ASCO 2026 | A community-based model for cervical cancer screening uptake in rural India

This is basically you know trying to bridge the gap between the science and uptake of the science because we know a lot about how to detect cervical cancer early how to treat people and there are lots of people who don’t get this service that is basically because again the four A’s lack of awareness and even if awareness is there is lack of availability of services and then there is a lack of accessibility of those services and the other thing is people cannot afford it and importantly in areas where people do not have enough health literacy people do not have self-efficacy and where decisions are not just by the person but the decisions are determined by the members of the family. It becomes all the more difficult to fill this nodal gap. We know that how to detect cervical cancer, how to treat cervical cancer early, how to reduce the morbidity and mortality with that. But then how do we make people participate in this care continuum from screening to treatment where so many multiple factors are associated. So in response to that, I formulated a strategy where a trusted community health volunteer from the same population where the people that we are going to screen are living. This trusted community health volunteer is an ambassador to try and bring the people into the system from screening to treatment. So the community health volunteer basically first participates in the study. She herself gives her vaginal swab, self-collected vaginal swab and demonstrates to the rest of the community that it is doable, that I can participate so you can. And not only this, because as I mentioned earlier, the decision of trying to undergo a test for the cervical cancer, the decision to follow up to the next steps like colposcopy, the biopsy, the treatment is not just related to the woman. It’s also related to what the family feels, what the husband feels, what the brothers or the sisters feel, what the mother says. So there are lots of factors apart from the individual that come into decision making, the shared decision making and in such cases it’s important that you also onboard the family in the decision making process. So this community health volunteer actually not only counsels the individual who is supposed to be the participant for the screening but also the family and to make it appear that you know not only appear but also to ensure that we are not just looking at cervical cancer as a standalone entity, but trying to address the holistic health care of the individual as well as the family. We offer screening, extended screening for the common diseases like hypertension, diabetes, anemia, thyroid, which are commonly prevalent conditions, not only to the woman who is supposed to be screened, but also to the family. This is to ensure that the comprehensive health care package embeds within itself the screening for cervical cancer. And when you have the entire family participating in something related to health, the probability that the acceptance for the participation and acceptance for the rest of the stages that the woman has to go through in terms of screening to treatment continuum is more so this is the ideology we used and once the woman is subjected to the cervical vaginal swab self collected and then the sample is processed if the test result comes to be positive what we are testing is high-risk HPV DNA like DNA of the high-risk HPV genotype viruses like 6, 11, 16, 18, 31, 45, and so on. The most common are 16 and 18, responsible for 70% of the cancers. Now, if you detect any one of these genotypes in the vaginal swab, then the woman has to undergo the next logical step called colposcopy. But that’s a big barrier. The mental barrier, the woman has to overcome, and then the family has to decide. And if you just leave it at that, the woman would never come up for colposcopy. And that is what happens in most low middle income countries. Only 40% of the women who are tested high risk HPV DNA positive come for colposcopy. Now, because this healthcare worker embedded in the community goes to the household, counsels the participant, counsels the family members, clears their doubts and motivates them and also provides transport connected to the hospital that is part of this research to ensure that the woman gets free transport to the center for the colposcopy. And, you know, these women from the rural areas, they find it difficult to navigate through different places in the hospital. This community health worker acts as a chaperone trying to navigate through various systems in the hospital make it easy and convenient for the participant to go to the right doctor get the colposcopy done and once the colposcopy is done if there is a need for a biopsy even that biopsy is done and the biopsy report is delivered to the home of the participant so if you see the screening is happening at the home transport is provided to come to the hospital and if a colposcopy biopsy is done that report is also delivered to the home of the participants so this way we are trying to make services more available accessible and acceptable to the people so the barriers that we discussed earlier are trying to be overcome through this community health volunteer embedded program, standing by the side of the person all the way, step by step, from screening at the home to laboratory where the test is done. The report is brought to the person, discussed with the family. The person is taken to the hospital for colposcopy and biopsy. And after that, the report is again given. Explanation of the report is given at the doorsteps to the extended family and once the decision is taken and if the woman is expected to receive some treatment because the biopsy shows that there is a suspicious lesion there is a need for the treatment to be done because there is pre-cancer then the treatment is also facilitated by the provision of transport and the health worker and the doctor explains everything. So if you see there is hand holding, there is a compassionate type of support and there is a provision of transport and the decision making is shared with the individual, the health worker, the doctor and the family making it that much more easier for the self-efficacy of the person to become confident. Yes, I can take this bold step to overcome these barriers and go for the treatment. So that is what we have done. And what we have seen with this is usually in India, the uptake of screening is only 2%. But with this model, because in a village or in a community, when you are implementing this strategy, the word spreads that how these people are caring, how these people have a continuum of care seamlessly integrated, how these people take us from the doorstep to the hospital and back. And over a period of time, the participation increases. And we have seen 93% of the people that we have approached for the screening participate in our program. So that is way more than the national average of 2%. The WHO says at least 70% of the eligible women should be screened. So we met that target by reaching 93%. And the other hurdle is if you screen people, the next thing is how many of them actually come for colposcopy. As I told earlier, only 40% come. What we found was more than 70% came for colposcopy because we allayed their anxiety. We gave them the transport. We handheld them. We helped them navigate through the complex systems in the hospital. And we got 70% to colposcopy. And after colposcopy, if there was a need for a biopsy, and if a biopsy was done, WHO says almost all the people who have tested positive for the biopsy, where it shows that there is a pre-cancer or a cancer, they should undergo treatment. In our case, we got all 100% of the women accept the treatment and undergo the treatment. So if you see, with this doorstep model, anchored on community healthcare worker, not only screening for the HPV DNA, screening for other non-communicable diseases, not only screening the individual, screening the entire family for the other non-communicable diseases not only screening the individual screening the entire family for the other non-communicable diseases trying to ensure that we break the barriers of availability accessibility affordability and helping shared decision making being there with them and helping them understand things very clearly dispelling on their myths has helped in maintaining you know the high uptake rate as well as ensuring that they get all the care as part of the care continuum in cervical cancer and achieving 90% screening uptake, 70% colposcopy and 100% linkage to treatment. So this is what is translating whatever is expected to be done, what is mentioned in guidelines, what is recommended and what actually is happening on the ground from 2% to 90% uptake is what we have achieved with the program that I just described.