This #IWD2022, Pledge to Love Yourself | In Conversation with Dr. Manjula Anagani

Dr. Manjula is the Clinical Director and HOD – OB GYN at Care Hospitals, Hyderabad. She is the recipient of numerous honours and awards, including the fourth highest honour for a civilian in India, the distinguished ‘Padma Shri.’ She also holds the Guinness world record for removing highest number of fibroids in a single operation.

A pioneer in laparoscopic and minimally invasive surgery, Dr. Anagani has successfully performed over 20,000 laparoscopic surgeries in Gynaecology. She is the first doctor in India to utilize Autologous Stem Cells to regenerate endometrium in case of endometrial aplasia. She was also instrumental in pioneering a new technique in India to create a Neovagina using a minimally invasive technique for women with absent vagina. She is armed with extensive expertise in performing complex obstetrics and gynaecological surgeries.

Namita Narkar: Dr. Manjula, thank you so much for granting this opportunity to interview you on the occasion of International Women’s Day. Your vision for and dedicated service to women’s healthcare is visible through all the work you have been doing. May I ask what drives you?

Dr. Manjula Anagani: Thanks, Namita, you are welcome.

Necessity is the master of innovation. Whenever there’s a need, we seek answers to mitigate that need. And that need I see is everywhere around us. We are surrounded by our fellow beings who are unaware of a lot of things in matters of health. Earlier, people would accept what was told to them without questioning, assuming not questioning was the norm. Now, people are on the other extreme, where they want to question everything despite it being the norm. That means we have a dire need for right people telling the right things in the right manner.?

There's a saying in Telugu that goes like: (Read as Sankham lo poste kani, tirtham avadu). It means even water when poured into the right vessel, takes the shape of what you want it to. When placed next to God, it's no more the same, but turns into holy water.

Unawareness in healthcare is at its lowest; despite the ongoing efforts, it isn't what we would like it to be at. Therefore, to be the right person and tell all that needs to be told to my patients, is what drives me day after day.

NN: That of course brings me to the topic of the day. What exactly is cervical cancer and what causes it?

MA: A recurrent, repeated insult to any region of the body will lead that region to change its structure into an abnormal one. Whether it’s the mouth that’s affected by chewing tobacco resulting into oral cancers, or the lungs that are affected by cigarette smoking leading to lung cancer, it’s the recurrent damage to these organs that bring about the changes.

In the same way, when cervix – present at the mouth of the uterus, connecting the vagina to the uterus – is abused by recurrent, repeated infections by the Human Papilloma Virus (HPV), it gets affected.

HPV infection is the most common sexually transmitted infection. All the women who are sexually active, will have some HPV infection at some point in time. The whole sexual act is such that the HPV hits the cervix more than the penis. It’s the principle of inclusion versus exclusion; the semen is included into the cervix, so HPV lasts there for long. And because it lasts there for long, it insults the cervix more. However, HPV infections usually resolve on their own. But persistent infections – those that don’t resolve with time – lead to cervical cancer.

There are a couple of other causes as well. Certain times, it’s multiple child deliveries that cause repeated insults to the cervix. Repeated use of tampons, multiple sexual partners and unsafe sex lead to HPV infections.

For those of us who are genetically predisposed to this cancer can acquire if the cervix faces repeated insults.

But having said this, it’s basically the HPV infection that is the cause in 99% of cervical cancer cases.?

NN: So where does the cervical cancer start?

MA: There is a zone in the cervix called the transformation zone. It’s from this zone that all the changes in the cells begin. Let’s say, we have a fall and get our skin wounded; the new skin grows in its place. Or for that matter, whenever we get facial peels done, the treatment gently removes dead skin cells allowing newer healthier cells to grow. Similarly, when the cervix gets insulted and injured, a new layer of cells is regenerated. Every time there’s erosion, there also regeneration. This continuous process starts from the transformation zone in the cervix.

Now if there’s an infection there, the erratic behaviour of cells sets in and there’s no control on cellular multiplication. The cells are multiplied lot more rapidly and, in the process, they lose their adhesiveness. ?Because they lose their adhesiveness, these cells start shedding.?The shedded calls come to our advantage to be observed under the microscope for any abnormality.

NN: And how much of the cervix is the transformation zone?

MA: It’s a very thin layer. The transformation zone is essentially the overlapping border between the endocervix and ectocervix. And depending on which area gets infected, the patient will have either endocervical cancer or ectocervical cancer.?

NN: Which age-groups are susceptible to cervical cancer?

MA: We are witnessing two extreme waves. One is in the reproductive age group, the younger age group, and then in the post-menopausal age group. Everything depends on whether the transformation zone is exposed on the inner side or the outer side.

In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.

Once the transformation zone is exposed more on the outer side, it gets affected by recurrent HPV infections potentially leading to cervical cancer.?

NN: Data says that cervical cancer claims one woman every 8 minutes? Can you shed some light on how grave the problem is?

MA: According to WHO, worldwide, cervical cancer is the fourth most cancer in women with an estimated 604,000 new cases in 2020. Of the estimated 342, 000 deaths from cervical cancer in 2020, about 90% of these occur in low- and middle- income countries.

When we come to India, we share the highest burden of cervical cancer than other country in the world does. India accounts for roughly 25% of the global incidence, and close to 27% of the worldwide deaths.

Earlier we used to believe it was a disease of the poor communities where hygiene was an issue, but now it’s clear that cervical cancer has got to do with HPV instead. Among people who use condoms, the incidence will be less, because it’s a barrier contraception so it prevents passing on of the infection. Those who don’t, stand at a higher risk. In sex workers, in those with multiple partners, they will have repeated insults in the form of infection.

So, the number you mentioned, it usually reflects the reality of regions the survey is conducted in. But I agree that the fear factor works at times. Or else people choose to live in denial thinking they would never contract it.

NN: In May 2018, the WHO Director-General announced a global call for action to eliminate cervical cancer. In August 2020, the World Health Assembly adopted the Global Strategy for cervical cancer elimination making it the first-ever global commitment to eliminate a cancer. All this clearly tells that now is the time to eliminate cervical cancer as a public health problem. How can we women contribute to this goal?

MA: Why do you think we can eliminate cervical cancer? Because we know that it’s the HPV infection that’s causing it.

First, I always tell that we are very lucky to be born as woman, because all our cancers are curable, treatable, and completely controllable. Ca Breast – early stage completely curable, or good life expectancy; Ca Vaginal – curable; Ca Endometrium – curable; Ca Tube – curable. Ca Ovary – early stages completely curable or controllable; and Ca Cervix – completely curable, even if you come in stage 3, can still be kept under control.

Second, knowing that cervical cancer is preventable makes a huge difference. The vaccine Gardasil was launched almost a decade ago. Initially, we had the bivalent (protection from two high-risk HPV subtypes), then quadrivalent (4), and now we have the nonavalent (9). Prevention is always better than cure. And primary prevention is nothing but vaccination, vaccination, and vaccination. While the ideal age to get vaccinated is between 10-12 years, because the immunogenic reaction of the body is the highest at that age, I am of the belief that age should not stop you from taking the vaccine.

Plus, the HPV vaccine protects us from vaginal, vulval, anal, head and neck cancers, and penile in case of men.

When it comes to screening, India is the last or least country to get pap smears done. I was a part of the study we conducted, and it turned out that only 4% of rural women and 5% of urban women get a pap done in a year. These figures are truly disturbing!

To sum up, to do your bit to this global initiative, and to stay protected –

• Get vaccinated
• Get screened regularly

NN: What is the algorithm for screening and diagnosis of cervical cancer?

MA: Previously we would depend only on the Pap smear test which was done by the pathologist. So, we would recommend an annual pap smear, at least for three continuous years if you are with the same partner. I always say that you can trust yourself but never the other person. How many partners he has, and how many partners the other partner of the partner has? We don’t know!

Now we have the Liquid-based Cytology (LBC). The LBC scores over the pap test because of the adequate cell sampling that makes its sensitivity, specificity, and accuracy higher than conventional testing. The LBC tells us two things. One, whether there’s an HPV infection and which of the high-risk HPV subtypes are present. Second, the cellular cytology where the nuclear morphology also is seen.

Therefore, the bottom line is to get the LBC done every year. That also gives you an opportunity to go to a doctor, get yourself checked up, not just for cervical cancer, but for breast examination, or any other health issues.

Make it a routine and make your gynaecologist your lifetime friend!

NN: On this #IWD2022, what is your message to all the women out there?

MA: [smiles] I always say, love yourself, believe in yourself, and never compromise with happiness. Unless you love yourself and take care of yourself, you cannot be of help to others. Trust yourself and take care of yourself.

NN: Dr. Manjula, thanks once again for your time and insights! It was a total pleasure talking to you and knowing how we women can take care of ourselves.