Do cervical cancer data justify human papillomavirus vaccination in India? Epidemiological data sources and comprehensiveness

In their paper, Mattheij et al.1 propose that current epidemiological data do not justify human papillomavirus (HPV) vaccination in India. They state ‘current data on HPV type and cervical cancer incidence do not support [the] claim that India has a large burden of cervical cancer’. As the source of many of these data, we strongly contest this viewpoint. Our GLOBOCAN 2008 estimates of the burden of cervical cancer in India indicate that the incidence rates are substantially in excess of those observed in, for example, the UK, where the authors are based and where there is a school-based vaccination programme (age standardized rates of 27 and 7 per 100,000, respectively).2 The national estimates for India have a complex derivation due to the need to adequately balance rural/urban populations in different geographical regions, but the methods are clear and reproducible.2 Cervical cancer is the most common or the second most common female cancer in data from the seven highest-quality Indian cancer registries.3 Our recent nationally representative mortality study based on verbal autopsies showed that, in 2010, cervical cancer was the leading fatal cancer among women aged 30–69 years in both rural and urban areas.4 Overall we estimate that over a quarter of the world's cervical cancer cases and over a third of the cervical cancer deaths occur in India.2 While we agree with Mattheij et al. that incidence rates are declining over time in some urban regions,3 this is mainly due to the impact of multiple social factors (family planning, education and socioeconomic improvement)5,6 combined with the developing programmes for screening and early detection.7 What is known about HPV and high-risk HPV prevalence in India would indicate that, rates are at the higher end of a global scale (exactly as for cervical cancer incidence) and, unlike in many other populations, tend to stay high in middle-age women.8 More than elsewhere, high-risk HPV types 16 and 18 predominate in invasive cancer9 indicating current vaccines would be very effective. Cancer surveillance in India is incomplete and faces uncertainties in estimation. However, there are a large number of cancer registries and more data are available than for many other countries at a similar developmental level. The surveillance data that we have, indicate quite clearly that HPV infection and associated cervical cancer risk in India is a substantive burden and clear health priority which can be addressed now by a combination of screening and vaccination.