Professor Albert Singer

With the present pandemic it is said that life will never be the same again, and this will apply to many things in our present life.  For those concerned with eliminating cervical cancer, the effect of resources being diverted to the COVID-19 response and of social distancing to contain the spread, are extremely concerning. We face challenges of reduced or delayed screening for women; of the issue of cervical cancer plummeting down governments’ agenda; and of scarce supplies of the HPV vaccine. We must act now to mitigate the impact this pandemic could have on our fight against cervical cancer.

We have been used to cervical cancer screening reaching millions of women across the world. The introduction of HPV screening in conjunction with cytology has meant that a new era has emerged; it has become usual for many scientists to predict that cervical cancer will become a rare disease within a few decades, or sooner in some developed countries [i].  Just last year we were talking about the possibility of cervical cancer being eliminated [ii], but now with the advent of the pandemic, I have serious concerns about this being achieved if the screening process continues to be impacted as it has been.

Many national screening organisations, including Australia and the UK,  have noted an automatic reduction in the ability of screening programmes to continue as they had been earlier this year [iii], [iv]. In the developed world many of these programmes will re-commence in their previous form once the pandemic has receded. Yet in places like Brazil, Eastern Europe, and some states in the USA that have been severely affected by the virus, re-establishing these programmes that were supposedly ‘temporarily suspended’ will be difficult because resources have already been diverted towards treating the positive COVID-19 population.

The WHO has also raised its concern about the issues facing developing countries, where the problems of logistics and resource loss have been accentuated by the challenges they already face.  In places where health services are already compromised and high rates of cervical cancer perpetuate, the outlook for cervical cancer screening will be dire, compounded if screening and HPV vaccination falls towards the bottom of their governments’ health agenda [v].

Conversely, some developing countries, especially in Africa, may not be as severely affected, especially those that have learned from previous epidemics such as SARS and Ebola and are now dealing relatively effectively with COVID-19. The hope is that their screening and HPV vaccination programmes may survive relatively intact.

Ultimately, it is the HPV vaccination which is most important for the future prevention of cervical cancer. In the last two years the efficacy of this vaccine has been proven many times and it is the major reason for the widespread optimism in our ability to make this cancer a rare disease.  However, even last year we were facing  a worldwide shortage in the HPV vaccine, with enormous problems in obtaining and maintaining sufficient supplies of the vaccine in both developed and developing countries [vi]. With the emphasis now on developing a COVID-19 vaccine one can only imagine that production of the HPV vaccine will be even more difficult. Resources are being diverted because of a focus by national governments on the seemingly more acute and important challenge of developing and producing a COVID-19 vaccine for the wider population.

Unfortunately, governments are going to be facing the same question for the foreseeable future: What is more important; delivering an anti-COVID-19 vaccine or a prophylactic HPV vaccine? The answer is inevitably going to be disheartening to those of us keen to keep up the fight against cervical cancer.

Faced with these problems, how can we ensure some semblance of normality, however limited, is restored to these programmes of screening and HPV vaccine administration?

The production of adequate supplies of the HPV vaccine will probably not increase sufficiently until a COVID-19 vaccine has been developed and produced in huge amounts. It is for the organisations that are concerned with HPV vaccination, such as GAVI, to press the pharmaceutical industry not to forget the importance of HPV vaccination [vii].

In the short term however, there appear to be two limited solutions that may help keep our battle against cervical cancer on track. Firstly, recent studies [viii] have shown the equal efficacy of delivering just one dose of the HPV vaccine compared to the previous recommended 2 or 3, thereby allowing increased dosages of this scarce product to be made available. Further, in relation to the present screening programs the International HPV society has recommended that as a way of saving valuable limited resources that organisations “should temporarily suspend gender neutral and multiple cohort vaccination programs[ix]. However, it is also noted that interrupting these types of HPV vaccine programmes where they are already established (e.g. in developing countries) may be detrimental to vaccine confidence and equity.

Secondly, if we’re looking for ways to improve access to screening in the current circumstances, there should be a more high-profile role for home-testing kits, with self-application devices for detecting HPV and abnormal cytology. It has been shown that this technique has a high level of efficacy in detecting the premalignant stages of cervical cancer; indeed, in many studies the specimen collected by this method is comparable to that of being physician-tested.  The great advantage of these kits is that the sample for the detection of HPV, abnormal cytology and indeed new molecular bio-markers, can be collected by a woman in the privacy of her own home. This would automatically reduce the need for women to visit a medical facility for a specimen to be collected. Although the first wave of the pandemic is coming to an end in many countries, there is still a very real risk of a second and possibly a third phase to the pandemic.  If this situation comes about it will likely mean that many women will be denied screening or be reluctant to attend because of an inability to staff clinics, reduced capacity at clinics, as well as the fear among many of contagion.

Finally, another possible technique which may help the present situation has been developed in the United States where the National Cancer Institute has trialled a mobile colposcopy camera with artificial intelligence enclosed. The NCI study [x] has shown that this relatively simple technique of photographing the cervix can give a 90% sensitivity for detecting cervical precancer and cancer. The photographs can then easily be shared, meaning that relatively untrained health workers can use the mobile colposcopy camera and send the images to experts anywhere around the globe for appraisal.

It is becoming clearer that many things we were so used to and took for granted before the pandemic will not be available or will have altered dramatically as a result of this catastrophe. The importance of continuing vaccination [xi] in general must not be forgotten at this time but as we adapt our lives in so many other ways, we must also recognise it is possible that the fight against cervical cancer, both screening and HPV vaccination, can be altered to fit the new reality that is  emerging.

At this time, it is crucial that all those involved in the fight against cervical cancer keep abreast of the changes affecting our work and be willing to quickly introduce alternative practices so we can continue to move forwards.

Albert Singer, London, 10th July 2020

 

[i] Impact of scaled up human papillomavirus vaccination and cervical screening and the potential for global elimination of cervical cancer in 181 countries, 2020-99: a modelling study. Simms KT,et al , Lancet Oncol. 2019 Mar;20(3):394-407 https://pubmed.ncbi.nlm.nih.gov/30795950/

[ii] “A future where cervical cancer is a rare disease – for some…”, Singer, A, Colposopy Courses blog,7 October 2019, https://colposcopycourses.com/uncategorised/a-future-where-cervical-cancer-is-a-rare-disease-for-some/

[iii] Guidance for managing National Cervical Cancer screening program during the pandemic, Version 1, 3 April 2020, http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/guidance-for-managing-ncsp-participants-during-the-covid-19-pandemic

[iv] Covid -19 pandemic –NHS England cervical cancer screening program, BSCCP, 1 April 2020, https://www.bsccp.org.uk/healthcare-professionals/professional-news/bsccp-clinical-advice-covid-19

[v] Global strategies for cervical cancer prevention and screening. Pimple SA, et al. Minerva Ginecol, 2019 https://pubmed.ncbi.nlm.nih.gov/30808155/

[vi] IPVS statement on “Temporary HPV vaccine shortage: Implications globally to achieve equity”.  Garland, S, published in Papillomavirus Res. 2020 Jun; 9: 100195, March 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7109621/

[vii] Can routine vaccination be carried out during COVID? 15 April 2020, https://www.gavi.org/vaccineswork/can-routine-immunisation-be-carried-out-safely-during-covid-19-pandemic

[viii] Dose-related Effectiveness of Quadrivalen Human Papillomavirus Vaccine Against Cervical Intraepithelial Neoplasia: A Danish Nationwide Cohort Study. Verdoodt F, et al. Clinical Infectious Diseases, Volume 70, Issue 4, 15 February 2020, Pages 608–614, https://pubmed.ncbi.nlm.nih.gov/30892587/

[ix] IPVS statement on “Temporary HPV vaccine shortage: Implications globally to achieve equity”.  Garland, S, published in Papillomavirus Res. 2020 Jun; 9: 100195, March 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7109621/

[x] An Observational Study of Deep Learning and Automated Evaluation of Cervical Images for Cancer Screening. Hu L,et al,.J Natl Cancer Inst. 2019 Sep 1;111(9):923-932, https://pubmed.ncbi.nlm.nih.gov/30629194

[xi] Vaccination guidance during a Pandemic, Centers for disease Control and Prevention, 9 June 2020, https://www.cdc.gov/vaccines/pandemic-guidance/index.html