- Lisa Rahangdale, professor1 2 3,
- Nicholas Teodoro, global women’s health fellow and clinical instructor1 4,
- Lameck Chinula, research associate professor1 5 6,
- Noel T Brewer, Gillings distinguished professor2 7
- 1Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- 2Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
- 3Center for AIDS Research, University of North Carolina, Chapel Hill, NC
- 4Wits Health Consortium Clinical HIV Research Unit, Women’s Cancer Research Division, Johannesburg, South Africa
- 5UNC Project Malawi, Lilongwe, Malawi
- 6Kamuzu University of Health Sciences, Blantyre, Malawi
- 7Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
- Correspondence to L Rahangdale
Imagine nearly eliminating a cancer that almost 350 000 women die from globally every year.1 The World Health Organization has set the goal of “elimination” of cervical cancer as a public health problem, defined as less than four incident cases per 100 000 women annually.2 To meet this goal, WHO recommends that countries fully vaccinate 90% of girls against human papillomavirus (HPV) by age 15, screen 70% of women for cervical cancer by age 35 and again by 45, and treat 90% of women identified with cervical disease. But health inequities risk delaying elimination goals, especially for countries and people without adequate access to vaccination, screening, and treatment. A strategic focus on tackling social determinants of health will be required to overcome barriers to elimination for countries and people affected by health inequalities.
Many high income countries have the public health infrastructure to achieve near elimination of cervical cancer. Australia is on track for near elimination by 2028 owing to high uptake of HPV vaccines delivered in schools, high quality screening with primary HPV testing, and tracking of outcomes.3 NHS England recently announced plans for near elimination by 2040.4 Modeling shows the US is on track for near elimination in 2038-46.5
While high income countries have many tools to make elimination a reality, progress is limited by geographical, socioeconomic, and ethnic inequalities. The poorest areas in the US will see near elimination 14 years after the wealthiest.6
England and the US are below WHO’s vaccination target, with 77% and 65% of adolescent girls, respectively, completing their HPV vaccination in 2022.78 The covid-19 pandemic hampered England’s model of school delivery and the US’ clinic based approach. England has lower HPV vaccine uptake among low income households and ethnic minority communities,78 and the US has lower uptake for people in rural areas or without health insurance.9 Populations at highest risk of remaining unvaccinated in England can benefit from more vaccination locations, simplified consent, and a single dose vaccination schedule.7 In the US, uptake can increase by providing more accessible healthcare though expansion of health insurance and ensuring clear recommendations for vaccination.10
England and the US have met WHO’s screening target, with 70% and 72% of women appropriately screened for cervical cancer, respectively.1112 Despite reaching the WHO target, the proportion of English women who are unscreened is at a 10 year high.13 Modeling from the US indicates that greater investment in screening could accelerate elimination goals by a decade.5 A cohort study indicated that 64% of women are missed from screening with the current US model, which underscreens black, Hispanic, and uninsured women for cervical cancer, partially because of language and access barriers and patient misunderstandings about screening.14151617 In England, women with lower incomes are screened less, with barriers including scheduling difficulties and mistrust of screening.1819 Patient navigation and validation of HPV self-sampling may especially benefit women from minorities and underscreened women.2021
Similarly, capacity for diagnosis and treatment of pre-cancerous lesions is high in high income countries, but completion of treatment remains a problem, especially for black and Hispanic women, and those with low incomes, in the US.2223 In the US, national reporting is lacking, but a population based cohort study reported only 47% follow-up for colposcopy.24 Barriers to follow-up are exacerbated by the multiple appointments required for screening, diagnosis, and treatment. US federally sponsored programmes for screening uninsured women are not always coupled with financial coverage for treatment. Women, particularly those with a history of trauma, can associate pelvic examinations with pain and fear.2526 Interventions to mitigate these issues include convenient hours and locations for appointments, further research into patient controlled home topical therapies,252627 and training healthcare staff in culturally sensitive and trauma informed care.
It is harder to imagine elimination in many low and middle income countries (LMICs) because of resource limitations and health systems that lack the infrastructure to deliver widespread coverage of basic health services, including vaccination and screening. The burden of disease disproportionately hits low and middle income countries, where 80% of cervical cancer incidence and 90% of deaths occur.28 Only around half of low and middle income countries have HPV vaccination programmes, and just over half of girls in countries with programmes have had two vaccine doses.29 Leaving school early limits access for many girls to a location for vaccination and basic education to navigate their health and livelihood. Moving to single dose vaccination schedules, support from Gavi and WHO for affordable vaccine supply, and lower cost vaccines manufactured in India will increase access, but manufacturing capacity and distribution will take time to develop.30
Cervical cancer screening and treatment of pre-cancer are limited or absent in many low and middle income countries and where screening is available, there is inequitable access among younger, lower income, rural, and less educated women.31 As governments build capacity, inclusion of equity goals alongside empowerment of women and girls to access healthcare and education is essential.
The near elimination of cervical cancer can become a reality in high income countries such as England and the US in the next few decades, but these countries must make a concerted effort to tackle inequitable access to vaccination, screening, and treatment. For most low and middle income countries, this outcome is not currently foreseeable until the end of the century.32 Addressing inequitable access to prevention strategies between and within countries according to rurality, income, race/ethnicity, immigration status, and lack of insurance requires public health initiatives that improve the underlying social determinants of health that lead to health inequalities. Such programmes will benefit women globally and help to end the large cervical cancer inequities between high and low and middle income countries.
Provenance and peer review: commissioned, not externally peer reviewed.
Funding: Lisa Rahangdale is supported by the National Cancer Institute (NCI) of the National Institutes of Health (NIH) under Award Numbers R01 CA250850 and UG1CA275403.
Lameck Chinula is supported by the NIH under Award Number UM1CA121947 and NCI under Award Number UG1CA275403.
Noel T Brewer is supported by the NCI or the NIH under Award Number P01CA250989. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Competing interests: Noel T Brewer has served as a paid adviser on vaccination for the US Centers for Disease Control and Prevention, Merck, Moderna, Novavax, Sanofi, and the World Health Organization.