One Death Every Two Minutes from Cervical Cancer – and Vaccination Trends Moving in Wrong Direction
Cervical cancer screening campaign in rural India – most women who die from cervical cancer live in low-income countries lacking access to screening or vaccinations.

Some two-thirds of deaths of women from cervical cancer are happening in low- and middle-income countries that have not yet included human papillomavirus (HPV) vaccines for girls and young women into their immunization regimes, said WHO’s Director General Dr Tedros Adhanom Gheybresus on Wednesday. 

He was speaking at a high level event that saw First Ladies from four African countries call for stepped up action on the disease, which is one of the largest but also most preventable causes of cancer deaths.   

“Cervical cancer is the fourth most common cancer among women globally, but it is almost completely preventable and, if diagnosed early enough, is one of the most successfully treatable cancers,” said Tedros, at the Cervical Cancer ELimination Day event, on the first anniversary of WHO’s launch of a new global strategy to eliminate cervical cancer

“This disease claims the lives of 300 thousand women each year – 1 every 2 minutes” he added. “Like COVID-19, we have the tools to prevent, detect and treat this disease. But like COVID-19, cervical cancer is driven by inequitable access to those tools.” 

Setbacks in strategy to expand access to vaccinations to 90% within a decade 

The WHO global strategy aims to: 

  • Vaccinate 90% of all girls against human papillomavirus by the age of 15; 
  • Expand access to screening services for 70% of women;
  • Expand access to treatment for 90% of women with pre-cancerous lesions, and palliative care for 90% of women with invasive cancer.

But the WHO Director admitted that there already have been setbacks in advancing those goals. Due to the pandemic, the proportion of girls globally with access to HPV vaccines has declined – from 15% pre-pandemic to %13 percent today. 

“At the same time, there are encouraging signs of progress,” he added, noting that over the past year, seven more countries have introduced the HPV vaccine into their national immunization schedules, including: Cameroon, Cabo Verde, El Salvador, Mauritania, Qatar, Sao Tome and Principe, and Tuvalu.

WHO has also prequalified a fourth HPV vaccine called Cecolin, produced by Innovax, which it expects will increase supply and decrease prices.

And WHO is promoting new innovations such as “self-sampling” for cervical cancer,   which can make it easier for women to be screened – even if they are reluctant to undergo a full pelvic exam. 

Botswana – three key approaches to elimination 

Neo Jane Masisi, First Lady, Botswana

Increasing coverage for HPV vaccines along with the successful treatment of women with pre-cancerous lesions – and effective access to treatment of women with full-blown cervical cancer – are three key strategies that Botswana has pursued in order to reduce cervical cancer deaths, said Neo Jane Masisi. Masisi was one of four “First Ladies” to appear at the WHO event – along with the wives of the heads of state of Rwanda, Burkina Faso and South Africa.    

“HPV vaccination coverage was about 90% until 2019, when the country started experiencing supply challenges,” Masisi noted, referring to a constraint faced by many developing countries that lack domestic vaccine manufacturing facilities – not only for COVID vaccines, but for other types of jabs.

Dearth of accurate screening techniques

Deaths from cervical cancer by age in 2018

Another key barrier has been the dearth of accurate screening techniques suitable for low- resourced settings. 

In high-income countries, traditional cervical cancer screening rely upon the laboratory analysis of a cervical smear and possible cell abnormalities by trained technicians – the so-called Pap smear named after its inventor. But in lower-income settings, that option is often unavailable. 

One alternative has involved the visual inspection of a cervical cell sample with acetic acid, which is cheaper and comparatively easier to carry out.  

However, such visual inspections are not as accurate – missing some 30% of potentially cancerous abnormalities, which, if caught at the earlier stages, could be more easily treated. 

New FIND initiative to improve cervical cancer diagnostic tools

The Smart Scope, an Indian invention, uses AI technologies to detect abnormal cells.

Other, new generation screening approaches focus on identifying the presence of high risk types of HPV infection –  most likely to cause pre-cancers and cancers of the cervix. 

DNA-based testing for high-risk strains of the HPV virus, was recently recommended by WHO as a preferred screening method – above either Pap smears or visual inspections. Such testing can be carried out affordably and with comparative ease in developing countries – providing test kits and tools are available, WHO says. 

Other emerging technologies, such as the Indian “Smart-Scope”, rely upon AI to provide better detection of cell abnormalities – and ready analysis via a link to a laptop computer.  The device was the focus of interest and review at the Geneva Health Forum in November 2020.

Just recently, the Geneva-based Foundation for Innovative New Diagnostics (FIND), announced a new initiative to further investigate and assess emerging digital and AI technologies with potential for mass application in cervical cancer diagnosis and screening in low and middle income countries. 

“Our work will encompass point of care, HPV tests, use of digital and mobile technology for screening, and self sampling approaches to screening to overcome barriers and improve access to testing,” said Ilona Kickbusch, a FIND senior advisor. “Together, we can make sure that everyone who needs a test can get one, that every woman can get a test.”

Stigma also impedes access 

Princess Nothema Simelela, WHO Assistant Director General and Special Advisor

But even when services are available, stigma about the disease and about conducting intimate physical exams, keeps many women away from clinics and checkups. 

“There are both supply side and demand side challenges,” said WHO’s Princess Nothemba Simelela, a Special Advisor to WHO’s Director-General.

“There is very limited access to the technologies that we need.  Many low income and lower middle income countries are still using very old fashioned methods of screening women, with acetic acid…. 

“And you have demand side issues, a stigmatized disease, a disease that really makes it difficult for women to come into the centre and ask for help.

“It’s a very very private part of a woman’s body.  And it’s something that we see makes it very, very difficult.”

Added Kickbusch, women may also often need money or permission from husbands and fathers to even attend a health service.  She referred to, “a complex cocktail of technical, social, cultural and economic barriers.”

“As we see with so many diseases, lack of access to testing is robbing women of that chance of an early diagnosis.  In low and middle income countries where health systems are weakest and access barriers are highest, three times as many women die of cervical cancer then in high income countries.”  

Image Credits: Shutterstock , Periwinkle Technologies, The Lancet.

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