In 2020, the World Health Organisation (WHO) announced a cervical cancer elimination initiative. Cervical cancer is the fourth most common cancer worldwide amongst women, with more than 300,000 deaths per year. That’s one woman dying of cervical cancer every two minutes. It is estimated that by 2030, the number of deaths will have increased to 400,000 per year.
By contrast, it may be surprising to learn that 99.8% of cervical cancer is preventable.
In the UK, there are 3,200 new cases every year, which is eight new cases every single day. The mortality rate in the UK is around 850 deaths per year. Cervical cancer is the fourteenth most common female cancer in the UK and over the past decade the incidences of cervical cancer have remained stable.
Cervical cancer is not a problem unique to the UK. The WHO estimates that nearly 90% of deaths from cervical cancer occur in low and middle income countries. This is due to access to public health care services being limited and screening and treatment for the disease not having been widely implemented.
The World Health Assembly, the decision-making body of the WHO, adopted a global strategy for cervical cancer elimination in 2018. In order to achieve this aim, the WHO has determined three ‘pillars’:
Each country should meet these targets by 2030 in order to eliminate cervical cancer within the next century.
The overarching aim of the WHO initiative is to eliminate cervical cancer as a public health problem. To achieve this, fewer than four women in every 100,000 worldwide would be diagnosed with cervical cancer each year.
The vast majority of cervical cancers are caused by the human papillomavirus (HPV). HPV is a common virus which infects the skin and cells lining the inside of the body. In the majority of people, HPV does not cause any problems but, like all viruses, HPV has many strains. There are over 100 types of HPV and only thirteen of these have been linked to cancer.
The HPV vaccine is on the WHO Model List of Essential Medicines and helps to protect against cancers caused by HPV including cervical cancer, some mouth and throat cancers and some cancers of the anal and genital areas. It also helps to protect against genital warts.
In the UK and Ireland, girls and boys aged twelve to thirteen years old are offered the first HPV vaccination. Typically, this takes place in school Year Eight. The second dose is offered six months to two years later. In order to be properly protected, both doses of the vaccine must be given.
For those who do not receive the vaccination at school, it is available on the NHS free of charge up to age 25. The take up rate in the UK is relatively high, with over 86% of eligible people receiving both doses.
By contrast, only 15% of girls worldwide are fully protected from HPV. Unfortunately, this simply highlights how far there is to go to reach the WHO target of 90%. Only 71 countries worldwide have included the HPV vaccine within their routine vaccinations programmes. Vaccination is the most effective long-term intervention for reducing the risk of developing cervical cancer.
The WHO’s strategy for achieving 90% coverage of HPV vaccination is to secure sufficient and affordable HPV vaccines, increase the quality and coverage of vaccination, improve communication and social mobilisation and innovate to advance the efficiency of vaccine delivery.
A recent study showed that in developing countries only 19% of women have cervical screening compared to 63% in developed countries. In the UK, the screening uptake is around 70% to 73%, which is considerably higher than the average. At least 2,000 cervical cancer deaths are prevented yearly through the UK screening programme.
The NHS invites all women to attend cervical screening (a smear test) from age 25 to 64. It is important to understand that the smear test is not a test for cancer but a test to prevent cancer. A small sample of cells are taken from the cervix and checked for the particular strains of HPV which can cause cancer. If these are not found, no further action is taken and a further cervical smear is performed after the normal recall period of three years.
If the sample is HPV positive but no abnormal cells are found, a further cervical smear is undertaken in one year and again in two years if the sample remains HPV positive. If after three years the result remains positive, a colposcopy is arranged. This is a simple procedure undertaken in hospital to look at the cervix.
The WHO seeks to achieve 70% screening coverage, and its strategy for this goal involves understanding barriers to accessing services and creating an enabling environment, integrating screening services into the primary care package, promoting a screen and treat approach, ensuring an affordable supply of quality-assured high-performance screening tests and strengthening laboratory capacity and quality assurance programmes.
The first line of treatment in the UK is colposcopy. Again, this is not cancer treatment but treatment to prevent cancer. A microscope is used to look at the cervix and identify any areas of abnormality. A biopsy may also be taken. If abnormal cells are present, further treatment may be offered but it is important to remember that abnormal cells are not necessarily cancer. They may be pre-cancer – cells which could turn into cancer if not treated.
UK statistics show that four in ten women who attend a colposcopy have no abnormal cells and are advised to continue on the cervical screening programme. Those who do have abnormal cells will receive treatment to remove those abnormal cells either by a large loop excision of the transformation zone (LLETZ, which is a heated wire loop used to remove the abnormal cells) or a cone biopsy, where a cone-shaped piece of tissue is removed. In 95% of cases, a single treatment is curative.
Similarly to the strategy for achieving wider screening coverage worldwide, the WHO’s strategy for achieving 90% treatment of pre-cancerous lesions is to understand barriers to accessing services and create an enabling environment, incorporate treatment services into the primary care package, advocate for a screen and treat approach, ensure an affordable supply of quality-assured high-performance treatment devices and bolster laboratory capacity and quality assurance programmes.
For those diagnosed with cervical cancer, treatment will depend on the size and stage of the lesion. Treatment may be a combination of surgery, chemotherapy, radiotherapy and brachytherapy. Many of these treatments can leave women with life-altering injuries including bladder dysfunction, bowel dysfunction, sexual dysfunction, lymphedema and psychosocial problems.
To achieve 90% treatment and care for cervical cancer cases, the WHO’s aims are to implement cervical cancer management guidelines, establish referral pathways and people-centred linkages throughout the continuum of care, strengthen pathology services, expand surgical capacity, widen access to radiotherapy and chemotherapy, improve and integrate palliative care services, optimise health workforce competencies throughout the continuum of care and reduce cancer stigma.
Vaccination, screening and treatment are proven and cost-effective measures for eliminating cervical cancer and need to be implemented worldwide as cervical cancer is preventable in the vast majority of cases. The WHO stresses that to be effective, these measures must be scaled to national levels and delivered using health service platforms that are sensitive to women’s needs, their social circumstances and the personal, cultural, social, structural and economic barriers which hinder their access to health services.