Cancer is a leading global health problem and, as of 2020, accounts for 10 million deaths per year.1 The World Health Organization (WHO) estimates that between 30 and 50% of cancer deaths can be prevented by avoiding risk factors, early detection via screening, and proper treatment. The majority of cases occur in low- and middle-income countries (LMIC).2 Despite awareness of the magnitude of this problem by the global health community and the large-scale efforts to implement screening programs, very few programs are successful and, more importantly, sustainable. Although there are several barriers to implementation of a cancer screening program, the critical barriers are lack of awareness and acceptance of the screening programs by the people residing in the specific geographic regions. In the article by Pak et al. entitled Cancer Awareness and Stigma in Rural Assam India: Baseline Survey of the Detect Early and Save Her/Him (DESH) Program, the authors highlight the cultural and psychosocial barriers to cancer screening.3
The DESH program is a well-organized screening program with multiple components that consists of an initial baseline survey followed by implementation of mobile cancer screening and subsequent follow-up of patients regarding final diagnosis and treatment. The DESH program in Assam, India, focuses on breast, oral, and cervical cancers due to the high incidence of these cancers in this region and the availability of validated screening tests. The baseline survey was validated in a smaller cohort (n = 20) of local participants before widespread implementation to nearly 1000 participants. The survey consisted of multiple sections that focused on areas such as awareness of the carcinogenic effects of certain lifestyle choices, i.e., consumption of betel nuts and smoking, spiritual/religious beliefs, stigma around cancer diagnoses, and knowledge about screening programs and local health care facilities. Through this approach, they found that the majority (92.9%) of participants were not aware of cancer screening availability and had never undergone prior screening. Additionally, over 90% of the survey participants reported consumption of betel nuts, but less than half (46.9%) were aware of the carcinogenic effects of betel nuts. Finally, 42–57% of participants reported negative stigma towards cancer diagnosis. Specifically, more than 30% of participants believed that either cancer is a punishment from God or is caused by bad karma and evil spirits. Furthermore, 20% of participants described fear of cancer screening. These results highlight the complex interplay between knowledge gaps, misconceptions, and cancer stigma that could affect the acceptance, and thereby the success, of a screening program.
Taneja et al. identified similar sociocultural barriers regarding cervical cancer screening in India. Specifically, barriers identified included lack of awareness about screening, poor knowledge about initial symptoms, social stigma, cost, and familial obligations. Hence, it is not surprising that only 5% of eligible women have undergone screening for cervical cancer in India, compared with up to 84% in developed countries.4 This is disconcerting since cervical cancer has the potential for prevention and/or cure due to the length of the premalignant and preinvasive period, emphasizing the importance of a population-based screening program. The benefits of an effective screening program for this disease were demonstrated by Sankaranarayanan et al. in a study of over 130,000 healthy women, in which participants were randomly assigned to undergo cervical cancer screening with either human papillomavirus (HPV) testing, cytologic testing, or visual inspection with acetic acid (VIA). Single-round HPV testing was associated with a significantly reduced number of advanced cases [hazard ratio (HR) 0.47, 95% confidence interval (CI) 0.32–0.69] and mortality5 (HR 0.53, 95% CI 0.33–0.83) compared with the control group. The results of this study highlight that implementation of a successful screening program with the right screening test is associated with decreased mortality, even in low-resource settings. However, the main challenge is to screen enough people for the screening program to be effective. The National Cancer Prevention and Control Program launched in 2010 in Morocco, with augmented and expanded infrastructure and considered an exemplar for screening programs in LMIC, had major challenges with uptake of screening and poor participation in early identification of precancerous lesions.