Persistently high cervical cancer mortality in India: Beyond screening modality alone

Dear Editor,

We read with interest the recent article by Singh, Grover, and Dhanasekaran, which offers a timely descriptive assessment of the burden of cervical cancer in India using GLOBOCAN 2022, GBD, and GHO data [1]. The study is especially informative in showing that screening coverage remains very low and that mortality has not declined after the adoption of India's 2016 screening policy, despite some slowing in the annual increase in deaths [1].

However, the interpretive step from those observations to a strong policy preference for replacing VIA is not fully justified by the study design. Ecological trend analyses can describe temporal coincidence, but they cannot isolate the effect of one policy component from concurrent changes in treatment, referral patterns, case mix, or the lag between program implementation and mortality response. This limitation is not peculiar to cervical cancer; trend reviews have repeatedly noted that mortality comparisons over time are at best an initial step and that such analyses are of limited value for estimating screening impact without individual-level data [2].

A more defensible interpretation is that persistent mortality in India may reflect failure across the full screening-to-treatment cascade rather than the inadequacy of the screening test alone. In a community-based program from South India, follow-up was “poor” and the authors concluded that success depends on the completion of the care continuum. Broader low-resource literature makes the same point: women with larger lesions and invasive disease require complete clinical pathways, including surgery, radiotherapy, chemotherapy, and palliative care. Recent implementation work on HPV-based screening in India emphasizes integration with existing health systems and improved follow-up rather than test choice in isolation [3], [4], [5].

Therefore, I would suggest a more cautious policy reading. India certainly needs better screening, and HPV-DNA testing with self-sampling may improve participation. However, the central epidemiologic question raised by this paper is whether women who screen positive are promptly triaged, diagnosed, treated, and retained in care, and whether enough time has elapsed for mortality effects to appear at the population level. Framed this way, the article remains valuable as a signal of ongoing burden, but its design does not support attributing persistent mortality primarily to VIA. The more policy-relevant conclusion is that cervical cancer control in India must strengthen the entire care pathway, not just the screening assay [2], [5].

Availability of data and materials

No new data were generated or analyzed in this study. Therefore, data sharing is not applicable.

CRediT authorship contribution statement

Abdikadir Ahmed Hassan: Conceptualization. Liibaan Abdulahi Sudi: Investigation. Mohamed Daud Mohamed: Writing – review & editing. Yakub Burhan Abdullahi: Supervision.

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Not applicable.

Consent for publication

Not applicable.

Ethical approval

Ethical approval was not required for this study.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have influenced the work reported in this study.