Findings from a comparative modelling analysis in 78 low-income and lower-middle-income countries (LMICs) performed by the World Health Organization (WHO) Cervical Cancer Elimination Modelling Consortium emphasise the importance of acting immediately on three fronts to scale up human papillomavirus (HPV) vaccination, screening, and treatment for pre-invasive and invasive cervical cancer. In the next 10 years, a one-third reduction in the rate of premature mortality from cervical cancer in LMICs is possible, contributing to the realisation of the 2030 United Nations (UN) Sustainable Development Goals (SDGs). Over the next century, successful implementation of the WHO elimination strategy would reduce cervical cancer mortality by almost 99% and save more than 62 million women’s lives, according to an article published on 30 January 2020 in The Lancet.
WHO is developing a global strategy towards eliminating cervical cancer as a public health problem, which proposes an elimination threshold of four cases per 100 000 women and includes 2030 triple-intervention coverage targets for scale-up of HPV vaccination to 90%, twice-lifetime cervical screening to 70%, and treatment of pre-invasive lesions and invasive cancer to 90%.
The researchers assessed the impact of achieving the 90–70–90 triple-intervention targets on cervical cancer mortality and deaths averted over the next century. They also assessed the potential for the elimination initiative to support target 3.4 of the UN SDGs—a one-third reduction in premature mortality from non-communicable diseases by 2030.
The WHO Cervical Cancer Elimination Modelling Consortium involves three independent, dynamic models of HPV infection, cervical carcinogenesis, screening, and precancer and invasive cancer treatment.
Reductions in age-standardised rates of cervical cancer mortality in 78 LMICs were estimated for three core scenarios: girls-only vaccination at age 9 years with catch-up for girls aged 10–14 years; girls-only vaccination plus once-lifetime screening and cancer treatment scale-up; and girls-only vaccination plus twice-lifetime screening and cancer treatment scale-up.
Vaccination was assumed to provide 100% lifetime protection against infections with HPV types 16, 18, 31, 33, 45, 52, and 58, and to scale up to 90% coverage in 2020.
Cervical screening involved HPV testing at age 35 years, or at ages 35 years and 45 years, with scale-up to 45% coverage by 2023, 70% by 2030, and 90% by 2045, and the researchers assumed that 50% of women with invasive cervical cancer would receive appropriate surgery, radiotherapy, and chemotherapy by 2023, which would increase to 90% by 2030. They summarised results using the median (range) of model predictions.
In 2020, the estimated cervical cancer mortality rate across all 78 LMICs was 13.2 (range 12.9–14.1) per 100 000 women.
Compared to the status quo, by 2030, vaccination alone would have minimal impact on cervical cancer mortality, leading to a 0.1% (0.1–0.5) reduction, but additionally scaling up twice-lifetime screening and cancer treatment would reduce mortality by 34.2% (23.3–37.8), averting 300 000 (300 000–400 000) deaths by 2030 with similar results for once-lifetime screening.
By 2070, scaling up vaccination alone would reduce mortality by 61.7% (61.4–66.1), averting 4.8 million (4.1–4.8) deaths. By 2070, additionally scaling up screening and cancer treatment would reduce mortality by 88.9% (84.0–89.3), averting 13.3 million (13.1–13.6) deaths with once-lifetime screening, or by 92.3% (88.4–93.0), averting 14.6 million (14.1–14.6) deaths with twice-lifetime screening.
By 2120, vaccination alone would reduce mortality by 89.5% (86.6–89.9), averting 45.8 million (44.7–46.4) deaths. By 2120, additionally scaling up screening and cancer
treatment would reduce mortality by 97.9% (95.0–98.0), averting 60.8 million (60.2–61.2) deaths with once-lifetime screening, or by 98.6% (96.5–98.6), averting 62.6 million (62.1–62.8) deaths with twice-lifetime screening.
With the WHO triple-intervention strategy, over the next 10 years, about half (48% [45–55]) of deaths averted would be in sub-Saharan Africa and almost a third (32% [29–34]) would be in South Asia. Over the next 100 years, almost 90% of deaths averted would be in these regions.
For premature deaths (age 30–69 years), the WHO triple-intervention strategy would result in rate reductions of 33.9% (24.4–37.9) by 2030, 96.2% (94.3–96.8) by 2070, and 98.6% (96.9–98.8) by 2120.
The authors concluded that their findings emphasise the importance of acting now on three fronts to scale up HPV vaccination, screening, and treatment for cervical cancer. In the next 10 years, achieving substantial reductions in cervical cancer mortality will depend on successful scale-up of cancer treatment services in LMICs, and supportive and palliative care will need to be scaled up alongside such services. Implementing the WHO strategy towards cervical cancer elimination will result in large-scale mortality reductions and more than 62 million women’s lives saved over the next century in LMICs.
These findings have informed the draft WHO global strategy for cervical cancer elimination, which will be presented to the WHO Executive Board in February 2020, and thereafter considered at the World Health Assembly in May 2020.
Reference
Confell K, Kim JJ, Brisson M, et al. Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries. The Lancet; Published Online 30 January, 2020. DOI: https://doi.org/10.1016/S0140-6736(20)30157-4