A calling card to strike at cancer
At a time when the growing cancer incidence remains a cause for concern, models and structured initiatives in Tamil Nadu are demonstrating how organised screening could pave the way for early and prompt diagnosis and treatment of some of the commonest cancers of breast, cervix and oral. Serena Josephine M. finds out more
Rukmani*, 52, does not respond when asked about her cancer diagnosis and treatment. With her medical file in hand, she and her husband, Sivabalan*, a welder, wait outside the Villupuram Cancer Screening and Education Centre at the government hospital for her periodic checkup. In their nearly 10minute conversation, not once do the couple mention the word, ‘cancer’, but Sivabalan is keen to talk. He recalls every detail, as he wants others to know what early detection and prompt treatment could mean for patients and their families. “In fact, I didn’t even tell her about her diagnosis until she was admitted for treatment, knowing well that she would get scared,” he said. It all started more than six years ago when Rukmani, who used to work as an agricultural labourer, began to experience abdominal pain. As the pain grew severe in six months, she turned up at private clinics where she was mostly treated for ulcers, he recalled. “No tests were done but they gave me medications for pain relief. I was finding it difficult to bend and eat, and had severe lower abdominal pain,” Rukmani quietly added.
It was in 2018 when a team of Cancer Institute’s Villupuram Cancer Screening and Education Centre landed at their village in the Koothampakkam panchayat of Kandamangalam block, and organised a screening camp that their journey towards finding an answer for her pain began. A doctor and a nurse knocked on their doors and asked her to come for a checkup at the camp. She was diagnosed with early cervical cancer, and was treated by doctors of the Cancer Institute (WIA), Adyar. Since then, she has been on a regular followup with the team in Villupuram.
Nearly six kilometres away, in a quiet neighbourhood of the Thanthai Periyar Transport Employees Nagar in the Kandamanadi panchayat of Koliyanur block, live Kamatchi* and her husband. A breast cancer diagnosis at the age of 42 came as a rude shock to the couple. It took them nearly six months and repeated house visits and phone calls to seek medical care. “The year was 2016. I was diagnosed with breast cancer following a screening camp here. The treatment — a surgery followed by chemotherapy and several cycles of radiation — took almost six months. I was always dizzy, unable to eat and had bouts of vomiting, but my husband did not leave my side,” she said. As her eyes welled up, Kamatchi is keen on staying strong. “We should fight cancer without fear, and getting treated on time is important,” she said. Diagnosis may have changed the lives of Rukmani and Kamatchi, but without the organised screening that ensured timely diagnosis and treatment, it would be difficult to say what might have happened to the women.
Making progress
In a span of seven years, after a pandemic disruption of 18 months, the team of Cancer Institute’s satellite cancer screening centre in Villupuram made progress in taking populationbased breast, cervix, and oral screening to people, reaching 61,799 women in Villupuram taluk alone, registering a net coverage of 53.2%. While the initiative has been scaled up in Pudukkottai, Tiruvannamalai, Sivaganga, and Ramanathapuram districts and has moved to the next taluk in Villupuram district, Thiruvennainallur, the Health Department in November 2023 launched a populationbased cancer screening in four pilot districts — Erode, Ranipet, Tirupattur, and Kanniyakumari — through 606 screening units.
“The Villupuram project was initiated in 2015 with CSR funding of ₹5 crore from Infosys Foundation,” said Malliga J.S., head of preventive oncology, Cancer Institute. The onetime grant was utilised to conduct this demonstration project and its successful implementation has led to the extension of the project to four more districts with the support of Cancer Institute Foundation. “When we started the programme, the screened positive women had to come all the way to Chennai for diagnosis and treatment. Now, with improved facilities like colposcopy and breastimaging services at districtlevel medical colleges, we are able to refer them to local facilities. This has improved the compliance with diagnosis and treatment,” she added
How important are organised communitybased screenings for a State like Tamil Nadu? T.S. Selvavinayagam, Director of Public Health and Preventive Medicine, explained, “Most cancers are diagnosed at late stages both in India and in Tamil Nadu. According to rough estimates, almost 60% of the cases are getting diagnosed only in stages three and four. The organised screening will facilitate diagnosing them earlier so that there is less suffering to the individual, and almost complete care and cure are possible.”
Vidhya Viswanathan, Deputy Director (NCD and Immunisation), Directorate of Public Health and Preventive Medicine, said a noncommunicable diseases screening programme had been going on in the State for the last 20 years. “Cancer screening is done at all primary health centres, government hospitals, and medical college hospitals. But this is opportunistic screening, meaning whoever comes to a facility is tested. Now, an organised communitybased screening has been rolled out as the first step towards reaching out to all women. In doortodoor visits, women health volunteers hand over invitations to women and men with their names written on it and motivate them to come to the screening units — women aged above 30 for breast and cervix screening and all aged above 18 years for oral screening,” she explained. In fact, the Health Department increased the number of screening units in these four pilot districts by adding 334 health and wellness centres. This was to avoid long hours of travel for women, she added. At these units, Visual Inspection with Acetic Acid (VIA) is done for cervical cancer screening, and if found positive, women are referred to the government hospital/ medical college hospital for colposcopy.
Data showed that invitations were given to 2,49,961 women for breast and cervical cancer screening, and 78,402 of them were screened for breast cancer and 59,670 for cervical cancer. “The response is good, and about 30%40% of our firstyear target group has reached the health facility as of now. We continue to motivate the others to get screened,” Dr. Vidhya said.
Good response
Dr. Selvavinayagam added: “We expect almost every woman who receives the invitation card to participate in the screening at the earliest, and those with suspected symptoms to go to a higher centre for confirmation. There is a little gap in this, which we hope to bridge in the coming days with regular followup. As of now, the initiative is highly successful. This type of organised screening, as far as I know, has not been attempted in any State so far. Even in Tamil Nadu, we did only opportunistic screening earlier.”
At the heart of the populationbased screenings lies the role of field workers. Take the Cancer Institute’s team, for instance. Reaching out to the rural pockets of Villupuram has been no easy task. Several of them recalled how residents used to shy away from the screening teams and how some requested them not to turn up at their homes in hospital uniforms so that information on their cancer diagnosis did not spread in the neighbourhood. The team, however, has its daily tasks cut out. Every morning, it packs all utilities and travels in an ambulance to the designated campsite. Prior to the camp day, the members make sure that the residents are informed.
Doortodoor visits form the core of the screening. At a camp held at the gram sabha building of Elandurai panchayat, nearly 35 kilometre from the Villupuram government hospital, social workers G. Periyanayagi and K. Sudha, armed with pamphlets, sheets of papers and registration cards attached to clipboards, knock on the door of every house, unmindful of the searing sun. They explain patiently, even repeating the lines, to make the message of the initiative clear. “Compared with 2016, awareness has improved though some still have the fear of coming for a checkup. We take up house visits two times during the camp; the first in the morning and then in the afternoon” Ms. Sudha said.
While the camp is in session, nurses and social workers run the registration area and send the women, after obtaining their informed content and details, to the makeshift clinic where they undergo breast and cervical examination. “At present, screening for cervical cancer is done with a simple test called VIA and examining the cervix for abnormal findings. Screening the cervix for the presence of highrisk Human Papillomavirus (HPV DNA test) is an objective method to detect precancers and cancers. According to studies, a woman above 30 years of age, negative for HPV infection, has very few chances of getting cervical precancer or cancer in the subsequent five to 10 years. A woman who has HPV infection can be evaluated, and if precancerous changes are present, it can be easily treated and cervix cancer can be prevented,” Dr. Malliga explained.
Dhanuraja Velusamy, assistant professor, Department of Preventive Oncology, Cancer Institute, added how a planned mopup in parts of Thiruvennainallur taluk has led to an increase in coverage. “We started the screening here in June 2022, and have reached a coverage of around 50%55% so far. We are doing a mopup and have started reaching out to women, including those who leave early for work. Through this, our coverage has increased to 60%,” he said.
The way ahead
Dr. Malliga added that many developed and developing countries had started implementing primary HPV DNA screening. “An effective implementation of HPV DNA testing and HPV vaccination has great potential to reduce the incidence of cervical cancer,” she said. While HPV DNA screening is more accurate, there are constraints in implementing it at the primary care level, a health official said, adding: “It needs to be done at least at the tertiary care level to start with.” Awareness is the key to better reach and sustained followup, Dr. Velusamy said. “The World Health Organization has set the 907090 strategy to eliminate cervical cancer by 2030: vaccinate 90% of girls by the age of 15, screen 70% of women, and treat 90% of those with cervical disease,” he noted. Dr. Malliga summed up how their efforts have started to pay off. “Through the Villupuram model, we have demonstrated that organised screening is feasible for two common cancers in women [breast and cervix] and oral cancers in both men and women, though there are challenges such as participation of all eligible persons. In an organised screening initiative, there is sustained awareness, and this is the way forward for early detection and prevention. When such screenings are widely done, the coverage will increase, leading to cancer control,” she said.
(*names have been changed to protect identity).
The Villupuram project was initiated in 2015 with CSR funding of ₹5 crore from Infosys Foundation. When we started it, the screened positive women had to come all the way to Chennai for diagnosis and treatment. Now, with improved facilities at districtlevel medical colleges, we are able to refer them to local facilities.
MALLIGA J.S.,
head of preventive oncology, Cancer Institute (WIA)