Page 33 - Essentia Vol 5 Issue 1

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A BIANNUAL NEWSLETTER OF ASSAM CANCER CARE FOUNDATION A BIANNUAL NEWSLETTER OF ASSAM CANCER CARE FOUNDATION

International guidance has also moved towards in the 30–49 year group versus 77.6% in the 50–65
HPV-based primary testing, with self-collected year group), a finding directly relevant to Northeast
vaginal sampling increasingly recognised as an India’s screening population given that cervical
option where systems can support it. cancer in several northeastern registries presents
For Northeast India, the evidence points to two across a wide age range and not infrequently in
priorities. First, primary screening should move younger women. Structured scoring systems
from VIA to HPV DNA testing wherever laboratory such as the Swede score further improve the
and logistic capacity permit. Its higher sensitivity consistency of colposcopic assessment: a Swede
and longer safe screening interval are especially score threshold of five or more has been shown to
important for populations reached intermittently achieve a sensitivity of 88.4% and specificity of
through outreach camps. Second, home-based 87.1% for CIN2+ lesions, while higher thresholds can
HPV self-sampling can help extend coverage to support same-visit “see-and-treat” management,
hill, tribal and remote communities where facility- minimising the loss to follow-up that plagues multi-
based pelvic examination remains a major barrier. visit screening pathways.
Pap cytology still has a defined role. It can help Community screening data from Andhra Pradesh
triage HPV-positive women, identifying those who offer an important warning for the Northeast.
need immediate colposcopy and those who can be When screen-positive women do not complete
safely re-tested at a shorter interval. It also remains colposcopy or biopsy, preventable disease is lost
relevant in centres where HPV DNA platforms are from the care pathway even when the screening
not yet available. For a tertiary referral institute, test performs well. National assessments show
the practical question is therefore not Pap versus similar gaps in infrastructure and staffing at
HPV DNA, but how to build a tiered system in which the levels responsible for diagnostic work-
HPV DNA is the primary screen and Pap cytology up and referral. In rural settings, few facilities
supports triage where appropriate. have personnel trained in cytology processing,
colposcopy or HPV testing, making colposcope
Colposcopy: The pivotal, under- availability and trained providers urgent priorities.
resourced link For the State Cancer Institute at Guwahati and
HPV DNA testing identifies women who need similar tertiary centres in the Northeast, this has
further evaluation, but colposcopy remains the three practical implications. First, every woman
key link between a positive screen and definitive with a positive VIA, Pap or HPV DNA test should have
care. In Northeast India, this link needs far greater a defined, time-bound pathway to colposcopy
attention. Colposcopy is resource-intensive and instead of an open-ended referral. Second,
operator-dependent, but it is also the step that colposcopy training and equipment must move
connects screening to confirmation and timely beyond tertiary institutes to district hospitals and
management. well-functioning community health centres. Third,
The performance data justify this central role structured scoring, such as the Swede score, along
when colposcopy is properly standardised. In with same-visit biopsy or see-and-treat protocols
the large multicentre ESTAMPA screening study, where feasible, should become standard. This
standardised colposcopy used to triage HPV- is what converts a positive screening result into
positive women achieved a sensitivity of 91.2% and diagnosis and treatment within a realistic patient
a specificity of 50.1% for detecting CIN3 or worse, pathway.
figures broadly consistent with an earlier meta- Way forward: A tiered, colposcopy-
analysis reporting a pooled sensitivity of 86% and anchored strategy for the region
specificity of 72% for colposcopy in this triage
role. Notably, sensitivity for high-grade disease • Transition primary screening from VIA to HPV
was significantly higher in younger women (93.5% DNA testing in a phased manner, prioritising

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