical cancer

Screening Recommendations for Low Risk Women
The effectiveness of routine screening of asymptomatic women using pelvic examination, abdominal or vaginal ultrasound and CA-125 has not been established. (Table 4). ACOG and USPSTF do not recommend routine screening for ovarian cancer. ACS recommends annual pelvic examinations starting at age 18 or when the
woman becomes sexually active.

Screening Recommendations for High risk women (Fig. 2)
The high risk factors are:

• Strong family history of ovarian cancer
• Familial syndromes: site-specific ovarian cancer, familial breast-ovarian cancer syndrome and cancer familial syndrome (Lynch type II)
• Those with mutations of BRCA 1 and BRCA 2.

Endometrial Cancer
The incidence of endometrial cancer increases with age, peaking at 100.7 cases per 100,000 women between the ages of 70 and 75. Most cases of endometrial cancer are diagnosed because of early symptoms, and have high survival rates.

Measuring endometrial thickness (ET) with transvaginal ultrasound (TVS) and endometrial sampling with cytological examination have been proposed as possible screening modalities for endometrial cancer

Table 3: Various guidelines for breast cancer screen


Table 4: Efficacy of Various Screening Modalities


Table 5: Screening algorithm for postmenopausal women with adnexal mass


Screening Recommendations for low risk women
ACOG, ACS and USPSTF have not issued any recommendations for endometrial cancer screening in low risk women. ACOG states that screening for endometrial cancer is neither cost-effective nor warranted.

Screening recommendations for high risk women (Table 6)
The high risk factors are:
• Obesity
• High-fat diet
• Reproductive factors such as nulliparity, polycystic ovarian syndrome, early menarche, and late menopause
• Hereditary non-polyposis colorectal cancer (HNPCC) syndrome is associated with a markedly increased risk of endometrial cancer compared with women in the general population. Among women who are HNPCC carriers, the estimated cumulative incidence of endometrial cancer ranges from 20% to 60% by age 70 years. This risk appears to differ slightly based on the germline mutation; for MLH1 carriers the lifetime risk at age 70 years is 25% while in MLH2 mutation carriers it is 35% to 40%.

Fig. 2: Screening Recommendations for High risk women



Table 6: Screening Recommendations For High Risk Women



Recommendations for Women on Tamoxifen
ACOG recommends that screening for endometrial cancer in women who are receiving tamoxifen be left to the discretion of the physician. Endometrial cancers that occur in tamoxifen-treated women are very similar to those occurring in the general population, with respect to stage, grade, and histology. Current evidence does not justify the use of any investigation (USG, hysteroscopy, endometrial biopsy or D&C) in post menopausal women receiving treatment with tamoxifen in absence of vaginal bleeding. Ultrasonography and endometrial thickness is not a useful discriminator. Hysteroscopy with biopsy is preferable investigation in symptomatic women taking tamoxifen.

Suggested Reading

1. World Health Organization. Human papillomavirus infection and cervical cancer. Geneva: WHO; 2003: 1-74.
2. Koss LG, Greenebaum. Precancerous lesions. In: Bourke GF, editor. The epidemiology of cancer. Charles Press: Philadelphia; 1983. p. 31-59.
3. Miller AB. Cervical Cancer screening programs: Managerial guidelines. WHO: Geneva; 1992.
4. Government of India, Ministry of Health & Family Welfare. District cancer control. National cancer control programme guidelines. New Delhi: Ministry of Health & Family Welfare; 2005.
5. American Cancer Society. Prevention and early detection. Retrieved September 21, 2003.
6. American College of Obstetricians and Gynecologists. Routine cancer screening. ACOG 2000 Opinion, No. 185.
7. United States Preventive Services Task Force. Guide to clinical preventive services. 2d ed. Baltimore: Williams & Wilkins, 1996. Retrieved September 19, 2000.
8. American College of Obstetricians and Gynecologists. Ovarian cancer. ACOG educational bulletin, No. 25. Obstet Gynecol 1998; 72(2).
9. American Academy of Family Physicians. Summary of policy recommendations for periodic health examination. Retrieved September 19, 2000.
10. Kerlikowske K, Brown JS, Grady DG. Should women with familial ovarian cancer undergo prophylactic oophorectomy? Obstet Gynecol 1992; 80: 700-7.
11. Schottenfeld D. Epidemiology of endometrial neoplasia. J Cell Biochem Suppl 1995; 23: 151-9.
12. Burke W, Petersen G, Lynch P, Botkin J, Daly M, Garber J, et al; for Cancer Genetics Studies Consortium. Recommendations for follow-up care of individuals with an inherited predisposition to cancer: Hereditary nonpolyposis colon cancer. JAMA 1997; 277: 915-9.
13. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 169, February 1996. Tamoxifen and endometrial cancer. Int J Gynaecol Obstet 1996; 53: 197-9.