Screening aims to detect early preclinical cancer and/or precancerous lesions in an asymptomatic person/population. There are two types of screening: opportunistic and population-based screening. Opportunistic screening occurs without a structured invitation and is offered based on health professionals’ recommendations or self-referrals. Population-based screening uses a systematic approach to reach the majority of high-risk individuals, as outlined in the National Screening Programme.

The programme has a mechanism to send personal invitations to eligible individuals to attend the screening. Though the federal government has proposed a plan for the entire nation, health being a state subject, there is a significant difference between states in the level of implementation.

Cancer screening in Kerala has a long history. Squamous cell carcinoma of the oral cavity, commonly referred to as oral cancer (OC) in Kerala, was the commonest cancer in Kerala and therefore many of the published results are for screening of OC.

In 1963, J.J. Pindborg, a Danish dental surgeon, visited Trivandrum and planned a screening for OC among the dental outpatients reporting to the dental OP. The findings were reported in 1966. (1) The important finding in the study was the highest frequency of oral submucous fibrosis and lichen planus in Trivandrum, when a meta-analysis was done with similar studies in dental OPs of Bombay, Lucknow, Bangalore and Madras Dental Colleges.

A screening for oral cancer was done in the rural areas of Ernakulam district by the Tata Institute of Fundamental Research from 1966-1970. The study was part of similar studies being carried out in three other Indian states and the results were published. (2)

A population-based oral cancer screening by physical examination by the dentist was carried out in the Dental College, Trivandrum with the financial aid from The Danish International Agency from 1969-1974. Though information was collected from about 50,000 persons, the result of the study is unpublished due to the unexpected death of the principal investigator.

A project financed by ICMR to study the feasibility of utilisation of grassroot level health workers in govt. service (PHN, JPHN and Health Inspectors) was carried out by the Community Oncology Division of Regional Cancer Centre, Trivandrum in 1988 and the results were published in 1995. (3) Another programme by ICMR called ‘District Level Cancer Control Programme” was carried out in the Ernakulam district during 1994-1999. In this study, a plan of action to cover the entire district in five years, utilising the field staff of the Health Services Department, was tested. The result of the study can be obtained from the administrative report of the Regional Cancer Centre, Trivandrum from 1995 to 2000. No paper was published on the results of the study.

In 1991, a programme named ‘Village-level Comprehensive Cancer Control Programme’ (VCCCP) was started in Kannur district with the collaboration of Malabar Cancer Care Society to train and utilise local volunteers for giving cancer awareness and identifying persons with warning signals of cancer, and motivating the suspect to undergo screening by a medical team. The results of the earlier programmes are published. (4) This programme is still ongoing and the results are reported in the administrative reports of the Regional Cancer Centre, every year.

A project to test the feasibility of utilising trained graduates to carry out a house-to-house survey on tobacco and/or alcohol habits, and to conduct a visual inspection of oral cavity, to identify cancer and precancerous lesions, and to motivate the suspects to undergo a clinical examination by doctors, was carried out from 1995-2004. This project was funded by the Association for International Cancer Research, St Andrews, U.K. The study showed screening oral cavity by visual inspection and subsequent diagnosis and timely treatment can reduce the mortality and morbidity from oral cancer, especially in persons with tobacco and/or alcohol habits. (5)(6)

The history of cervical cancer screening in Kerala dates back to 1980, when a pap smear screening was done in the Thrikkadavoor Panchayath of Kollam district under the leadership of Dr N Sreedevi Amma. Later she started the cytotechnologist course and cytotechnician course in the Regional Cancer Centre, Trivandrum, in 1987. Pap smear screening was done for the employees of Trivandrum Corporation. In this period of time, pap smear was taken from the women attending the GyneOP of SAT Hospital, Trivandrum. Studies to evaluate the VIA with pap smear test as a screening tool were carried out in the Community Oncology Division from 1999. Based on the result, the WHO has accepted VIA/VILI as suitable and equitable screening tests for cervical cancer. (7)

Preliminary studies on the HPV Genome testing are going on now in the Community Oncology Division. (8)

A cluster randomised controlled trial was initiated in the Trivandrum district in 2006 to evaluate whether three rounds of triennial Clinical Breast Examination (CBE) can reduce the incidence rate of advanced disease and breast cancer mortality. 115,652 healthy women aged 30-69 years were randomly allocated to the intervention (CBE) group or control (no screening) group, in 133 and 142 clusters. When the first round of screening was completed, out of 50,366 women who underwent CBE, 30 breast cancers were detected. Sensitivity, specificity, false positive rate and positive predictive value of CBE are reported. The age-standardised incidence rates for early stage (Stage II A or lower) breast cancer were 18.8 and 8.1 per 100,000 women; and for advanced stage (Stage II B or higher), breast cancer were 19.6 and 21.7 per one lakh women in the intervention and control groups, respectively. (9)

Opportunistic breast cancer screening was carried out in 100,000 women by a voluntary group ‘Swasthi Foundation’ from 2016; the result of the study is not yet published. Another voluntary group called ‘Snehitha’ has published a paper in cancer in 2023 titled ‘Effectiveness of triennial screening with clinical breast examination: 14-years follow-up outcomes of randomised clinical trials in Trivandrum, India’.

The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCs) was launched in 2010. This programme was modified from time to time: in 2013, 2016 and 2023.

A Cancer Control Strategy by decentralised approach was launched by the Govt. of Kerala, in 2018. ASHA workers in Health and Wellness centres were assigned the duty of creating cancer awareness, motivating suspects to the preliminary health centres. Screening for uterine cervical cancer by pap smear, oral cavity by visual inspection and breast by clinical examinations were done in PHCS. Diagnostic tests were carried out in Community Centres and positive cases were referred directly to cancer treatment hospitals.

On 4th February 2025, the Govt. of Kerala declared a cancer control programme called ‘Arogyam Anandam’. Within a month, over a million women were screened for breast and cervical cancers. On 31st May 2025, oral cavity cancer and colorectal cancers were added to the screening list.

By the turn of the 21st century, many voluntary organisations got involved in community cancer awareness programmes and screenings. Mostly, they carried out opportunistic screening. There is hardly any information or published data on the reduction of mortality and morbidity from the screened cohort, or on the improvement of quality of life. Evaluation of the outcome should be an integral part of all screening programmes. Though not within the mandate, I want to remind the policymakers and politicians that successful completion of the screening programmes are achieved only when the screen-detected patients are given timely investigations to map the disease and state-of-the-art treatment. I am told that the Pothencode Panchayath in Trivandrum district has come out with a programme ‘First Check’ last year where each screen-detected patient is given ₹10,000 to start the treatment without delay.(10) The pros and cons of this can be analysed by experts and can be added on to the Arogyam Anandam Project.

References:
1) Zachariah J, Mathew B, Varma NAR, et al. Frequency of oral mucosal lesions among 5,000 individuals in Trivandrum, India. All India Dent Assoc 1966; 38:290-96.

2) Mehta FS, Pindborg JJ, Gupta PC, et al. Epidemiological and histologic study of oral cancer and leukoplakia among 50,915 villagers in India. Cancer 1969; 24:832-498.

3) Mathew B, Sankaranarayanan R, Wesley R, et al. Evaluation of utilisation of Health Workers for secondary prevention of oral cancer in Kerala, India. Oral Onc, Eur J Cancer 1995; 31B: 193-96.

4) Mathew B, Wesley R, Dutt SE, et al. Cancer screening by local volunteers. World Health Forum 1996; 17:377-28.

5) Mathew B, Sankaranarayanan R, Sunilkumar KB, et al. Reproducibility and validity of oral visual inspection by trained health workers in the detection of oral precancer and cancer. British J Cancer; 1997; 76(3): 390-94.

6) Sankaranarayanan R, Ramadas K, Thomas G, et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster randomised controlled trial. The Lancet 2005; 365: 1927-1933.

7) Wesley R, Sankaranarayanan R, Mathew B. Evaluation of visual inspection as a screening test for cervical cancer. Brit J Cancer 1997; 75(3): 436-40.

8) Thomas G, Personal Communication.

9) Sankaranarayanan R, Ramadas K, Thara S, et al. Clinical breast-examination: preliminary results from a cluster randomised controlled trial In India. J Natl Cancer Inst 2011; 103:1476-80.

10) Jayakrishnan R, Personal Communication.