When we started working on cervical cancer prevention at PATH 25 years ago, most people were skeptical that much could be done. It was clear that Pap smears (a test to check for cellular abnormalities) were not feasible in low-resource settings where most cases of cervical cancer occur. Even 10 years ago—when new screening and precancer treatment options were becoming available—no one was using the “e” word with cervical cancer. We simply weren’t convinced elimination was possible. But that’s all changing now.
Eliminating a disease means that the number of cases has fallen so low that the malady is no longer considered a public health problem. Elimination is different from eradication; in the latter case, the human papilloma virus or HPV—the bug that causes cervical cancer—would no longer exist in the population. We still don’t believe that HPV can be eradicated, but with the tools now at our disposal—HPV vaccination and screening and treatment of cervical precancer—PATH and our partners feel confident that we can dramatically reduce levels of disease to achieve new elimination targets.
A global tragedy
Cervical cancer kills an estimated 285,000 women each year, mainly in low-resource countries. It is an awful disease—very painful and drawn-out—with an offensive odor that drives women to remove themselves from their compounds and villages to avoid causing discomfort to their friends and families. If they do seek treatment, it is usually too late to benefit much and the expenses may drive the family further into poverty. They suffer, and eventually pass away, often secluded and stigmatized. Every two minutes a woman dies from the disease.
It doesn’t have to be that way. Over 270 million doses of HPV vaccine have been administered, mostly to young adolescent girls, and it works so well—even better, in fact, than we had anticipated—that they can expect to be nearly free of the threat of disease as adults. HPV vaccines have been proven to be safe and effective for use in adolescents. Unfortunately, only a small percentage of girls who need the vaccine, and boys who would also benefit from vaccination because of the other cancers caused by HPV, have been immunized so far.
The vaccine is less effective when given to women once they become sexually active, and are likely to have already been infected with HPV. For those women, screening, and precancer treatment when necessary, is crucial. The good news is that we have reliable tools for that as well, including exciting new options for women to collect their own sample for testing for HPV infection.
A new era with a new goal
This week, Dr. Tedros—the Director General of WHO—threw down the gauntlet asking all nations to join in bringing an end to cervical cancer during the World Health Assembly in Geneva. This is the latest in a series of moves the UN has made to mobilize against the scourge—the first being in 2016 when then Secretary-General Ban Ki-moon called for elimination. Last year, leaders of major health organizations and professional societies added their voices to the call for an end to cervical cancer. In 2018, the World Health Organization (WHO) began the process of officially defining what would constitute “elimination,” and PATH was invited along with other technical experts to contribute to the process. For example, in order to certify a country free of cervical cancer, it is necessary to set a threshold like “fewer than X cases per 100,000 population per year.” This already has been done for malaria, newborn tetanus, and other diseases.
Because we have the tools we need to end cervical cancer, it is clear that the barriers to elimination are primarily economic and political—a deficit of will to allocate the funds needed to achieve this important goal. So advocacy aimed at urging Health Ministers, Parliaments and other decision-makers to focus on the issue at the national level is the next big hurdle. Countries also need technical assistance designing appropriate and affordable national programs to ensure that all girls, and boys if possible, are vaccinated and that all women have access to screening programs.
Allowing the current situation to continue—with hundreds of thousands of preventable deaths occurring each year—violates universal ethical and social values. Furthermore, it does not make economic sense because losing women in the productive prime of their lives cripples families, communities and nations (see an analysis of the investment case). With this new focus on elimination, countries can join with PATH, the WHO and other global partners to advance the fight against cervical cancer, a victory that we think is achievable with concerted action in the next decade or two.
- Vivien Tsu is an associate director in the Reproductive Health Program at PATH.