Survival of Patients With Cervical Cancer in Rural India

A icles © The au ho s | Jou nal compila ion © J Clin Gynecol Obs e and Elme P ess Inc™ | www.jcgo.elme p ess.com This is an open-access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License, which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed 290 O iginal A icle J Clin Gynecol Obs e . 2015;4(4):290-296 ess Elme Su i al o Pa ien s Wi h Ce ical Cance in Ru al India Jissa Vinoda Thulaseedha ana, b, Nea Malilab, c, Raja aman Swamina hand, Puliko il Oku u Esmye, Ma i Hakamab, c, Richa d Muwonge , g, Rengaswamy Sanka ana ayanan Abs ac Backg ound: Pa ien s’ su i al a e diagnosis o ce ical cance is indi ec ly in luenced by socio-economic ac o s. We e alua ed his su i al and i s socio-economic de e minan s in a u al popula ion in sou h India. Me hods: We assessed 165 women diagnosed wi h ce ical cance om he ou ine ca e con ol a m o a andomized sc eening ial conduc ed in u al sou h India. Kaplan-Meie cu es we e plo ed o illus a e he obse ed su i al o cance pa ien s. The e ec o socio-economic ac o s was assessed using Cox p opo ional haza ds eg ession analysis. Resul s: The 5-yea obse ed su i al was 32.5%, anging om 9% o s age IV o 78% o s age I cance s. Women wi h poo socio- economic s a us (SES) had up o a 70% highe isk o dea h. Highe household income was signi ican ly associa ed wi h poo e su i al. Howe e , mos women in he highe income g oup we e ma ied women and housewi es, hence wi h no pe sonal income. Conclusion: Ce ical cance su i al was disappoin ingly low in hese u al popula ions o India and s age o disease a diagnosis was he s onges de e minan . A highe household income is no always associa ed wi h women being empowe ed in e ms o seeking heal h- ca e. The s udy indings u he s ess he impo ance o s eng hen- ing p e en ion and sc eening oppo uni ies o women in u al popula- ions. Keywo ds: Ce ical cance ; Su i al; Ru al India; Socio-economic de e minan s In oduc ion Incidence and mo ali y es ima es a e used o measu e he bu den o cance in a popula ion and su i al es ima es a e ideal o e alua ing he ou come o cance con ol ac i i ies [1]. Su i al s udies e alua e he quali y and quan i y o li e o a g oup o pa ien s a e diagnosing he disease [2]. Long- e m su i al, usually o mo e han 5 yea s, e lec s cu e and is conside ed a posi i e measu e o e alua e he e iciency o he heal h sys em [3]. Globally, ce ical cance su i al a ies widely be ween coun ies. The 5-yea su i al a es o women diagnosed wi h ce ical cance du ing 1995 - 1999 in de eloped coun ies a - ied om 50% o 70% [4]. Fo A ica, Asia, and Cen al Ame i- ca, he lowes su i al a es du ing 1990 - 2001 we e obse ed in Uganda and Gambia wi h a 5-yea age s anda dized ela i e su i al (ASRS) o 19% and 23%, espec i ely, and he high- es su i al a es we e epo ed in China, Singapo e, Sou h Ko ea, and Tu key, whe e he ASRS a ied om 63% o 79% [5]. The median 5-yea ASRS o ce ical cance in India was 46% anging om 34% o 60% [5]. The ema kable inequali y in cance su i al be ween and wi hin coun ies is la gely due o he di e ences in gene al awa eness, a ailabili y o ea ly de ec ion p ac ices, ained hu- man esou ces, and accessibili y o cance se ices, diagnosis and ea men [3]. Age a diagnosis, agg essi eness and clini- cal ex en o cance , willingness and de e mina ion o he pa- ien o comple e his/he ea men and socio-economic ac o s also in luence su i al om cance [1]. E en hough ce ical cance is conside ed an eminen ly p e en able cance , la e s age diagnosis and delay in ge ing ea men lead o educed ce ical cance su i al in low esou ces se ings [6]. Thus, he inequali y in ce ical cance su i al is ela ed o he di e - ences in medical, biological, cul u al, gene ic, geog aphic, and socio-economic ac o s [7-9]. To assess he socio-economic ac o s ha a ec ce ical cance su i al in a u al popula ion o sou h India, we used Manusc ip accep ed o publica ion Oc obe 21, 2015 aAchu ha Menon Cen e o Heal h Science S udies (AMCHSS), S ee Chi a Ti unal Ins i u e o Medical Sciences and Technology (SCTIMST), T i an- d um, India bSchool o Heal h Sciences (HES), Uni e si y o Tampe e, Tampe een Ylio- pis o, Finland cFinnish Cance Regis y, Pieni Roobe inka u, Helsinki, Finland dBios a is ics and Cance Regis y, Cance Ins i u e (WIA), Chennai, India eCh is ian Fellowship Communi y Heal h Cen e (CFCHC), Ambillikai, Tamil Nadu, India Sc eening G oup, In e na ional Agency o Resea ch on Cance (IARC), Lyon, F ance gCo esponding Au ho : Richa d Muwonge, Sc eening G oup, In e na ional Agency o Resea ch on Cance , 150 Cou s Albe Thomas, 69372 Lyon Ce- dex 08, F ance. Email: [email p o ec ed] doi: h p://dx.doi.o g/10.14740/jcgo367w A icles © The au ho s | Jou nal compila ion © J Clin Gynecol Obs e and Elme P ess Inc™ | www.jcgo.elme p ess.com 291 Thulaseedha an e al J Clin Gynecol Obs e . 2015;4(4):290-296 he ma e ial consis ing o 165 women diagnosed wi h ce ical cance du ing 2000 - 2006 om a coho o 31,000 women in he con ol a m o a la ge VIA sc eening ial. Ma e ials and Me hods The de ails o he base popula ion and he sc eening ial we e desc ibed in ea lie pape s [10-12]. This ial aimed o e alua e he e ec o a single ound o VIA sc eening on ce ical cance incidence and mo ali y. The ial p o ocol was e iewed and app o ed by he ins i u ional scien i ic and e hical commi ees o Ch is ian Fellowship Communi y Heal h Cen e (CFCHC) and he In e na ional Agency o Resea ch on Cance (IARC). Clus e s o eligible women aged 30 - 59 yea s, wi h an in ac u e us and no his o y o cance , we e andomized in o in e - en ion and con ol a ms du ing 2000 - 2003. Be o e en ol- men , he ial was explained o he pa icipan s in he local language and a signed in o med consen was ob ained. A s uc- u ed ques ionnai e was used o ob ain he pa icipan s’ demo- g aphic and socio-economic cha ac e is ics. Women in he in e en ion a m we e o e ed sc eening wi h VIA, whe eas hose in he con ol a m we e in o med abou sc eening, symp- oms and isk ac o s o ce ical cance , whe e he sc eening, ea ly diagnosis and ea men acili ies a e a ailable, and ad- ised o u ilize such ou ine heal hca e acili ies. The ial popula ion was ollowed annually un il Decem- be 2006 o collec in o ma ion on dea h, mig a ion and ce i- Table 1. Cha ac e is ics and Su i al Expe iences o Women Diagnosed Wi h Ce ical Cance F om he Con ol A m Du ing 2000 - 2006 and Followed Un il Decembe 31, 2011 Women’s cha ac e is ics Numbe o women wi h cance n (%) Obse ed su i al (%) a P- alue 1-yea 3-yea 5-yea To al 165 67.3 40 32.5 Indi idual Age a diagnosis 30 - 39 37 (22.4) 70.3 45.9 37.3 40 - 49 53 (32.1) 66.0 39.6 34.0 50+ 75 (45.5) 66.7 37.3 29.1 0.5458 S age o disease S age I 18 (10.9) 88.9 83.3 77.6 S age II 32 (19.4) 68.8 37.5 21.4 S age III 62 (37.6) 69.4 35.4 25.3 S age IV 11 (6.7) 36.4 9.1 9.1 Unknown 42 (25.5) 61.9 38.1 35.7 0.0023 Educa ion* No schooling 145 (87.9) 66.9 37.9 30.9 Some schooling 17 (10.3) 82.4 64.5 51.6 0.1794 Occupa ion House wi e/o he s 60 (36.4) 73.3 48.3 36.4 Manual 105 (63.6) 63.8 35.2 30.3 0.3117 Ma i al s a us Cu en ly ma ied 146 (88.5) 66.4 39.7 31.3 Widowed/sepa a ed 19 (11.5) 73.7 42.1 42.1 0.4668 Household Type o house Tha ched 27 (16.4) 48.2 29.6 25.9 Tiled/conc e e 138 (83.6) 71.0 42.0 33.8 0.2588 Income (INR) < 2,000 117 (70.9) 69.2 43.5 38.2 2,000+ 48 (29.1) 62.5 31.3 18.8 0.0143 *The in o ma ion on educa ion is missing o h ee obse a ions. INR: Indian Rupees. 50 INR was equi alen o 1 US dolla du ing 2000 - 2003. A icles © The au ho s | Jou nal compila ion © J Clin Gynecol Obs e and Elme P ess Inc™ | www.jcgo.elme p ess.com 292 Su i al A e Ce ical Cance Diagnosis J Clin Gynecol Obs e . 2015;4(4):290-296 cal cance s. The Dindigul Ambillikai Cance Regis y (DACR) s a ac i ely collec ed in o ma ion on women diagnosed wi h ce ical cance om he en i e Dindigul dis ic [13] and sub- sequen ly ma ched he in o ma ion wi h he s udy da abase on a case-by-case basis o ob ain all he inciden ce ical cance cases diagnosed du ing 2000 - 2006 om he s udy popula ion. In he inal analysis, he e o e, we used he upda ed in o ma- ion o 165 women diagnosed wi h ce ical cance du ing 2000 - 2006 om he con ol a m. The ial base popula ion was again ollowed in 2011 - 2012 o collec in o ma ion on dea h and mig a ion. The women’s cha ac e is ics s udied we e age a diagno- sis (ca ego ized in 30 - 39, 40 - 49 and 50+), s age o disease (s age I, II, III, IV and unknown) and he baseline in o ma- ion on socio-economic ac o s such as o mal educa ion (no schooling and some schooling), occupa ion (housewi e/o he and manual wo ke s), ma i al s a us (cu en ly ma ied and widowed/sepa a ed), ype o house ( ha ched and iled/con- c e e), and household income (ca ego ized in < 2,000 and 2,000+ Indian Rupees (INR)). Da a analysis was done using he S a a/IC 11.2 so wa e package (S a a Co p LP, TX, USA). The p ima y endpoin was dea h om ce ical cance . To gi e each o he included pa- ien s a chance o ha ing a leas 5 yea s o su i al, Decem- be 31, 2011 was used as he la es da e o ollow-up. Fo he de ini ion o he s udy ou come, he i al s a us o all included pa ien s by Decembe 31, 2011 was es ablished as dead, ali e o los o ollow-up. Su i al ime was calcula ed om he da e o diagnosis o da e o dea h, o he pa ien s who had died, o Decembe 31, 2011 o hose who we e s ill ali e o da e o las seen o hose los o ollow-up. Only wo women we e los o ollow-up. Kaplan-Meie cu es we e plo ed o illus a e he obse ed su i al o cance pa ien s and he log- ank es was used o es he equali y o su i o unc ions. The e ec o socio-economic ac o s was assessed using Cox p opo ional haza ds eg ession analysis. Adjus men was made by includ- ing all he ac o s s udied in a single eg ession model. Resul s Cha ac e is ics and su i al expe ience o 165 women diag- nosed wi h ce ical cance a e p esen ed in Table 1. O e all, 54.5% o he women we e diagnosed wi h ce ical cance un- de he age o 50 yea s. Mos women (63.6%) we e diagnosed in s age II o wo se wi h a la ge numbe o women (37.6%) in s age III and one-qua e o hem had unknown s age a di- agnosis. Only 10.3% o he women had had some educa ion and 70.9% o women had low household income (i.e., < 2,000 INR). Kaplan-Meie su i al cu e o he o e all su i al o he 165 women wi h ce ical cance is shown in Figu e 1. O e hal o he pa ien s did no su i e o 2 yea s a e diagnosis. The obse ed 1-, 3- and 5-yea su i al es ima es we e 67.3%, 40% and 32.5%, espec i ely (Table1). Su i al es ima es by age a diagnosis we e 37.3% o 30 - 39 yea s, 34% o 40 - 49 yea s and 29.1% o women aged 50 yea s and abo e (P = 0.5458). Women wi h o mal educa ion had a 20% highe di - e ence in 5-yea su i al han women wi hou o mal educa- ion (P = 0.1794; Table 1). The su i al es ima es di e ences wi hin he di e en ca ego ies o occupa ion, ype o house and ma i al s a us also a ied om 6% o 11% (Table 1). The e was a signi ican educ ion in 5-yea su i al wi h he inc easing s age a diagnosis; he su i al es ima es o s ages I, II, III and IV we e 77.6, 21.4, 25.3 and 9.1, espec- i ely (P = 0.0023; Table 1). These es ima es esul ed in he Figu e 1. Kaplan-Meie o e all su i al cu e o 165 women diagnosed wi h ce ix cance om he con ol a m. A icles © The au ho s | Jou nal compila ion © J Clin Gynecol Obs e and Elme P ess Inc™ | www.jcgo.elme p ess.com 293 Thulaseedha an e al J Clin Gynecol Obs e . 2015;4(4):290-296 adjus ed haza d a ios o s ages II, III and IV cance s compa ed wi h s age I cance s o 3.81 (95% CI: 1.54 - 9.40), 3.67 (95% CI: 1.56 - 8.64) and 6.74 (95% CI: 2.34 - 19.02), espec i ely du ing he 12 yea s o ollow-up (Table 2). Su i al a e ce ical cance diagnosis was no signi i- can ly associa ed wi h age a diagnosis, educa ion, occupa ion, ma i al s a us and ype o house. Con a y, he 5-yea su i al es ima e o women wi h highe household income was signi i- can ly lowe compa ed o he su i al o hose wi h low house- hold income (18.8% s. 38.2%; Table 1) showing an adjus ed haza d a io o 1.59 (95% CI: 1.05 - 2.41; Table 2). Discussion Su i al es ima es o pa ien s wi h ce ix cance ob ained om popula ion-based da a a e sca ce in low- and middle-in- come coun ies because cance egis a ion is no common and mainly due o p oblems in ollow-up o pa ien s. In a coun- y wi h limi ed esou ces, he su i al es ima es a e ob ained om only a ac ion o he cance pa ien s. This p oblem is agg a a ed u he o u al popula ions. He e we epo ed he ce ix cance su i al in a u al popula ion co e ed by a can- ce egis y and wi h e y ew losses o ollow-up. Ou obse ed su i al expe ience o women diagnosed wi h ce ical cance was poo , wi h o e a hal o he women dying wi hin he i s 2 yea s and only abou 30% s ill ali e a e 5 yea s o ollow-up. S age o disease was he s onges de e minan o su i al. The obse ed 5-yea su i al (32.5%) in his s udy is qui e simila o ha epo ed by DACR (35%) o he ce ical cance cases egis e ed in 2003 om u al Ta- mil Nadu [14]. The 5-yea obse ed su i al o women diag- Table 2. C ude and Adjus ed Haza d Ra ios o Assess he E ec o Women Cha ac e is ics on Su i al A e Ce ical Cance DiagnosiS Women’s cha ac e is ics C ude haza d a io (95% CI) Adjus ed* haza d a io (95% CI) Indi idual Age a diagnosis 30 - 39 1 1 40 - 49 1.13 (0.68 - 1.90) 1.24 (0.73 - 2.14) 50+ 1.29 (0.80 - 2.08) 1.38 (0.83 - 2.32) S age o disease S age I 1 1 S age II 3.15 (1.36 - 7.31) 3.81 (1.54 - 9.40) S age III 3.12 (1.40 - 6.91) 3.67 (1.56 - 8.64) S age IV 6.77 (2.56 - 17.91 6.74 (2.34 - 19.02) Unknown 3.00 (1.31 - 6.83) 3.51 (1.44 - 8.54) Educa ion No schooling 1 1 Some schooling 0.64 (0.33 - 1.23) 0.71 (0.35 - 1.40) Occupa ion House wi e/o he s 1 1 Manual 1.21 (0.83 - 1.77) 1.11 (0.74 - 1.68) Ma i al s a us Cu en ly ma ied 1 1 Widowed/sepa a ed 0.80 (0.44 - 1.45) 0.68 (0.35 - 1.32) Household Type o house Tha ched 1 1 Tiled/conc e e 0.75 (0.47 - 1.22) 0.68 (0.39 - 1.18) Income (INR) < 2,000 1 1 2,000+ 1.60 (1.09 - 2.33) 1.59 (1.05 - 2.41) *All a iables we e included in he eg ession model. CI: con idence in e al; INR: Indian Rupees. 50 INR was equi alen o 1 US dolla du ing 2000 - 2003. A icles © The au ho s | Jou nal compila ion © J Clin Gynecol Obs e and Elme P ess Inc™ | www.jcgo.elme p ess.com 294 Su i al A e Ce ical Cance Diagnosis J Clin Gynecol Obs e . 2015;4(4):290-296 nosed wi h ce ical cance du ing 1990 - 1999 in he Chennai u ban PBCR in Tamil Nadu was 54%, and 62% in he Chennai HBCR da a o women who ecei ed ea men du ing 2000 - 2001 [14]. Be e cance heal h se ices wi h mo e accessibil- i y o diagnosis and ea men esul in la ge a ia ions in su - i al be ween di e en egions o India, pa icula ly in u ban s. u al a eas [5]. Delays in ea men due o lack o acili ies, suppo echnology, ained pe sonal, inancial esou ces and social o amily suppo a ec su i al o ce ical cance pa- ien s in low- esou ce se ings [6]. S udies om Eu ope [7, 15] and India [8, 9] showed no associa ion be ween socio-economic s a us (SES) and ce i- cal cance su i al, bu p esence o co-mo bid condi ions, se - e al clinical and/o pa hological ac o s such as s age we e o p ognos ic impo ance. These s udies also sugges ha i may no be possible o clea ly es ablish he ole o socio-economic ac o s in ce ical cance su i al wi hin a g oup o pa ien s who had simila socio-economic cha ac e is ics and/o access o ea men and/o inaccessibili y o cance ea men acili- ies. Howe e , one hospi al-based egis y s udy om Sou h India showed ha socio-economic ac o s p edic ce ical can- ce su i al along wi h pe o mance s a us and clinical s age o disease [1]. Socio-economic ac o s a e in ac no di ec ly linked o su i al, bu i is di ec ly ela ed o a pe son’s gene al s a e o heal h, nu i ional s a us, a i udes, belie s and heal h beha io . I can a ec he chances o being ea ly de ec ed, ac- cess o o comple ion o ea men and ollow-up and pe haps su i al is media ed by all hese ac o s [1]. In addi ion, he su i al analysis by socio-economic ac- o s is p oblema ic by many ways. In ou s udy, we used he baseline in o ma ion o socio-economic ac o s. A su i al s udy equi es long- e m ollow-up, and a pe son’s SES can a y o e ime and i may in luence he su i al es ima es. In his su i al analysis, educa ion ( o mally educa ed o no ) is he mos eliable socio-economic indica o because i does no change o e ime. The a ailable scales o assessing he SES o amilies in India usually de i e om a single piece o in- o ma ion using many componen s o socio-economic ac o s [16-18]. The analysis o su i al using such single in o ma ion on SES can only gi e he a ia ion acco ding o SES in gene al and ha may no be help ul o unde s and he mechanism o indi idual componen s o socio-economic ac o s which de e - mine he es ima es di e en ly. Also, i is possible ha he le el o indi idual ac o s can ha e di e en di ec ions o associa- ion o di e en ou comes; o ins ance educa ion is nega- i ely associa ed wi h ce ical cance incidence, bu posi i ely associa ed wi h b eas cance incidence [19]. Fu he mo e, he ac o s which de e mine he SES o one popula ion may no be applicable o ano he . Consequen ly, he assessmen o SES should be a ied acco ding o he popula ion unde s udy and pu pose o he s udy. Acco dingly, in ou s udy we ocused on he a ia ion in su i al by di e en componen s o SES using se e al indi- idual and household cha ac e is ics. Old age, no schooling, manual occupa ion, li ing in ha ched houses, and low house- hold income indica ed poo SES. When we conside he a i- able “ ype o house”, we canno say ha he women who li ed in iled/conc e e houses had a e y high SES; howe e , we can say ha e y poo people li ed in ha ched houses and peo- ple whose ci cums ances we e a li le be e in iled/conc e e houses in u al a eas. Howe e , he ac ha only 4% (1/27) o women li ed in ha ched houses we e o mally educa ed and had a highe household income, and 78% (21/27) o women who li ed in ha ched houses we e manual wo ke s u he suppo s he e iciency o his a iable o measu e poo SES in his popula ion. Today, howe e , i has become imp ac ical o Figu e 2. Kaplan-Meie su i al cu es showing su i al o ma ied women wi h di e en le els o income and occupa ion. A icles © The au ho s | Jou nal compila ion © J Clin Gynecol Obs e and Elme P ess Inc™ | www.jcgo.elme p ess.com 295 Thulaseedha an e al J Clin Gynecol Obs e . 2015;4(4):290-296 use such a a iable o measu e SES because ha ched houses a e g adually disappea ing om u al a eas h ough he ini ia- i es o he s a e and cen al go e nmen s o p o ide conc e e houses o he poo . Ma ied women and hose wi h an income mo e han 2,000 INR pe mon h had poo su i al. In ac , he di e ence in su - i al by income was he only s a is ical signi ican esul by he SES a iables. This seems o be in con adic ion wi h he poo SES hypo heses. As pa icipan s p o ided in o ma ion on hei income g oup o he in e iewe a he ime o baseline in e iew, his opens he possibili y o in o ma ion bias. Only 29% (48/165) o he women epo ed o ha e income g ea e han 2,000 INR and because o his small sample, chance ob- se a ions (dea hs) a e also possible. I was obse ed om he da a ha 31.5% (46/146) o ma - ied women epo ed a household income 2,000+ INR e sus 10.5% (2/19) o single women. Con e sely 96% (46/48) o he women epo ed ha ing household income 2,000+ INR we e cu en ly ma ied. Fu he , we ound ha 38% (55/146) o he ma ied women we e housewi es compa ed o 26% (5/19) o he single women. The emaining ma ied and single women we e manual wo ke s (62% s. 74%) ha ing hei own ea n- ings. I is common in u al India ha he ma ied women a e no ee o spend money wi hou he pe mission o hei hus- bands, e en hough hey ha e hei own ea nings. The house- wi es epo ed he income gene a ed by hei amily mem- be s and depend on hei husbands/ amily membe s o ge he money necessa y o access heal hca e acili ies. Howe e , his inancial ins abili y o en leads o igno ance o heal h needs. I his is ue, he housewi es a e a poo su i al g oup. To demons a e his, we u he made ou ca ego ies o ma ied women wi h di e en combina ions o income and occupa ion and we could clea ly illus a e ha hose housewi es who e- po ed ha ing a highe household income we e he poo es su - i al g oup (Fig. 2). Hence hese indings sugges ha a highe household income may no always be a suppo ing ac o o imp o ed su i al. A majo limi a ion o ou s udy was ha we did no ha e in o ma ion on clinical ex en o disease and ea men de ails o women on a ou ine basis. Also, he es ima es do no ake in o accoun dea hs due o o he causes. Howe e , we ha e comple e and accu a e in o ma ion o all inciden cance cases diagnosed du ing 2000 - 2006 o he s udy popula ion, and an adequa e and ac i e ollow-up o he cance cases by DACR and mo ali y egis a ion sys em and he ollow-up o he base popula ion in 2011 - 2012. We had a e y minimal numbe o women wi h incomple e ollow-up s a us, so we did no ha e o adjus he es ima es o losses. Also we ook only hose women diagnosed wi h cance du ing 2000 - 2006 o a oid bias in ou selec ion c i e ia since ce ical cance sc eening was p o ided o all 30 - 59 yea s old women om he con ol a ea du ing 2007 - 2010. In ou s udy, he a ia ion in haza d wi h espec o socio- economic cha ac e is ics was no s a is ically signi ican p ob- ably due o small numbe o pa ien s. We ound ha he poo socio-economic cha ac e is ics had up o 70% highe isk o dea h. Fo example, he e was a 30% educ ion in mo ali y o a 70% be e su i al among hose wi h some schooling com- pa ed o no schooling. E en i he di e ence is no s a is ically signi ican , i should no be conside ed o be ze o di e ence in mo ali y o su i al among he wo schooling ca ego ies. In addi ion, he non-signi ican su i al a ia ion by SES may seem less han expec ed. One explana ion may be he gene al lack o heal h se ices in u al India. Specialized se ice migh be oo a away o no e icien o cance diagnosis and ea - men . In conclusion, he ce ical cance su i al is likely o be poo also in u al popula ions o o he a eas in India and in low- and middle-income coun ies in gene al. The only s ong de e minan was he s age o umo a diagnosis. Ou esul s u he s ess he impo ance o p o iding p e en ion and sc eening oppo uni ies o he women in low- esou ce se ings, and he need o s eng hen he quali y o heal hca e acili ies in u al a eas. Acknowledgemen We acknowledge he Bill & Melinda Ga es ounda ion o hei inancial suppo o ou s udy h ough he Alliance o Ce ical Cance P e en ion. Con lic o In e es None o he au ho s ha e any con lic ing in e es . Financial Disclosu es All au ho s ha e no inancial disclosu es o make. G an Suppo The o iginal s udy was inancially suppo ed by he Bill & Melinda Ga es ounda ion. Re e ences 1. Sanka ana ayanan R, Nai MK, Jayap akash PG, S an- ley G, Va ghese C, Ramadas V, Padmakuma y G, e al. Ce ical cance in Ke ala: a hospi al egis y-based s udy on su i al and p ognos ic ac o s. B J Cance . 1995;72(4):1039-1042. 2. Dha M, Lahi i S, Takia R, Ashok NC, Mu hy NS. An indi ec s udy o cance su i al in he con ex o de el- oping coun ies. Asian Pac J Cance P e . 2008;9(3):479- 486. 3. Sanka ana ayanan R, Swamina han R. Cance Su i al in A ica, Asia, he Ca ibbean and Cen al Ame ica. IARC Scien i ic Publica ions No. 162. Lyon: In e na ional Agency o Resea ch on Cance ; 2011. 4. Ame ican Cance Socie y. Global Cance Fac s & Figu es. 2nd Edi ion. A lan a: Ame ican Cance Socie y; 2011. 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