Global feasibility of cervical cancer elimination: a multidimensional scenario-based modelling analysis across 175 countries

BACKGROUND: Cervical cancer remains a major cause of preventable cancer mortality worldwide. Progress towards elimination remains uneven, with persistent disparities in health system capacity, governance, and education. Existing models often rely on income classifications, overlooking structural determinants critical for success. We aimed to evaluate the global feasibility of cervical cancer elimination under structurally differentiated policy scenarios. METHODS: We developed a multidimensional scenario-based model integrating 270 structural indicators obtained from WHO, IARC, UN, World Bank, and other international databases across 175 countries. Principal component analysis and clustering identified four structural readiness groups beyond income-based typologies. Regression modelling and Monte Carlo simulations (500 iterations per country-scenario trajectory) were used to project age-standardised incidence and mortality rates from 2022 to 2050 under four policy scenarios: Inertia (no structural improvements), Vaccination Focus (increased HPV vaccine uptake), Empowerment (vaccination plus education gains), and Comprehensive Progress (multidimensional structural strengthening). Monte Carlo simulations propagated uncertainty. Time-series projections to 2050 were independently benchmarked using autoregressive integrated moving average models based on historical trends from 2004-2022. FINDINGS: Structural readiness was more strongly associated with elimination feasibility than income classification. Of 175 countries, 48 were more likely than not (probability ≥0·50) to meet both WHO elimination targets by 2050 under Comprehensive Progress, compared with 15 under Empowerment, two under Vaccination Focus, and none under Inertia. Across countries, estimated probabilities ranged from near 0·00 in several high-burden settings to 1·00 in some high-readiness countries. Mortality reductions lagged incidence declines across all scenarios. INTERPRETATION: Achieving cervical cancer elimination globally will require strategies addressing systemic barriers beyond vaccination. Integrating education, health infrastructure, and targeted financing is essential, but many countries will remain above elimination thresholds without sustained policy engagement and equitable resource allocation. FUNDING: Center for Cancer Prevention and Control (CECAN).