On this year’s World Cancer Day, February 4, 2020, it is particularly fitting that the Executive Board of the World Health Organization (WHO) is meeting to review a draft global strategy to accelerate the elimination of cervical cancer as a global public health problem. At the January 2019 meeting of the Executive Board, several member states requested that WHO Director-General Dr. Tedros Adhanom Ghebreyesus develop a draft global strategy for cervical cancer elimination in consultation with member states and other stakeholders. The strategy is based on country implementation and scale-up of interventions that have been proven to be effective against cervical cancer:
vaccination against the causative agent human papillomavirus (HPV),
screening for and treatment of pre-cancerous cervical lesions,
early detection and treatment of invasive cervical cancers, and
palliative care.
In 2018, an estimated 570,000 women around the world developed cervical cancer and 311,000 died, according to the International Agency for Research on Cancer. In the absence of a concerted global public health response, the number of annual cases is projected to rise to 700,000 by 2030, with a projected 400,000 deaths annually. Approximately 90 percent of cervical cancer cases and deaths occur in low- and middle-income countries (LMICs). Noting the immense suffering and mortality still caused by cervical cancer, as well as the availability of effective preventative, screening and treatment measures, Dr. Tedros issued a global call to action in May 2018 towards the elimination of cervical cancer as a public health problem. It is important to note that elimination as a public health problem falls along a continuum of infectious disease control, ranging from control to eradication, that was put forth by the WHO in 1998.
Control: Reduction in incidence, prevalence, morbidity, or mortality to a locally defined level
Elimination as a public health problem: Reduction in incidence, prevalence, morbidity, or mortality to commonly agreed targets that will improve public health
Elimination of infection / disease: Incidence of infection or disease reduced to zero in a defined geographical area, such as a country
Eradication: Worldwide incidence of infection reduced permanently to zero
WHO has set the threshold for the elimination of cervical cancer as a public health problem as an incidence of four new cases per 100,000 women annually. According to modelling studies, cervical cancer incidence cannot be reduced to zero with current interventions, but elimination as a public health problem is achievable in every country within this century. To make progress towards elimination, the draft global strategy sets the following targets for 2030:
90% of girls fully vaccinated with HPV vaccine by 15 years of age;
70% of women screened twice by 35 and 45 years of age;
90% of women identified with pre-cancerous lesions or invasive cancers treated
Following deliberation and input by the WHO Executive Board, the draft global strategy will be presented to all member states for adoption at the World Health Assembly in May 2020.
If the global strategy is adopted, implementation will require strong leadership by country governments and multi-sectoral collaboration. Because there is a current HPV vaccine shortage in LMICs, an increase in the global supply of HPV vaccines and improved vaccine affordability will be needed to scale up vaccine coverage. Evidence-based communication, social mobilization, and vaccine delivery strategies will be critical to supporting vaccine acceptance and uptake in all countries. For screening and treatment of pre-cancerous lesions, novel diagnostic approaches (such as HPV testing with self-sampling) and novel treatment approaches (such as simple hand-held devices for thermal ablation) must be evaluated and implemented in countries with limited capacity for cytology and surgical interventions. It will be important to integrate cervical cancer screening and treatment services into primary health care systems and to build health care worker capacity. In LMICs, diagnosis and treatment of invasive cancers will require expanded capacity for pathology, surgery, radiotherapy, chemotherapy, and palliative care. Strategies to build capacity include training programs, partnerships, and the establishment of regional diagnostic and treatment centers.
There are numerous challenges to achieving the 2030 targets for HPV vaccination, screening, and treatment of pre-cancerous and invasive cervical cancer cases. But if the challenges are met, an estimated 74 million cases of cervical cancer will be averted and 62 million lives saved over the next century.