By Dr Márcia Costa, manager at Deloitte Centre for Health Solutions
Every year January is designated as Cervical Cancer Awareness Month and is followed on February 4th, by World Cancer Day which is aimed at raising cancer awareness and incentivising action for a cancer-free world. This blog, spurred by the similar aims of these two campaigns, explores the extent and causes of inequities in eliminating cervical cancer, where the availability of effective vaccines and cervical screening programmes makes elimination entirely feasible. Today, however, large inequities exist with some 90 per cent of cervical cancer cases occurring in low- and middle-income countries (LMICs), where few women have access to vaccines and 64–67 per cent have never been screened.1 Even in high-income countries, inequities exist between socio-economic groups. We believe that reducing health inequities in cervical cancer prevention could help provide a blueprint for reducing inequities in the treatment and outcomes for other cancers.
About cervical cancer
Cervical cancer is a type of cancer that develops in the cervix and is the fourth most common cancer in women globally, with the highest rates in LMICs and the highest incidence in the 25 to 44 age group. The primary cause of cervical cancer (some 95 per cent of cases) is infection with the human papillomavirus (HPV).2 The established link between the HPV virus and cervical cancer in the 1980s led to two important strands of research; the development of accurate and reliable tests for the virus that have transformed cervical screening, and also the development of effective vaccines to prevent HPV infection.
Estimates suggest some eight out of ten people will be infected with HPV at some point in their lives, albeit most infections are inconsequential and cleared from the body within 12 months. While there are more than 100 HPV strains, only 14 of these are high-risk strains where persistent infections, left untreated, can result in cervical cancer (HPV16 and HPV18 account for some 70 per cent of cases).3
HPV vaccine: a magic bullet?
In 2006, the US Food and Drug Administration (FDA) approved the first vaccine against cervical cancer, a quadrivalent HPV vaccine (protecting against HPV 6, 11, 16 and 18.) Other regulators soon followed suite. As of 2023 there are six HPV vaccines available globally, with one nine-valent vaccine protecting against nine strains that together account for 80-90 per cent of cervical cancers.4
HPV is mainly sexually transmitted and the vaccines are more effective in people who have not been previously infected with the virus so programmes primarily vaccinate girls (and in some countries boys as carriers of the virus) up to the age of 15 years old with two doses delivered 6-12 months apart.5 Some countries such as England now offer the option to all girls under 25 years who were not fully vaccinated at a younger age and other groups at higher risk of HPV infection.6 In April 2022, the World Health Organization (WHO)’s Strategic Advisory Group of Experts (SAGE) on Immunisation published evidence from around the world that showed that a single dose offered robust protection comparable to two doses.7 In fact, England has moved its vaccination programme to a single dose regimen from September 2023.8
A number of countries with mature HPV immunisation programmes have been successful in virtually eliminating cervical cancer in women born since 1995, which should be a strong incentive for LMICs to invest more in HPV vaccination campaigns.9
Cervical screening is recommended for every woman
Although HPV vaccination significantly reduces the risk of cervical cancer, it does not completely eliminate it. Moreover, many women were outside the age range for vaccination when vaccine programmes were first established. Thereafter, cervical screening, was and remains crucial in preventing cervical cancer providing the great advantage of early detection, including identifying precancerous lesions that can be more easily treated before evolving to cancer, thereby increasing the chances of survival.
Worldwide, 139 countries have adopted cervical cancer screening recommendations, most of whom provide publicly funded primary screening tests.10 Recommendations vary between countries, but the WHO recommends testing with a high-performance HPV test every 5–10 years starting at age 30 years.11 In England, women aged between 25 and 49 are invited every 3 years, and from ages 50 to 64 every 5 years.12 However, take-up of screening and vaccination still vary widely between and within countries.
Progress in improving cervical cancer outcomes is widely inequitable
Few diseases reflect global inequities as much as cervical cancer, with incidence nearly twice as high and its death rates three times as high in LMICs compared to high-income countries. In 2020 the WHO launched its first global strategy to eliminate cervical cancer as a public health problem (meaning incidence rates of less than four cases per 100,000 women). To achieve this goal, countries need to meet the following 90–70–90 targets by 2030:
- 90 per cent of girls fully vaccinated with HPV vaccine by age 15
- 70 per cent of women screened with a high-performance test by age 35 and again by 45
- 90 per cent of women identified with cervical disease receive treatment (90 per cent of women with precancer treated, and 90 per cent of women with invasive cancer managed).
However, availability and uptake of these programmes differs between countries. By the end of 2022, 130 (67 per cent of countries) had introduced HPV vaccines as part of their national immunisation services. However, vaccine coverage continues to be sub-optimal with global coverage of the first dose of HPV among girls estimated at 21 per cent (up from 16 per cent in 2021).13 Screening also varies, with estimates indicating that while 84 per cent of women aged 30–49 years in high-income countries have been screened at least once in their lifetime, this proportion decreases to 11 per cent in low-income countries.14 Large investment will be needed if LMICs are to reach current targets.
Disparities also exist within countries. In England, for example, evidence shows that women from ethnic minorities and living in more deprived areas tend to attend screening less and are less likely to take their teenagers to be vaccinated. Further, mortality rates from cervical cancer are 148 per cent higher in women living in the most deprived areas in England than those in the least deprived areas.15 In November 2023 NHS England pledged to eliminate cervical cancer by 2040 and one of the key goals will be to increase HPV vaccination rates in girls from 86 per cent to more than 90 per cent.16
Funding and difficulties in maintaining these programmes evenly across countries contribute to these discrepancies. This is increased at the individual level due to lack of awareness and education, cultural mistrust in healthcare and vaccine hesitancy along with access to the programmes. Some countries are now exploring self-collection options for screening. Self-testing can empower women who might not feel comfortable getting undressed and examined by a nurse or doctor, either for personal or cultural reasons, or those who cannot easily access services, thus increasing screening uptake as shown in pilot studies in LMICs. As is the case with many other cancers, education in schools and via local communities, and addressing social determinants of health, are crucial in decreasing the gap between population groups.
As we wrote in our blog on World Cancer Day last year, the three years 2022-2024 have been dedicated to a single campaign, ‘Close the Care Gap’. In 2024, the final year of this campaign the focus is ‘Together, we challenge those in power’. Both are pertinent sentiments for eliminating cervical cancer. It is in every country’s best interest to tirelessly incentivise and educate citizens on the benefits of screening and vaccination programmes, and the importance of investing in improving access and affordability. Those in power have the potential to make this possible. The success of the drive to eliminate cervical cancer depends on political will, country-led action investments, and global solidarity, as well as sustainable and adaptable partnerships. Moreover, given the clear link between cause and effect which are more evident in cervical cancer than many other cancers, and currently the only one with a vaccine solution, eliminating cervical cancer could lead the way for both vaccines for, and equitable improvements in, other cancers.