4 steps towards wiping out cervical cancer

Cervical cancer is the fourth most common cause of cancer-related deaths among women globally. Every year, 530,000 new cases are diagnosed, with approximately 270,000 deaths worldwide. Without any intervention, it is estimated that by 2050, patients diagnosed with cervical cancer will increase to 1 million per year with approximately 90% of the deaths occurring in developing countries.

So what is being done to minimize deaths from cervical cancer? Here are the four main advances from the last year on cervical cancer prevention

Women now have more options for screening for cervical cancer: the HPV DNA test to check for high-risk HPV infection; cervical cytology, also known as Pap test or Pap smear test; and co-testing.

Cervical cancer is caused by human papillomavirus (HPV), and the new HPV DNA test detects the presence of HPV. This test has proven to be more effective at detecting cervical cancer before progression and reduces the frequency for screening from 26 times with the Pap smear to 10 times with the HPV test. Prior to the widespread knowledge of HPV test as a primary screening method, HPV test was only conducted on patients with abnormal smear samples. The Pap smear test was used as the primary screening method for over 75 years and only detects about 55% of cervical cancer cases.

In 2018, the US Preventive Services Task Force (USPSTF) released a recommendation of co-testing, using Pap smear and HPV test as the gold standard. There is consensus that co-testing is slightly more effective than using only the HPV DNA test. However, some researchers hold the belief that co-testing does not improve the effectiveness of testing; in addition, the procedures and cost associated with co-testing remain high, making it a financial burden on the health system.

Late 2018 also saw the introduction of a new cervical cancer test, the epigenetics-based test. Research shows that this test outperforms both Pap smear and hrHPV tests. Currently, Pap smears only detect one-quarter of cervical cancers, and the HPV test only detects about half. The epigenetics-based test works by examining chemical matters that sit on top of the DNA, forming its “epigenetic profile”. In a trial study conducted out of Queen Mary University in London, all cancers were detected in the group of women participating in the study. The test predicted the development of cervical cancer up to five years in advance and can detect high-grade cervical cancer in its early stages. The introduction of this test will advance the prevention of cervical cancer by identifying individuals who are most at risk, detecting high-grade cervical cancer in its early stages and reducing the number of screenings. Moreover, it is cost-effective.

A do-it-yourself approach to screening for cervical cancer could prove to be another intervention for cervical cancer prevention by increasing screening rates among hard-to-reach women. This self-administered smear test has been tested widely in countries such as New Zealand, India, Uganda and the Netherlands, and has proven to be successful in increasing screening rates. It is thought this approach, if widely implemented, will increase access for under-screened women, such as those on low income with limited access to medical care. A study conducted by Jo’s Cervical Cancer Trust in the United Kingdom shows 72% of sexual violence survivors will not attend a cervical cancer screening due to trauma they have experienced. Cervical cancer screening is an intimate and invasive process that can trigger memories of sexual violence or abuse to those who have experienced it, so the opportunity for women to self-administer could see an increased uptake.

HPV vaccination combined with cervical cancer screening could see the elimination of cervical cancer. Twenty countries have already rolled out HPV vaccination for boys, and the introduction of gender-neutral vaccination in countries such as Australia has shown that HPV vaccine in boys can provide herd immunity, protecting both boys and girls in the transmission of HPV strains. Countries such as the United Kingdom (Wales announced HPV gender-neutral vaccination) and Ireland are now following in Australia’s footsteps by making commitments to introduce the HPV vaccine to teenage boys as early as 2019.

HPV does not stop at 26 years of age. Canada and Australia are two countries where HPV vaccine is approved for use among women aged nine-45 as well. In 2018, US regulators expanded the use of Gardasil 9, Merck’s cervical cancer vaccine, to adults up to the age of 45. Gardasil 9 protects against nine strains of HPV, including 16 and 18, which are responsible for most cervical, anal and other HPV-related cancers.

The prospect of eliminating cervical cancer is bright especially in middle- and high-income countries. The application of these advances must trickle down to the rest of the world, especially low- and middle-income countries, for us to truly eliminate the disease. For example, the widespread implementation of Pap smears in developed countries has been attributed to the significant drop in cervical cancer rates, whereas in low- and middle-incomes countries Pap smear tests have proven difficult to implement widely given challenges such as lack of inadequate infrastructure, shortage of trained pathologists and multiple clinic visits. The introduction of the HPV test and self-administered screening test could increase the screening rates in low- and middle-income countries, as they address some of the current challenges to screening.

These advances on cervical cancer prevention present the prospect of eliminating cervical cancer in the next 10 to 15 years, and 2019 will see more use of artificial intelligence (AI) and technology to advance cervical cancer prevention and treatment to help countries in low-resource settings to eliminate cervical cancer.

• Written with input from Sakirat Makanjuola-Akinola, general practitioner