CHAPTER-1

INTRODUCTION

1.1 CONCEPT AND BACKGROUND

According to World Health Organization (2024) cervical cancer ranks as the fourth most
prevalent cancer among women worldwide. In 2022, around 660,000 women were diagnosed
with cervical cancer across the globe, and approximately 350,000 women died from the
disease. In India, cervical cancer ranks as the 2nd most frequent cancer after breast cancer
among women and the 2nd most frequent cancer among women between 15 and 44 years of
age [(ICO/IARC Information Centre on HPV and Cancer, 2023); (Statistics – ICMR –
National Institute of Cancer Prevention and Research, n.d.)].

Figure 1.1 Cancer Statistics (Global Cancer Observatory, 2024)

As reported by the ICMR – National Institute of Cancer Prevention and Research, under the
Ministry of Health and Family Welfare, Government of India, cervical cancer accounts for
22.86% of all cancer cases among women and 12% of all cancer cases in both men and
women in India. It is the third leading cause of cancer-related deaths in the country,
contributing to nearly 10% of all cancer fatalities. In India, one woman dies of cervical
cancer every 8 minutes.

Cervical cancer develops in a woman's cervix (the entrance to the uterus from the vagina)
(World Health Organization: WHO, 2019). The cervix, as defined by the National Cancer
Institute (2022), is the lower, narrow end of the uterus (womb).

Cervical cancer usually develops gradually. Initially, the cells in the cervix undergo changes
called dysplasia, leading to the appearance of abnormal cells in the cervical tissue. These
precancerous changes are referred to as Cervical Intraepithelial Neoplasia (CIN), which is
classified into three grades—CIN 1 (mild dysplasia), CIN 2 (moderate dysplasia), and CIN 3
(severe dysplasia or carcinoma in situ)—based on the extent of abnormal cell growth. While
CIN does not always progress to cervical cancer, it serves as a critical indicator for early
detection and timely intervention. Over time, if not destroyed or removed, the abnormal cells
may become cancer cells and start to grow and spread more deeply into the cervix and to
surrounding areas.

Figure 1.2 Natural History of Cervical Cancer and Program Implications (International
Agency for Research on Cancer, 2000)

Almost all cervical cancer cases (99%) are linked to infection with high-risk human
papillomaviruses (HPV), an extremely common virus transmitted through sexual contact
(World Health Organization: WHO, 2019). Long-lasting (persistent) infection with high-
risk types of human papillomavirus (HPV) causes virtually all cervical cancers. Two high-
risk types, HPV 16 and HPV 18, cause 70% of cervical cancers worldwide.

Nearly all people who are sexually active will contract HPV at some stage in their lifetime.
The majority of HPV infections clear up on their own within one to two years as the body's
immune system manages the infection. These transient infections do not result in cancer.
When a high-risk HPV infection persists for several years, it can cause alterations in the
cervical cells, leading to a precancerous lesion. If this precancerous lesion is not detected and
eradicated, it may ultimately progress to cervical cancer (National Cancer Institute, 2024).

1.2 HUMAN PAPILLOMAVIRUS (HPV)

Human papillomavirus (HPV) is one of the most prevalent sexually transmitted infections
around the globe. It is caused by the HPV, a DNA virus that targets epithelial cells in
different mucous membranes and skin areas. HPV consists of over 200 related viruses, with
certain types transmitted through vaginal, anal, or oral intercourse. The sexually transmitted
types of HPV are categorized into two groups: low risk and high risk (Wolf et al., 2024).
High-risk HPV types are responsible for causing various cancers.

There are 12 high-risk HPV types: HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59.
Among these, HPV 16 and HPV 18 account for the majority of cancers associated with HPV.
Typically, infection with high-risk HPV does not produce any symptoms. However,
depending on where the infection occurs, the precancers and cancers linked to a persistent
high-risk HPV infection over many years may result in symptoms such as lumps, bleeding,
and pain.

Most low-risk HPV types infrequently lead to cancer, although certain low-risk types can
result in the development of warts on or near the genitals, anus, mouth, or throat. If warts
develop in the larynx or respiratory tract, it may result in a condition known as respiratory
papillomatosis, which can lead to difficulties in breathing (National Cancer Institute, 2025).
 Figure 1.3 Human Papillomavirus Types (CDC, 2024)

It can also be transmitted through non-penetrative sexual activities that involve skin-to-skin
contact. In addition to sexual transmission, vertical transmission from mother to child during
childbirth is possible but relatively rare.

1.3 CAUSES AND RISK FACTORS OF CERVICAL CANCER

Human papillomavirus (HPV) infection is the main cause of cervical cancer, with various risk
factors affecting both the likelihood of contracting HPV and the progression to cancer. Early
onset of sexual activity, having multiple sexual partners, smoking, and co-infections with
other sexually transmitted infections, such as HIV, considerably heighten the risk of lasting
HPV infection. Moreover, conditions like immune suppression, having many children, being
young at the time of the first pregnancy, and extended use of hormonal contraceptives lead to
a quicker transition from precancerous conditions to cervical cancer.

Although cervical cancer generally develops over 15 to 20 years, women with immune
system compromise, especially those who do not receive treatment for HIV, experience a
significantly faster progression, often occurring within 5 to 10 years [(World Health
Organization: WHO, 2024b); (Schiffman et al., 2017)].
 Figure 1.4 Risk Factors of Cervical Cancers (Bowden et al., 2023)

1.3.1 HPV Infection (primary cause)

Human papillomavirus (HPV) is a virus with double-stranded DNA that mainly infects the
skin and mucous membranes. It can spread through sexual interactions and contact with
contaminated surfaces. There are more than 200 different genotypes of HPV, with around 40
capable of infecting the anogenital area. Certain high-risk HPV types, including HPV-16 and
HPV-18, are associated with the onset of various cancers, especially cervical cancer (Yüksel
& Deniz, 2024).

As per National Cancer Institute (2025) long-lasting infections with high-risk HPV types
can lead to cancer in areas where the virus infects cells. HPV targets the thin, flat squamous
cells that line the inner surfaces of these organs. Consequently, most cancers linked to HPV
are known as squamous cell carcinomas. However, some cervical cancers originate from
HPV infections in the cells that produce mucus and line the inside of the cervix and uterus
known as glandular cells and are classified as adenocarcinomas. HPV-associated cancers
include:

• Anal cancer: More than 90% of anal cancer cases are attributed to HPV. Both the
incidence and mortality rates of anal cancer are rising.
 • Cervical cancer: Nearly all cervical cancer cases are caused by HPV. Regular
screening with an HPV test or Pap test can prevent most cervical cancers by detecting
and allowing the removal of precancerous cells before they progress to cancer. The
highest occurrence of cervical cancer is among women who are rarely or never
screened.
• Oropharyngeal cancers: Also known as throat cancer, this type of cancer develops in
the tissues of the oropharynx, which is the middle part of the throat located behind the
mouth. Approximately 70% of oropharyngeal cancer cases are linked to HPV. It is
important to note that oropharyngeal cancer is distinct from oral cavity cancer, which
develops in the mouth; however, both are considered types of head and neck cancer.
• Penile cancer: About 63% of penile cancer cases are caused by HPV. This rare cancer
typically forms on or beneath the foreskin.
• Vaginal cancer: Approximately 75% of vaginal cancer cases are linked to HPV. This
type of cancer is considered rare.
• Vulvar cancer: Around 69% of vulvar cancer cases are attributed to HPV.

1.3.2 Early sexual activity and multiple partners

Early age at first sexual intercourse (AFSI) has been associated with an increased risk of
high-risk human papillomavirus (HPV) infection, a sexually transmitted infection (STIS), that
in susceptible women is responsible for virtually all cases of invasive cervical cancer (ICC)
(Bosch et al, 2002). Since sexual behavior influences exposure to HPV, AFSI is particularly
relevant as it has been linked to higher-risk sexual practices, including unprotected sex,
multiple sexual partners, and a partner with multiple partners. Additionally, it is suggested
that the heightened risk of HPV may be due to a biological vulnerability of the immature
cervix during adolescence, making it more prone to persistent HPV infections and increasing
the likelihood of cancer development [(Louie et al., 2009); (Mekonnen & Mittiku, 2023)].

As indicated by the Canadian Cancer Society, women’s risk of developing cervical cancer is
higher if their male partners have a history of multiple sexual partners or partners who have
had cervical cancer. Engaging in sexual relationships with many partners elevates the chances
of HPV exposure, which is transmitted through sexual contact. Therefore, an increased
number of sexual partners is associated with a heightened risk of cervical cancer.
1.3.3 Weak immune system
The immune system plays a crucial role in eliminating cancer cells and inhibiting their
growth and spread. However, the human immunodeficiency virus (HIV) weakens the
immune system, making individuals more susceptible to other infections, including HPV. As
a result, HIV increases the risk that precancerous changes in cervical cells will progress to
cervical cancer.
Women who are HIV positive face an increased risk of developing cervical cancer, and in
them, precancerous cells advance to cervical cancer more rapidly compared to women who
are HIV negative [(Canadian Cancer Society, n.d.); (American Cancer Society, n.d.)].

1.3.4 Smoking
According to the Canadian Cancer Society, smoking exposes both smokers and those
around them to numerous cancer-causing chemicals that impact organs beyond the lungs.
These harmful substances are absorbed through the lungs and distributed throughout the body
via the bloodstream. Additionally, smoking weakens the immune system’s ability to fight off
HPV infections. Studies have detected tobacco by-products in the cervical mucus of women
who smoke, suggesting that smoking makes it more likely for an HPV infection to persist. If
the infection does not eliminate on its own, it can lead to precancerous changes in the cervix,
eventually increasing the risk of cervical cancer.

1.3.5 Long-term use of oral contraceptives

Oral contraceptives, often referred to as the pill, may raise the likelihood of an HPV infection
progressing to cervical cancer if used for an extended period. This increased risk does not
seem to be linked to the presence of an HPV infection itself. Women who use oral
contraceptives for more than five years are at the greatest risk of developing cervical cancer.
However, this risk decreases gradually after stopping the pills. A decade after discontinuing
their use, the heightened risk for cervical cancer is no longer present (Canadian Cancer
Society).

1.3.6 Poor diet and low intake of antioxidants

A diet deficient in vitamin and mineral is associated with reduced immune function, higher
DNA damage, and a higher risk of cervical cancer.
Nutrients such as vitamins, minerals, dietary fiber, plant sterols, carotenoids, and various
phytochemicals may help prevent multiple cancers through their antitumor, antioxidant, and
anti-inflammatory activities (Hajiesmaeil et al., 2022). Women whose diets don’t include
enough fruits and vegetables may be at increased risk for cervical cancer (American Cancer
Society, 2024).

1.4 SIGNS AND SYMPTOMS OF CERVICAL CANCER

According to World Health Organization (2024) and American Cancer Society (2024)
cervical cancer is often asymptomatic in its early stages. Most women with early cervical
intraepithelial neoplasia (CIN) or early-stage cervical cancer do not experience noticeable
symptoms. Clinical signs typically manifest only after the disease has progressed and the
tumor begins to invade surrounding tissues.
The most common symptoms associated with cervical cancer include:
• Abnormal vaginal bleeding: This may present as bleeding following sexual
intercourse, postmenopausal bleeding, intermenstrual bleeding, or unusually heavy
and prolonged menstrual periods. In some cases, bleeding may also occur following
vaginal douching.
• Unusual vaginal discharge: The discharge may be watery or thick and can contain
blood. It may occur between menstrual periods or after menopause.
• Dyspareunia: Pain or discomfort during sexual intercourse is frequently reported in
cases with cervical involvement.
• Pelvic pain: Persistent or intermittent pain in the lower abdomen or pelvic region may
indicate disease progression.
In more advanced stages of cervical cancer, the following symptoms may be observed:
• Lower limb edema: Swelling of the legs may occur due to obstruction of lymphatic or
venous flow.
• Urinary and bowel symptoms: These may include difficulty or pain during urination
or defecation, which can result from tumor invasion into adjacent organs.
• Hematuria: The presence of blood in the urine may indicate advanced disease
affecting the urinary tract.
• Unexplained or sudden weight loss: Significant and unintentional weight loss may
occur as the disease progresses, reflecting systemic involvement and increased
metabolic demands of the tumor.
Recognition of these symptoms, particularly in high-risk populations, is critical for early
detection and timely intervention.
1.5 PREVENTION STRATEGIES FOR CERVICAL CANCER
Cervical cancer is largely preventable and treatable if detected in the early stages. Almost all
cases of cervical cancer can be avoided through HPV vaccination, regular screening for
cervical cancer, and timely follow-up treatment when necessary.
In 2018, the World Health Organisation (WHO) made a call to eradicate cervical cancer
and introduced a global strategy to hasten its elimination in 2020. This global strategy
consists of three interrelated components: 1) achieving 90% HPV vaccination coverage
among eligible girls; 2) ensuring 70% screening coverage with a high-performance test; and
3) guaranteeing that at least 90% of women with a positive screening result or cervical lesion
receive appropriate treatment.

1.5.1 HPV Vaccination

The HPV vaccine is a reliable and efficient method for reducing the risk of cervical cancer.
Like other vaccines designed to prevent viral infections, HPV vaccines prompt the immune
system to generate antibodies that attach to the HPV virus during future exposures,
preventing it from entering cells. The existing HPV vaccines utilize virus-like particles
(VLPs) composed of components from the HPV surface. These VLPs cannot cause infection
as they do not contain the virus’s DNA. However, they closely mimic the natural virus, and
antibodies generated in response to the VLPs also target the actual virus. Research has shown
that VLPs are highly immunogenic, meaning they trigger a robust antibody response from the
body. This property contributes to the strong effectiveness of the vaccines (National Cancer
Institute, 2021).
HPV vaccines are administrated to prevent cervical premalignant lesions and cancers induced
by high-risk HPV infections.

Types of vaccines: Cervarix, Gardasil, Gardasil-9, Cervavac

1. Bivalent (HPV2): This vaccine contains HPV types 16 and 18
2. Quadrivalent (HPV4): This vaccine contains HPV types 6, 11,16 and 18
3. Nonavalent (HPV9): This vaccine contains HPV types 6, 11, 16, 18, 31, 33, 45, 52 and
58. This vaccine is expected to broaden the protection against cervical cancer by -15%.

In India, the Bivalent vaccine (HPV2) and the Quadrivalent HPV vaccine (HPV 4) is
expected to prevent ~ 83% of cervical cancers, whereas the Nonavalent vaccine (HPV 9) is
expected to prevent ~ 98% of cervical cancers.
All the 3 vaccines are very effective in preventing cervical cancers caused by the types
contained in the vaccine.

The first HPV vaccine was licensed in 2006, and so far, six prophylactic vaccines have been
approved. All HPV vaccines contain virus-like particles (VLPs) similar to HPV types 16 and
18, which are the two most prevalent genotypes (Wang et al., 2025).

Two HPV vaccines are licensed by the FDA and recommended by CDC. These vaccines are
Cervarix (made by GlaxoSmithKline) and Gardasil (made by Merck) Indian Academy of
Pediatrics (IAP, 2021). Gardasil 9 has received FDA approval for both females and males
between the ages of 9 and 45. The vaccine is designed to prevent precancers and cancers
associated with seven HPV types linked to cancer (16, 18, 31, 33, 45, 52, and 58) and to
prevent genital warts resulting from HPV types 6 and 11. Cervarix protects against infection
from types 16 and 18, while Gardasil offers protection against types 6, 11, 16, and 18. The
HPV vaccine is not designed to cure an existing HPV infection (National Cancer Institute,
2024).

Cervavac®- India’s First Indigenous & Gender-Neutral HPV Vaccine

Cervavac® is the first vaccine created and manufactured in India by the Serum Institute of
India (SII) in partnership with the Department of Biotechnology, the Biotechnology Industry
Research Assistance Council, and the Bill & Melinda Gates Foundation to safeguard against
four strains of the human papillomavirus (HPV).

Figure 1.5 India’s pioneering HPV vaccine- CERVAVAC (Serum Institute of India)
Approved by International Agency for Research on Cancer (IARC) in January 2023, this
quadrivalent vaccine targets HPV types 6, 11, 16, and 18—effectively addressing the
oncogenic strains responsible for the majority of cervical cancer cases as well as genital
warts.

• For children and adolescents aged 9-14 years, CERVAVAC® should be given
following a 2-dose regimen – 0.5 ml at 0 and 6 months.
• For individuals 15 years and older, CERVAVAC® should be administered using a 3-
dose regimen – 0.5 ml at the beginning, then at 2 months, and again at 6 months.

Schedule for HPV vaccination

The HPV vaccine is administered in either two or three doses, based on the recipient's age.
According to Centers for Disease Control and Prevention (CDC, 2021) and Indian
Academy of Pediatrics (IAP, 2020-21) the vaccination schedule is as follows:

• For girls aged 9 to 14: Two doses should be given with a 6-month interval, at 0 and 6
months.
• For girls who are 15 years and older: It is recommended to administer three doses
with the schedule of 0-1-6 months for Cervarix and 0-2-6 months for Gardasil.
• In individuals with compromised immune systems of any age: Three doses are
advised following the schedule of 0-1-6 months for Cervarix and 0-2-6 months for
Gardasil.
• HPV9 is approved for a three-dose regimen of 0-2-6 months for females aged 9-26
years and males aged 9-15 years. The optimal age to begin the vaccination is between
9 and 10 years old.
• For pregnant individuals, HPV vaccination should wait until after the pregnancy;
however, there is no need for pregnancy tests before receiving the vaccine. Current
evidence indicates that the vaccination does not impact pregnancy or pose risks to a
developing fetus.
 Table 1.1 List of HPV vaccine (Wang et al., 2025)

Vaccine Type Name Target Target Routine

Population Age

Bivalent (HPV types 16 Cervarix Girls and 9-14 2 doses (5-13 months
and 18) boys apart)

15+ 3 doses (0, 1-2.5

months, and 5-12
months)
Cecolin Girls 9-14 2 doses (6 months
apart)

15+ 3 doses (0, 1-2 months,

and 5-8 months)

Walrinvax Girls 9-14 2 doses (6 months

apart, with a minimum
interval of 5 months)
15+ 3 doses (0, 2-3 months,
and 6-7 months)

Quadrivalent (HPV Gardasil Girls and 9-13 2 doses (6 months

types 6, 11, 16, and 18) boys apart)

14+ 3 doses (0, 1-2 months,

and 4-6 months)

Cervavac Girls and 9-14 2 doses (6 months

boys apart)

15+ 3 doses (0, 2, and 6

months)

Nonavalent (HPV types Gardasil9 Girls and 9-14 2 doses (5-13 months
6, 11, 16, 18, 31, 33, 45, boys apart)
52, and 58)
14+ 3 doses (0, 1-2 months,
and 4-6 months)
1.5.2 Safe Sexual Practices
HPV can be spread through sexual activities; however, conventional strategies for preventing
sexually transmitted infections usually do not apply to HPV. Reducing the number of sexual
partners, practicing abstinence, and postponing the initiation of sexual activity can lower the
risk but cannot completely remove it (Wang et al., 2025). Use of condoms during intercourse
has been associated with decreased HPV infection and cervical cancer development
[(National Cancer Institute, 2024); (Centers for Disease Control and Prevention, 2024);
(WHO, 2024)]

1.5.3 Lifestyle and Dietary Prevention

Dietary factors are estimated to contribute to approximately 20-60% of all cancers globally.
Diet and nutrition not only provide essential physiological components for the body but also
play a vital role in cancer management. Micronutrient deficiency (Vitamin A, B, C, D, E, K,
Folate, Zinc, Selenium) increases susceptibility to infections, including high-risk human
papillomavirus (HPV), and contributing to the risk of cervical cancer [(Avila et al., 2023);
Huang et al. (2020); (Ono et al., 2020c); (Koshiyama, 2019); (Piyathilake et al., 2004)].

Antioxidants, including flavonoids, polyphenols, and carotenoids, neutralize oxidative stress

and reduce the risk of HPV-induced malignancy. Diets rich in cruciferous vegetables, green
tea, and berries lower cervical cancer risk (Ono et al., 2020b).

Figure 1.6 The effects of individual nutrients and foods on the development of cervical
cancer. (Ono et al., 2020b)
Western dietary pattern, characterized by high consumption of processed meats, snacks, and
sweets, increases cervical cancer risk by 22%. Conversely, a prudent dietary pattern rich in
fruits, vegetables, whole grains, and legumes reduces risk by 19%. Notably, high intake of
omega-3 fatty acids lowers risk by 17%, while high processed meat consumption increases
risk by 23%. Adopting a balanced diet rich in whole foods and omega-3 fatty acids may be an
effective strategy for cervical cancer prevention [(Barchitta et al.,2018b); Hwang et al.
(2009)].

Thus, various dietary components, particularly those with immune-enhancing, anti-

inflammatory, and antioxidant properties, play a crucial role in reducing oxidative stress and
boosting immunity. These effects can influence HPV infection outcomes and serve as a
preventive strategy against cervical cancer.

1.5.3 Regular Screening

As a preventive measure, it is essential to emphasize that while the HPV vaccine provides
protection against many of the high-risk HPV types associated with cervical cancer, it does
not protect against all strains. Thus, regular cervical cancer screening remains a critical
component of prevention.
Regular screening for cervical cancer, such as the Pap smear or HPV testing, is essential for
early detection of abnormal cell changes that could lead to cancer. Early-stage cervical cancer
and its precursors, such as Cervical Intraepithelial Neoplasia (CIN), often show no
symptoms, making routine screenings crucial. These tests help detect high-risk HPV
infections, as well as abnormal cellular changes and precancerous lesions that can be treated
before they develop into cervical cancer.
Regular screenings, starting in the early 20s, are necessary for those with a cervix to ensure
early detection and intervention.
For these screening methods to be effective, it is crucial that individuals adhere to timely
screening schedules and receive appropriate follow-up care for any abnormal results, which
can significantly reduce the risk of progression to invasive cancer (National Cancer
Institute, 2024).

1.6 SCREENING AND EARLY DETECTION

Screening refers to the process of detecting a disease before any symptoms appear. For
individuals with a cervix, cervical cancer screening is a crucial element of regular healthcare.
The purpose of cervical cancer screening is to identify precancerous changes in cervical cells,
allowing for treatment to prevent the development of cervical cancer. Occasionally, cancer
may be detected during cervical screenings. Usually, cervical cancer diagnosed at an early
stage is more manageable. Once symptoms arise, the cancer may have started to spread,
complicating treatment efforts (National Cancer Institute, 2025).

1.6.1 Pap Smear Test (Papanicolaou Test)

The Pap test (also known as a Pap smear or cervical cytology) gathers cervical cells for
analysis to check for changes induced by HPV, which could develop into cervical cancer if
left unaddressed. It can identify both precancerous cells and cervical cancer cells, as well as
conditions that are not cancer-related, such as infections or inflammation (National Cancer
Institute, 2025).

1.6.2 HPV DNA Test

The World Health Organization (2021) defines the HPV DNA test as a molecular
diagnostic procedure that detects the presence of high-risk human papillomavirus (HPV)
DNA in cervical epithelial cells. The test involves collecting a sample of cervical cells,
typically using a swab or brush, which is then analyzed in a laboratory to identify the DNA of
high-risk HPV types. Detecting these high-risk strains is crucial, as persistent infection with
them can lead to cervical intraepithelial neoplasia (CIN) and, if untreated, progress to cervical
cancer.
WHO recommends HPV DNA testing as the first-choice method for cervical cancer
screening, especially for women aged 30 and above. This recommendation is based on the
test's superior sensitivity in detecting precancerous lesions compared to other screening
methods.

1.6.3 Visual Inspection with Acetic Acid (VIA)

Visual inspection using acetic acid involves a direct observation of the cervix after applying
5% acetic acid, with the interpretation of results occurring after one minute. This test is
straightforward and cost-effective for identifying precancerous lesions and early-stage
invasive cancer in the cervix of women who appear healthy and exhibit no symptoms.
Results from the VIA test are available right away and do not depend on laboratory analysis.
It is a low-cost alternative for resource-limited settings (ICMR-National Institute of Cancer
Prevention and Research, 2019).
 Dehydration of cells and
Application of acetic acid coagulation of cellular
protein

Higher concentration of
Light reflected back to proteins (increase nuclear
observer protein and chromatin
material in dysplatic cells)

Area looks white in color

Figure 1.7 Principles of VIA Test (ICMR-National Institute of Cancer Prevention and
Research, 2019)

The evaluation of the VIA test relies on identifying a clearly defined dense acetowhite region
in the cervical transformation zone one minute after the application of acetic acid, indicating
potential precancerous changes. This test is particularly effective for women between the
ages of 30 and 49, as most high-grade cervical precancers are discovered within this age
group.

The sensitivity of the VIA test (its ability to accurately identify precancers and cancers)
diminishes in postmenopausal women. The test is appropriate for screening women living
with HIV, for whom screening should commence at the age of 25. There are no
contraindications for conducting the VIA test on a pregnant woman (International Agency
for Research on Cancer, n.d.).

Age Group Screening Method Frequency

21 to 29 Pap test Every 3 years if the result is normal
30 to 65 HPV test only (Primary Every 5 years if the result is normal
HPV testing)

Co-testing (HPV + Pap Every 5 years if both results are normal

test)
Pap test only Every 3 years if the result is normal
Older than 65 No screening required At least 3 normal Pap tests or 2 negative HPV
if: tests in the last 10 years, and no history of
cervical precancer
Cervix removed in a total hysterectomy for
non-cancerous reasons

Table 1.2 Screening Recommendations (Centers for Disease Control and Prevention,
2024)

Regular screening is essential for identifying precancerous changes prior to their

development into cervical cancer. The Pap smear test, HPV DNA test, and VIA screening
serve as effective methods for early detection, greatly lowering the mortality rates associated
with cervical cancer.

1.7 CONCLUSION
Cervical cancer continues to pose a significant global health challenge, particularly in low-
and middle-income countries such as India, where the incidence and mortality rates remain
disproportionately high. Despite the availability of effective preventive measures, including
HPV vaccination, routine screening, and health-promoting lifestyle modifications, the burden
of cervical cancer persists. This ongoing challenge highlights a disconnect between available
scientific interventions and their implementation at the community level.
Furthermore, the successful prevention of cervical cancer depends not only on clinical efforts
but also on the widespread awareness, timely health-seeking behavior, and active
participation of the population in preventive strategies. Cultural beliefs, low health literacy,
and insufficient community-level engagement further restrict the effectiveness of prevention
programs. Therefore, understanding how women perceive, engage with, and act upon cervical
cancer-related knowledge is essential for public health advancement.

1.8 RATIONALE FOR THE STUDY

While cervical cancer is largely preventable, existing evidence indicates considerable gaps in
public knowledge, attitudes, and preventive practices, particularly among women in various
urban and semi-urban settings. There remains a paucity of region-specific data exploring
these dimensions, especially in relation to the integration of clinical prevention strategies
with lifestyle-related factors such as diet, sexual hygiene, and overall health behaviors.

In the context of Chandigarh—a region characterized by rapid urbanization and

heterogeneous socio-economic strata—there is a pressing need to assess the knowledge,
attitudes, and practices (KAP) of women concerning cervical cancer prevention. This study is
positioned to address this gap by systematically investigating not only biomedical awareness
but also behavioral and lifestyle determinants.

This study aims to fill that gap by exploring cervical cancer-related awareness and behaviors
among women in Chandigarh, to inform effective, targeted public health interventions.

1.9 GENERAL OBJECTIVE- Assessment of Knowledge, Attitude, and Practice (KAP)

towards cervical cancer, its prevention, and the role of diet and lifestyle among
women in Chandigarh.

SPECIFIC OBJECTIVES:
1. To evaluate the level of knowledge among women regarding HPV, cervical cancer, its
symptoms, causes, and risk factors.
2. To assess the attitudes of women towards cervical cancer screening, HPV vaccination,
and preventive health behaviors.
3. To examine the actual practices adopted by women for the prevention and early
detection of cervical cancer.
4. To explore the awareness and application of dietary and lifestyle-related preventive
strategies in relation to cervical cancer.
5. To identify associations between demographic variables and KAP scores to understand
influencing factors.