By Professor Albert Singer
One of the things which delights me most about having specialised in cervical cancer for more than 50 years is the prospect of it becoming a rare disease. After decades spent treating and counselling women whose lives and families have been torn apart by this dreadful illness, it is a remarkable proposition that cervical cancer could be virtually eliminated down to measurable global targets set by WHO, although not eradicated. Total eradication means a permanent reduction to zero rates worldwide when possible intervention measures will be no longer necessary. Unfortunately eradication is not possible with the existing HPV vaccines for a number of reasons: the vaccine does not protect against all oncongenic (cancer related) HPV viral types; even some already vaccinated women might get cervical cancer from non targeted oncogenic HPV viral type; and finally screening, be it by smear or HPV analysis, is not completely failsafe.
Ten or fifteen years ago elimination would have been impossible to propose but earlier this year a paper was published entitled “The projected timeframe until cervical cancer elimination in Australia”. It’s not surprising that Australia should be one of the first countries to achieve this, it is easy to identify the main factors in their success. It was one of the first countries to introduce a national HPV vaccination program and has achieved very high coverage for both sexes. At present their annual incidence rate for cervical cancer is just 7 per 100,000, one of the lowest rates in the world. It is aiming to reduce this figure to 6 per 100,000 women by 2020 and to 4 new cases per hundred thousand by 2028. It is at these levels that cervical cancer is heading towards becoming classed as having been eliminated and designated as a rare disease. By 2066 they feel that the annual incidence will remain fewer than one case per 100,000 women assuming HPV tests are done every five years.
Compare these rates to those of Southern Africa which has a rate of 44 per 100,000, Central America at 14 or the Caribbean at 16, and even northern Europe where the rate is about 10 per 100,000 and in North America about 7.
It was interesting that at the EUROGIN meeting in Lisbon last December, speakers from countries such as the United States and Canada also admitted they were vying for the title of the first country to have cervical cancer classified as a rare disease. Although even they have problems with high rates in certain areas, as recently demonstrated by a Human Rights Watch report, which identified that black women in Alabama were dying of cervical cancer at twice the national average.
However, what is most distressing is that for many millions of women in the less-developed regions of the world, a future without cervical cancer is never going to be a reality. Despite the best efforts of the most talented scientists and physicians, they and their families will continue to be devastated by this almost entirely preventable disease. There were 311,000 deaths in 2018 globally and ninety percent of those HPV associated cancers occurred in low and middle-income countries. By 2030 it is estimated that 363,000 women in these countries will die of cervix cancer compared to only 41,000 in more developed parts of the world.
We can only hope this inequality between developing and developed countries becomes less rather than more in the future. The WHO is currently working on a strategy to ensure all countries are on their way to eliminating cervical cancer within the century and has proposed a “90-70-90 target” by 2030:
- 90% of girls fully vaccinated with the HPV vaccine by 15 years of age;
- 70% of women are screened with a high-precision test at 35 and 45 years of age; and
- 90% of women identified with cervical disease receive treatment and care.
But despite our best efforts, even in the UK where we have a world leading smear program, around one in four eligible women do not go for free testing for cervix cancer. The testing is in the form of either a smear test which entails the taking of cells from the cervix, or the use of a swab in the vagina to detect the virus (HPV) that causes cervical and other genital cancers in women.
What is upsetting is that three million women in the UK have not had a smear test in three and a half years or longer. Screening starts at 25 and in some areas, half of women under 50 have not had the test within the recommended time frame of every three years. A total of ~220,000 British women are diagnosed with cervical abnormalities every year but due to the screening program and the efficiency of treating the precancerous stages of cervical cancer, mercifully only 854 deaths from this cancer occurred in 2016 (the most recent year for which statistics are available). Unfortunately after rates of testing rose by over 30% in 2009 following the death of UK reality TV star Jade Goody, they have now dropped to the lowest in 20 years.
So why this avoidance by so many women to go for a test? One reason is that cervical abnormalities (the precancerous stages) are generally without symptoms and so cause no concern to many women. These early precancerous changes are 95% curable with one simple treatment, however, if left, over 10 years they will develop into cancer in around 30% of women. When this occurs symptoms such as abnormal bleeding or blood stained discharge develop.
A second major reason is embarrassment and the perception that the test is painful, a fact that Jo’s Cervical Cancer Trust #endsmearfear campaign is trying to combat. Many young women find the insertion of the vaginal speculum to be painful. A considerate and competent nurse or doctor should be able to accomplish this insertion with minimal discomfort.
Religiously observant women or those from more traditional backgrounds and countries may also be embarrassed, especially when a male doctor performs the test. In this situation they can be given a simple test to do in the privacy of their home. This procedure entails the insertion of a small swab stick into the vagina, the stick with the sample is placed in a small test tube and sent to a lab for testing. Although slightly less accurate than the traditional test it still is very acceptable as a form of screening, especially if testing for the HPV virus is also done on this sample. If the virus test is negative then the chance of having an abnormality is about 1 percent.
The good news is that the present tests, especially for HPV, detect the precancerous stages and prevent their progression to cancer. The future could theoretically see the eventual elimination of this cancer. However, we have to work harder both to vaccinate as many and as widely as we can, particularly in the developing world, at the same time as increasing the rates of smear and HPV testing.