In Mumbai you’re doing very original work with this ingenious test, a very simple test, the acetic acid test for cervical cancer. At the moment that is big news because you were talking about it at ASCO but also you’ve got things in breast cancer. Can you tell me what you’re doing because I know one of the really fascinating parts of this is introducing it to the community, the psychological barriers can prevent screening from happening, can’t they?

Sure. What we have done is 150,000 women were divided into two halves. The first half had visual inspection of cervix after painting it with acetic acid and the other half had awareness about cervical cancer. The same thing also happened with breast cancer, that a physical examination performed by a trained health worker happened in these women and the other half had awareness of breast cancer.

And this is huge numbers of women involved?

Yes, so 75,000 women in each group and we are now onto the twelfth year of follow-up.

What are the data coming out of this?

We are presently ready with the cervical cancer data, we will be ready with the breast cancer data a year from now. But talking about cervical cancer, the first and the foremost thing that happened which we were aware of about five years ago is that a steep down-staging, that late diagnosis had moved to early diagnosis by this simple technology. So that statistically significant down-staging had already happened.

And the vinegar test was nearly as good as Pap smearing or as good?

Absolutely, sensitivity-wise we were identical. The beauty of this was that when we looked at the final results we find that there is a 31% reduction in deaths related to cervical cancer that, if I were to extrapolate for India, it would mean about 25,000 lives saved annually. If I were to extend it globally it would mean about 75,000 lives saved across the globe.

And in breast cancer could you expect a similar migration from late stage to early stage?

We’ve already reported that there is a stage migration already seen. We are waiting for the final analysis which will happen a year from now but the best part, whether you do Pap smear, whether you do colposcopy, whether you do HPV, whatever you do, the first thing that happens is that there is an increase in the incidence of cancer because you pick up more.

You’re finding it.

You pick up more. When we go to the tenth year of follow-up or the eleventh year of follow-up this excess diagnosis done by VIA comes together with clinical in which case there is zero over-diagnosis. Nobody is diagnosed unnecessarily, as against that with any conventional modality, maybe mammography, there is so much talk about over-diagnosis. That means women who would never manifest their cancer live with cancer.

And what are the details about how you do the breast screening?

The breast screening is done by health workers who are trained for one month in the Tata Memorial Hospital in a clinical setting and they do a physical examination once a year of every individual. The moment they find there is something not appropriate approximately 3% of such women wherein they perceive that there is some abnormality are brought into hospital.

So the initial screen is by clinical observation only?

Yes.

And that’s pretty good?

Absolutely. It produces down-staging and early detection. Once the women are in Tata Hospital or in any other hospital that they wish then they have the battery of tests – needle aspiration, mammography, everything to decipher and confirm whether there is cancer.

Now whether it’s breast cancer screening or indeed cervical cancer screening you have the facilities because you have this wonderful organisation at the Tata Hospital. But this might not be so easy in other settings - what kind of advice would you give?

The kind of treatment that is necessary for both these are easily possible in any district general hospital which is a government supported hospital. Every district in India and I’m sure that’s the case in any developing country…

You need to have the back-up once you’ve discovered the disease, though, don’t you?

Yes, so that we don’t create a problem and leave it like that. We create a problem and also give a solution to that.

So how do you introduce that to governments to say, ‘Look you need to provide this back-up and then we can give you this very low cost screening using community workers’?

True, so what has happened is that about nine states in India have already approached us, we’re training the health workers and we simultaneously are creating infrastructure in the district general hospital for anybody to be treated for that. But I must say that if I were to see something abnormal, today cryotherapy can be delivered by the technician herself.

So there is a moral, there’s a lesson in this in that you don’t necessarily have to have fully qualified doctors who have been trained for lots of years at great expense in order to deliver effective anti-cancer care.

Effective early detection, no doubt about it, and treatment of pre-cancerous conditions. So cryotherapy, as you see you treat and it’s over. The possibility of lack of compliance, whether the patient comes subsequently for follow-up, all those don’t exist. Once seen it’s done.

And because you’re using clinical diagnosis in breast cancer you don’t suffer from a big over-diagnosis either.

Yes, but we will come to know only when we have a complete follow-up. I know for sure that there is no over-diagnosis in cervical cancer by VIA. Whether that happens with physical examination it remains to be seen, maybe in a year’s time.

So what are the simple few words that you would say to doctors to sum up what you’ve achieved so far?

In my opinion early detection within the clinical setting saves lives. That does not produce unnecessary diagnosis. So I will not produce an increased number of cases in society which will have a greater burden but I will have lives saved by this simple test.

Raj, thank you very much for joining us on ecancer.tv.

My pleasure.