Although cervical cancer is a highly preventable disease, women in the developing world continue to die needlessly from it. That’s because global attention and funding in countries and from donors for prevention efforts are minimal, leading to more than 528,000 new cases and 266,000 deaths annually.(1) The majority of deaths–85%–occur in low- and middle-income countries.(2) Over the next 25 years, 4 million women will die unless prevention efforts are ramped up.
Jhpiego’s approach to address this disease includes primary prevention—vaccinating girls before sexual debut against human papillomavirus (HPV), the cause of cervical cancer—and secondary prevention, notably, increasing coverage of screening and treatment for women. To prevent the most deaths, Jhpiego recommends a global scale-up of HPV vaccines in countries that have the greatest burden of cervical cancer, including Ghana, Malawi, Tanzania, Kenya and India.
Until the use of vaccines reaches a critical high coverage rate, the global community must prioritize screening and treatment of precancerous lesions using the single visit approach (SVA). Randomized controlled trials (3, 4) and demonstration projects (5) have proven that using the low-technology approach of visual inspection with acetic acid (VIA) to detect precancerous lesions—followed by immediate treatment with cryotherapy—is safe, effective and appropriate for low-resource settings and scalable within limited-resource settings. Screening a woman only once in her lifetime, at the age of 35, as part of a SVA program will reduce her lifetime risk of developing cervical cancer by 25%–36%.(6)
When two vaccine doses are given, the efficacy is very high, ranging from 93% for the bivalent vaccine (Cervarix) and 100% for the quadrivalent vaccine (Gardasil) against 70% of cervical cancers.(7) Recent assessments of HPV vaccination programs in eight low-income countries demonstrated the feasibility and acceptability of delivering the HPV vaccine at scale through a combination of schools and health facilities.(8) Rolling out vaccines in Tanzania (9) showed us that scaling up vaccination coverage of girls to 75% will prevent the most deaths long term, and these effects will start to be seen approximately 16 years after the start of mass campaigns.
Both prevention interventions are highly cost-effective—at less than $500 per year of life saved. Yet, there are many countries that still do not have the means to scale up either or both approaches, which is unfortunate because these same countries also do not have the means to pay for vastly higher costs for treating cervical cancer.
However, these approaches will not be successful in isolation. There needs to be strong political will and support at the national level to turn proven interventions into meaningful action. This support includes allocating sufficient financial resources, strengthening health systems, providing technical support and establishing robust accountability measures to determine progress. The challenge is before us, and with decisive action, it’s a challenge we can surely meet.
Dr. Sanghvi is Jhpiego’s Vice President for Innovations and Chief Medical Officer.
1 International Agency for Research on Cancer (IARC). 2012. GLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012. http://globocan.iarc.fr/.
2 World Health Organization (WHO). 2012. Comprehensive cervical cancer prevention and control: a healthier future for girls and women. Geneva: WHO.
3 Denny L et al. 2005. “Screen-and-Treat Approaches for Cervical Cancer Prevention in Low-Resource Settings: A Randomized Controlled Trial.” Journal of American Medical Association 294:2173–81.
4 Sankaranarayanan R et al. 2005. “A cluster randomized controlled trial of visual, cytology and human papillomavirus screening for cancer of the cervix in rural India.” International Journal of Cancer 116:617–23.
5 WHO. 2012. Prevention of Cervical Cancer through Screening using Visual Inspection with Acetic Acid and Treatment with Cryotherapy: A Demonstration Project in Six African Countries: Malawi, Madagascar, Nigeria, Uganda, the United Republic of Tanzania, and Zambia. Geneva: WHO.
6 Goldie SJ et al. 2005. “Cost-Effectiveness of Cervical-Cancer Screening in Five Developing Countries.” New England Journal of Medicine 353:2158–68.
7 Centers for Disease Control and Prevention (CDC). 2012. Human Papillomavirus: Epidemiology and Prevention of Vaccine-Preventable Diseases. http://www.cdc.gov/vaccines/pubs/pinkbook/hpv.html. HPV 16 and 18 cause up to 70% of cervical cancers worldwide. The bivalent vaccine (Cervarix) protects against HPV 16 and 18 and was proven to have a 93% vaccine efficacy in preventing cervical precancers. The quadrivalent vaccine protects against HPV 6 and 11, which cause 90% of genital warts, and has an almost 100% vaccine efficacy in preventing cervical precancers.
8 Ladner J et al. 2012. “Assessment of eight HPV vaccination programs implemented in lowest income countries.” BMC Public Health 12:370.
9 Tracy K, Schluterman N and Million-Mrkva A. 2013. “Modeling the Impact of Cervical Cancer Screening and HPV Vaccination in Tanzania.” Unpublished modeling exercise presentation given by Clinical and Translational Research Informatics Center at the University of Maryland, College Park, Md., October 24.