A blueprint for elimination of cervical cancer

On Nov 17, countries around the world marked the third Cervical Cancer Elimination Day of Action with renewed commitments, mass screening, and awareness campaigns. The first Day of Action in 2020 saw 194 countries commit to the elimination of cervical cancer within the next century and the launch by WHO of its Global Strategy to Accelerate the Elimination of Cervical Cancer as a Public Health Problem. Cervical cancer is the first noncommunicable disease to be targeted for elimination, which is possible because most cases are caused by oncogenic subtypes of the human papillomavirus (HPV), for which highly effective screening strategies and vaccines are available. Around 80% of people are infected with HPV in their lifetime, with a small risk that those infected with high-risk subtypes will go on to develop cancer. However, although the risk is small, the burden of morbidity and mortality is large, especially in low-income and middle-income countries (LMICs). To eliminate cervical cancer (incidence <4 per 100 000 women-years), WHO has set out targets for immunisation, screening, and treatment that countries should aim to reach by 2030. These include fully vaccinating 90% of girls by age 15 years, screening 70% of women with a high-performance test by age 35 years (and then again by age 45 years), and providing treatment for 90% of women with cervical cancer disease. In his opening remarks on the third Day of Action, Tedros Adhanom Ghebreyesus, Director-General of WHO, described the remarkable progress made towards these goals, with 30 countries introducing the HPV vaccine since the launch of the Global Strategy, bringing the total number of countries that include HPV vaccination in ther national immunisation programmes to 140. When drawing attention to specific countries, Tedros commended Belize for introducing HPV screening into its public health system, Benin for organising a 7-day nationwide campaign to raise awareness and expand screening of cervical cancer, Indonesia for announcing a national elimination plan, and Australia for being on target to become the first country to eliminate cervical cancer, likely within the next 10 years. Also noted was evidence from Norway of no cases of cervical cancer caused by HPV in the first cohort of women to have received the vaccine in the country as children through routine immunisation. It was not all good news. Disadvantaged girls and women, especially those in LMICs and marginalised groups, are still disproportionately affected by cervical cancer. Although HPV vaccines have been available for almost two decades, access to the vaccines has not been equal and coverage of two doses has been low, in part due to vaccine hesitancy. Progress on screening and treatment is lagging. Many countries do not offer cervical cancer screening, and most countries with official recommendations for cervical cancer screening begin to screen women at age 30 years, repeating every 5 years, with the potential for delayed detection of early, treatable stages of cervical cancer. Tedros said that access to surgery, radiotherapy, chemotherapy, and palliative care needs to be better in most countries. There is hope that the situation will improve. Recommendations supporting single-dose strategies for HPV immunisation make incorporating HPV vaccines into routine immunisation programmes a more realistic option for many countries and mean that many more girls can be protected. Nigeria, for instance, is aiming to reach 7·7 million girls with a single dose of HPV vaccine after introducing the vaccine into its immunisation programme in October, 2023. Production of HPV vaccines in LMICs—perhaps leveraging new vaccine manufacturing capacity in these countries in the wake of the COVID-19 pandemic—should ensure more equitable access to the vaccines. The Serum Institute of India, for example, is producing the country's first domestic HPV vaccine, Cervavax, after its approval on the basis of immunological data. This pathway to licensure, made possible by the established efficacy of existing vaccines, is less costly and time-consuming than the traditional route of demonstrating efficacy against disease in large trials and could expedite approval of other HPV vaccines in development. In terms of screening, WHO now endorses testing for high-risk HPV subtypes as the most cost-effective strategy and supports self-sampling for its convenience. Country experiences, such as in Guinea, have shown that, to be effective, cervical cancer screening and treatment must be integrated into existing services and offered as part of a universal health care package. Scale up of prevention, screening, and treatment to achieve the Global Strategy targets will require strong political will, increased support from global partners, and novel strategies to reach women and girls at greatest risk. As evidenced on the third Day of Action, the blueprint is there; now is time for all countries to implement it. For the Global Strategy see https://www.who.int/publications/i/item/9789240014107 For the Global Strategy see https://www.who.int/publications/i/item/9789240014107