Objective: Give All Women the Opportunity to Prevent Cervical Cancer

[This text has been written by Silvia de Sanjosé, Associated Researcher at ISGlobal and consultant at the National Cancer Institute (NCI), United States; and Marta del Pino, consultant at Hospital Clínic]

We were flying from Málaga to Barcelona. The plane was full of gynaecologists who had attended the annual meeting of the Spanish Association of Cervical Pathology and Colposcopy (AEPCC) to discuss the latest research on how to prevent, diagnose and treat cervical cancer. Just over a year earlier, the World Health Organisation (WHO) had called on all countries to define strategies to eliminate cervical cancer worldwide. Each year, this form of cancer claims the lives of more than 300,000 women—one every 30 seconds!—and is diagnosed in more than 600,000 women. And yet, we now know that virtually all cervical cancers can be prevented, and that we have the knowledge and tools to do so.

Each year, cervical cancer claims the lives of more than 300,000 women—one every 30 seconds!—. And yet, we now know that virtually all cervical cancers can be prevented, and that we have the knowledge and tools to do so

Fortunately, cervical cancer is rare in most rich countries. Thanks to the possibility of regular gynaecological check-ups, pre-malignant cervical lesions (or early-stage cancers) are almost always detected at an early stage and can be treated and prevented. And this is in addition to vaccination against human papillomavirus (HPV). We now know that HPV is the cause of almost all cervical cancers, but effective vaccines are available to prevent infection.

On the plane, the group of gynaecologists was in high spirits. During the conference, they had heard the good news about the latest scientific findings, which would shape the worldwide cervical cancer prevention strategy. The research showed that countries needed to vaccinate at least 90% of their girls between 9 and 15 years of age, screen at least 70% of women between 35 and 45 years of age for HPV with cervicovaginal samples, and ensure that 90% of women who needed treatment could get it. All countries would aim to achieve these targets by 2030.

Campaign of the World Health Organisation (WHO)

This ambitious plan could mean that cervical cancer—which for years has been a leading cause of cancer deaths in women—might practically disappear within the next 75 years. In our estimation, these goals will be difficult to achieve worldwide. However, we believe that in Spain, not only are we very close to achieving these goals, but this cancer is also becoming less and less common, thanks mainly to awareness about the importance of prevention. Despite some initial problems, HPV vaccination is well established in Spain; results showing a reduction in cervical cancer are expected very soon. Moreover, most women recognise the importance of gynaecological screening.

In Spain, this cancer is becoming less and less common, thanks mainly to awareness about the importance of prevention

A Disease That Punishes the Poorest

However, there are two major problems that must be solved. Firstly, all the knowledge we have acquired needs to be able to reach all women, regardless of their country of residence. Unfortunately, this is not the case. A woman in Spain has access to a public health system that provides early diagnosis and, if necessary, effective treatment, at no cost to her. In contrast, in a sub-Saharan country, for example, the cost of an examination, test or treatment is unaffordable for most women, not to mention the barriers to access and the lack of available information. This is a disease that is preventable, but its unequal behaviour tends to punish the poorest.

This is a disease that is preventable, but its unequal behaviour tends to punish the poorest

The second problem is that the method of early diagnosis of cervical cancer has changed over the years. The Papanicolaou test—also known as the Pap smear—came into use in the mid-20^th century. This test is performed by examining a cervical sample under a microscope and identifying any abnormal cells. The Pap smear has reduced rates of cervical cancer and decreased the mortality of the disease. In fact, it is still the most widely used test in most countries.

However, in recent years, the Pap smear has started to be replaced by safer, more sensitive and more robust molecular techniques capable of identifying changes in cells before they become apparent under a microscope. Over the past 20 years, numerous diagnostic techniques have appeared on the market. Some detect papillomavirus, while others detect molecular alterations caused by the presence of papillomavirus. In short, a wide range of tests and combinations of tests are available, so much so that it sometimes leads to confusion.

Campaign of the World Health Organisation (WHO)

The Best Tests for Early Diagnosis

We are co-authors of a new article in the prestigious New England Journal of Medicine that reviews the scientific evidence on which tests are most useful for the early diagnosis of premalignant cervical lesions. This review effort brought together scientists and researchers from all over the world to work in groups for months, evaluating and discussing the quality of each publication on the early detection of precancerous cervical lesions and eventually reaching a consensus on the value of each technique. These endless hours spent summarising years of hard work on the part of countless researchers will clearly have been worthwhile if it leads to progress in cancer prevention—and even more so if it enables us to advance in the elimination of this cancer.

We are co-authors of a new article in the prestigious 'New England Journal of Medicine' that reviews the scientific evidence on which tests are most useful for the early diagnosis of premalignant cervical lesions

A young gynaecologist attending our AECCP meeting was surprised to hear for the first time about the global inequality in cervical cancer prevention. She asked us what could be done to help close this gap. We responded that the WHO’s new vision, which is partly reflected in our publication and has been unanimously approved by member countries, calls for a change of course and a global commitment the likes of which has never been seen before.

Governments will have to find ways to improve prevention, scientists will have to continue our search for practical and sustainable solutions, and health systems will have to find strategies to ensure that no one is left behind on the road to cervical cancer prevention. Because the goal is not just to achieve elimination; the goal is to do so without leaving any woman behind. But as Nelson Mandela said, it always seems impossible... until it’s done.

And so, we would like to leave you with a final image: 17 November marked the first anniversary of this race towards elimination. Many countries illuminated public buildings in honour of these efforts, shining a spotlight on what until recently was a utopia, but tomorrow might just become reality.