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  Table of Contents  
Year : 2016  |  Volume : 53  |  Issue : 1  |  Page : 77-79

Cancer cervix: An uncommon malignancy in Kashmir, India

1 Department of Radiation Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
2 Department of Cardiovascular and Thoracic Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
3 Department of Gynecology and Obstetrics (Lal Ded Hospital), Government Medical College, Srinagar, India

Date of Web Publication28-Apr-2016

Correspondence Address:
M T Rasool
Department of Radiation Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-509X.180817

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 » Abstract 

Objective: To study the distribution of cancers among females with particular emphasis on cancer cervix in Kashmiri population, which is geographically and socio-culturally distinct from the rest of India. Materials and Methods: All patient records were screened from January 1, 2009 to December 31, 2011 at Regional Cancer Centre, Srinagar. Most common cancers among females were recorded and analysis of cancer cervix cases was performed. Results: Female cancers comprised of 40% of total cancers with oesophageal and breast cancer as most common malignancies. Cancer cervix did not figure in top ten cancers and only 45 (0.01%) cases were recorded of the total of 3084 adult female cancers. Conclusion: We conclude that due to different socio-cultural and sexual practices, this cancer is highly uncommon in Kashmir and screening or possibly should be directed specifically at only high risk selective subjects.

Keywords: Cancer cervix, incidence, Kashmir, sexual practices

How to cite this article:
Afroz F, Rasool M T, Nasreen S, Lone M M, Wani M L, Akhter S, Zaffar S, Yousuf S, Akhter A. Cancer cervix: An uncommon malignancy in Kashmir, India. Indian J Cancer 2016;53:77-9

How to cite this URL:
Afroz F, Rasool M T, Nasreen S, Lone M M, Wani M L, Akhter S, Zaffar S, Yousuf S, Akhter A. Cancer cervix: An uncommon malignancy in Kashmir, India. Indian J Cancer [serial online] 2016 [cited 2021 Jun 13];53:77-9. Available from:

 » Introduction Top

Worldwide, cancer of cervix uteri is the second most common cancer among women (GLOBOCAN 2008: IARC, Section of Cancer Information). Cervical cancer incidence rates vary from 1 to 50 per 100,000 females; rates are highest in Latin America and the Caribbean, sub-Saharan Africa, and South-Central and South-East Asia.[1] In India, cervical cancer ranks number one among cancer in females with an annual incidence of more than 132,000 and around 740,00 deaths every year [2] and accounts for 25.9% of all cancers in females and 23.3% cancer deaths (GLOBOCAN 2008: IARC, Section of Cancer Information). Though there are multiple and varied reasons for the high incidence of this malignancy nearly all over India with the incidence of human papilloma virus as the main causative agent for this malignancy, but this trend is significantly diverging in some parts of the country. Early age at first intercourse, multiple sexual partners, a history of venereal infection, and other parameters of sexual activity have long been recognized as factors associated with the development of invasive cervical cancer. The Indian Council of Medical Research initiated a network of cancer registries under the National Cancer Registry Programme (NCRP) in 1981 and data collection commenced in these registries from January 1982 (Annual Report, 1982, National Cancer Registry, New Delhi: Indian Council of Medical Research; 1985). These registries (including cancer registry at our Regional Cancer Centre) have provided information on incidence and patterns of cancer that in terms of quality and validity meet international standards. In India, the cancer registry perhaps is the only programme for reliable incidence and mortality rates. We report disproportionately low incidence of this cancer in Kashmir, which is geographically a remote place and with different social and religious practices.

 » Materials and Methods Top

A cross sectional study was conducted at our centre. From January 1, 2009 to December 31, 2011, during a period of three years, all patients were screened for diagnosis of cancer cervix at our centre, which has acquired the status of Regional Cancer Centre through National Cancer Control Programme and presently has the largest hospital based cancer registry in the state, with a catchment of nearly 6.7 million population. Only histologically confirmed cases were included in the study. Descriptive statistics was obtained from well maintained files of patients from the hospital based cancer registry. The evaluated variables included gender, age, stage at presentation, parity, socioeconomic status, religion, marital status, etc. Disease stage was determined using the clinical staging system adopted by the International Federation of Gynaecology and Obstetrics (FIGO). The pattern of cancer cervix in comparison to other common cancers among females in Kashmir was studied with their epidemiological profile. Data was analysed and presented statistically.

 » Results Top

From January 1, 2009 to December 31, 2011, 8741 patients were registered out of which 3513 (40%) were females with a male to female ratio of 1.48:1. Cancer of esophagus followed by cancer of the breast and colorectal cancer were the most common cancers in females [Table 1]. Cancer of cervix did not figure in top 10 adult female cancers, and ranked at number 12, and comprised barely 0.012% overall and 0.014% of all adult females.
Table 1: Commonest cancers in adult females in Kashmir (n=3084*)

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Most of the patients were in the fifth and sixth decade of their life and only 7 (15.5%) patients were less than or equal to 40 years of age [Table 2]. Average age at marriage was 22 years but such age was not available in 10 patients. Majority of patients were multiparous with a parity of three and four most common. Though all patients were married (all married once only), two patients were nulliparous [Table 3]. 28 (62.2%) patients had rural dwelling [Table 4] and all patients were Muslims [Table 4]. All females were married to Muslim males. Though history of male circumcision was not available in all cases but universally, Kashmiri Muslims are circumcised early during their life.
Table 2: Patient characteristics (n=45)

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Table 3: Patient characteristics (n=45)

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Table 4: Patient characteristics (n=45)

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Most Patients had infiltrating tumors with squamous cell carcinoma as the main histological finding. Only three patients had adenocarcinoma. Large cell was the predominant histological type among squamous cell carcinomas. Since there is no population based screening programme, most patients present in relatively advanced stage of disease. In this study, FIGO stage IIB was the main presenting stage [Table 5].
Table 5: Tumor characteristics (n=45)

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 » Discussion Top

Kashmir is largely an isolated place from the rest of country and represents a different geographical and socio-cultural population. Since our centre represents the main cancer data from whole Kashmir valley, comprising a population around seven million with a total female count of 3260157 (Census 2011: Office of the Registrar General and Census Commissioner, India). The data represents the patterns of cancer, including cervical cancer, in the whole population. International incidences of cervical cancer tend to reflect differences in cultural attitudes toward sexual promiscuity and differences in the penetration of mass screening programs. Due to low incidence of this malignancy, no population screening has been done outside of a small pilot study. In one such study, which included 270 study subjects, none of the study subjects had evidence of cervical dysplasia or malignancy in the  Pap smear More Detailss.[3] The highest incidences tend to occur in populations that have low screening rates, although screening has increased the incidence of this cancer in many countries in the west. In Kashmir, absence of population based mass screening programme may not be the reason of low incidence and is unlikely to significantly increase any such rates. In a recently published national survey in India it has been found that the age-standardised rates for cervical cancer in women in Jammu and Kashmir and Assam, were less than a quarter of the national rates for cervical cancer.[4] The very low incidence of this cancer in Kashmir is of high importance in India, since an explanation for this phenomenon may possibly assist in the prevention of the neoplasm.

The low incidence of this cancer among Jewish women has been extensively studied and has been variously attributed to traditional habits, to different risk factors, or to genetic factors that provide some degree of resistance or immunity. The low prevalence of the homozygous arginine polymorphism may play a role in determining the low incidence of cervical cancer in Jewish women and may also explain the differences between the ethnic groups.[5] No such studies have been performed in Kashmir, which shares some traditional habits with Jewish population.

In Jammu, second major division, of Jammu and Kashmir, with significant differences in population profile, cancer cervix was the most common tumor in females, followed by cancer breast, gall bladder and uterus.[6] In the same study cancer cervix was infrequent among Muslim females.

High background prevalence of human papilloma virus (HPV) infection among females has been reported as the main cause. The true prevalence of background HPV infection in Kashmir is not known. However, in one such study, HPV16 was detected in 6.6% and HPV18 in 3.8% of patients presenting with various complaints in a gynaecology clinic and the study population was not truly healthy in this study. No history of multiple sexual partners or promiscuity was reported in any patient in our study. Though relatively liberal attitudes toward sexual behaviour has been reported in multiple societies, but Kashmiri population especially Muslims is highly conservative towards sexual behaviour. All patients were ethnic Kashmiri Muslims. In this study, cancer cervix does not figure in most common ten cancers which may suggest low prevalence of common risk factors such as infection with HPV and altered sexual behaviours. Boon et al.[7] characterized the male partner as potential vector of HPV, especially in countries where the rate of male circumcision is low. In our study all patients were Muslims and married to Muslim males. Although history of male-partner circumcision was not available in all cases but ritual circumcision is universal among Kashmiri Muslims. Studies have provided epidemiologic evidence that male circumcision is associated with a reduced risk of genital HPV infection in men and with a reduced risk of cervical cancer in women with high-risk sexual partners.[8] The data suggest that after pregnancy or childbirth, in particular at an early age, there is a greater risk of getting a cervical cancer. By contrast, nulliparous married women seem to have a low risk of cervical cancer.[9] In our study, all patients were married with an average parity of 4.5. All 35 patients, in whom data regarding age at marriage was available, were married below the age of 30.

Though in Muslim populations incidence of this cancer is relatively low but the malignancy figures among most common cancers such as in Pakistan.[10] In India, the peak age for cervical cancer incidence is 45-54 years, which is similar to the rest of South Asia [WHO/ICO Information Centre on HPV and Cervical Cancer (a)]. We observed that median age of presentation was 55 years and most common age group was fifth and sixth decade. An association between cigarette smoking and development of cervical cancer has been reported.[11],[12] Only one patient had been an active smoker in this study.

Approximately 75% of invasive cervical carcinomas are squamous cell carcinomas, and adenocarcinomas account for 15% to 25%. A number of studies suggest that the incidence of cervical adenocarcinoma has been increasing, particularly among women in their third and fourth decade.[13],[14] We found that 38 (84.4%) patients had squamous cell carcinoma with large cell as the most common morphology. Only 3 (6.6%) patients had adenocarcinomas [Table 5].

Since the approval of bivalent and quadrivalent vaccines have been used for secondary prevention of this cancer in high incidence areas, due to resource limitation and very low incidence, the application of either screening or vaccination should be used only in selected high risk subjects in Kashmir and to apply mass screening in this population needs serious justification.

 » References Top

Human papillomavirus vaccines. WHO position paper. Wkly Epidemiol Rec 2009;84:118-31.  Back to cited text no. 1
Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005;55:74-108.  Back to cited text no. 2
Yasmeen J, Qurieshi MA, Manzoor NA, Asiya W, Ahmad SZ. Community-based screening of cervical cancer in a low prevalence area of India: A cross sectional study. Asian Pac J Cancer Prev 2010;11:231-4.  Back to cited text no. 3
Dikshit R, Gupta PC, Ramasundarahettige C, Gajalakshmi V, Aleksandrowicz L, Badwe R, et al. Cancer mortality in India: A nationally representative survey. Lancet 2012;379:1807-16.  Back to cited text no. 4
Arbel-Alon S, Menczer J, Feldman N, Glezerman M, Yeremin L, Friedman E. Codon 72 polymorphism of p53 in Israeli Jewish cervical cancer patients and healthy women. Int J Gynecol Cancer 2002;12:741-4.  Back to cited text no. 5
Kapoor R, Goswami KC, Kapoor B, Dubey VK. Pattern of cancer in Jammu region (hospital based study 1978-'87). Indian J Cancer 1993;30:67-71.  Back to cited text no. 6
Boon ME, Susanti I, Tasche MJ, Kok LP. Human papillomavirus (HPV)-associated male and female genital carcinomas in a Hindu population. The male as vector and victim. Cancer 1989;64:559-65.  Back to cited text no. 7
Castellsagué X, Bosch FX, Muñoz N, Meijer CJ, Shah KV, de Sanjosé S, et al. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med 2002;11;346:1105-12.  Back to cited text no. 8
de Graaff J, Stolte LA, Janssens J. Marriage and childbearing in relation to cervical cancer. Eur J Obstet Gynecol Reprod Biol 1977;7:307-12.  Back to cited text no. 9
Badar F, Anwar N, Meerza F, Sultan F. Cervical Carcinoma in a Muslim Community. Asian Pacific J Cancer Prev 2007;8:24-6.  Back to cited text no. 10
Becker TM, Wheeler CM, McGough NS, Parmenter CA, Jordan SW, Stidley CA, et al. Sexually transmitted diseases and other risk factors for cervical dysplasia among Southwestern Hispanic and non-Hispanic white women. JAMA 1994;271:1181-8.  Back to cited text no. 11
Gram IT, Austin H, Stalsberg H. Cigarette smoking and the incidence of cervical intraepithelial neoplasia, grade III, and cancer of the cervix uteri. Am J Epidemiol 1992;135:341-6.  Back to cited text no. 12
Smith HO, Tiffany MF, Qualls CR, Key CR. The rising incidence of adenocarcinoma relative to squamous cell carcinoma of the uterine cervix in the United States: A 24-year population-based study Gynecol Oncol 2000;78:97-105.  Back to cited text no. 13
Vizcaino AP, Moreno V, Bosch FX, Muñoz N, Barros-Dios XM, Parkin DM. International trends in the incidence of cervical cancer. I. Adenocarcinoma and adenosquamous cell carcinomas. Int J Cancer 1998;75:536-45.  Back to cited text no. 14


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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