Featured Journal Content

Featured Journal Content

PATH  [to 15 July 2017]
Press release | July 13, 2017
Now is the time to eliminate cervical cancer for all women
Experts agree it is feasible, including in low-resource countries
SEATTLE, July 13, 2017 – The International Journal of Obstetrics and Gynecology this week released a series of papers with recommendations on state-of-the-art cervical cancer prevention tools and strategies that could lead to elimination of the disease in low- and middle-income countries as well as in wealthier nations.
In a call to action published in the journal, 14 global health leaders highlight the impact that human papillomavirus (HPV) vaccination has had in recent years in high-income countries, with dramatic decreases in HPV infection and associated cervical disease.
They urge the health community to increase HPV vaccination everywhere and to accelerate cervical precancer screening and treatment for women who are beyond vaccination age to reduce incidence and mortality worldwide…
International Journal of Obstetrics and Gynecology
Volume 138, Issue Supplement S1   July 2017  Pages 1–73
Special Issue: Cervical Cancer Prevention: Recent Progress and the Unfinished Agenda in Low‐ and Middle‐Income Countries
Guest Editor: Vivien Davis Tsu. IJGO Supplement Editor: Claudio Sosa. Publication of this supplement was supported by the Bill & Melinda Gates Foundation.

Cervical cancer prevention for all women: Why now?
In the past 25 years, the view of cervical cancer has changed from resigned acceptance of a seemingly inevitable and inequitable blight to guarded optimism that we are on the brink of eliminating this dreaded disease that has taken so many women in the prime of their lives. The projections in GLOBOCAN 2012 that the estimated 285 000 annual deaths in 2015 would grow to nearly 385 000 by 2030, with 95% of those deaths in lower-income countries, were based on the assumption that incidence and mortality rates would continue unchanged.[1] That assumption is now being called into question on both scientific and social justice grounds.[2]

Much of the recent change is due to stunning advances in our understanding of the role of human papillomavirus (HPV) in the development of cervical (and other) cancer and of the virus itself and related biomarkers, which enabled the creation of HPV vaccines and screening tests. But these technologies alone do not tell the whole story, since they would be meaningless without the programmatic knowledge of how best to deploy them in the low-resource settings that need them most. Also essential has been the parallel development of a growing contingent of global and national advocates calling for allocation of adequate financial and human resources and implementation at scale of evidence-based strategies for prevention and effective management of cervical cancer. Multilateral agencies such as WHO and UNFPA, international and national nongovernmental organizations (NGOs), coalitions such as Cervical Cancer Action, federations such as the Union for International Cancer Control and FIGO, and donors such as the Bill & Melinda Gates Foundation have joined forces to set norms, strengthen capacities, generate knowledge, and build community demand and political support.

An effort to make screening for cervical cancer available in low-resource settings was started in 1991 by PATH, an international nonprofit NGO devoted to improving the health of women and children through innovation. The modest goal was to identify a screening method that was more feasible than the Papanicolaou test that had become standard in high-income countries and had dramatically reduced previously high rates of cervical cancer through organized, regularly repeated screening.[3] Over the next decade and a half, several organizations, including PATH, generated persuasive clinical and operational evidence that visual inspection with acetic acid (VIA) could be an effective screening modality, despite its shortcomings of user variability and moderate sensitivity.[4]

In the past 5–8 years, the pace of scientific discovery has accelerated, and the body of programmatic experience with cervical cancer prevention in Africa, Asia, and Latin America has grown dramatically. More than 20 low- and middle-income countries (LMICs) have introduced HPV vaccine in either pilot or national programs.[5] Three LMICs in Central America are introducing HPV testing using self-collected specimens in their routine national screening programs,[6] while others in Africa and elsewhere are conducting pilot programs with this method. Countries in Africa and Asia are building service platforms using VIA for screening and cryotherapy for managing precancerous lesions, in line with recent WHO recommendations.[7] As best practices emerge through systematic evaluation, new challenges and remaining gaps are also more clearly delineated.

This Supplement to the International Journal of Gynecology and Obstetrics (IJGO) comes at a critical juncture for cervical cancer prevention. Decisions that are made (or not made) now will affect several generations of women.
:: Will the current inequitable distribution of cervical cancer incidence and mortality be perpetuated or even exacerbated by slow rollout of HPV vaccination in LMICs?
:: Will women in their 30s and 40s, who were too old to benefit from HPV vaccine when it became available, or younger women who missed the opportunity to be vaccinated fully, be offered the life-saving chance to be screened at least once by a qualified provider using an effective screening test followed by treatment when indicated?
:: Will countries heed the call to invest national resources now to prevent the oncoming tidal wave of noncommunicable diseases such as cervical cancer?
:: Will donors expand their funding agendas to support national governments and NGOs with start-up costs and capacity building?

In this Supplement we focus on cervical cancer prevention and gather the latest information on the progress that has been made in recent years, the challenges that remain, and the priorities for action and investment in the next 5–10 years.

In the first paper, a group of world leaders in cancer and reproductive health make an urgent appeal for action to accelerate and expand prevention efforts, building on what is already in place.[8] Next, LaMontagne et al.[9] review the surprisingly rapid initial uptake of HPV vaccine among LMICs, while acknowledging the daunting challenges faced by countries wanting to transform their pilot efforts into sustainable nationwide programs. For secondary prevention, there is a widening set of options for screening, with a growing consensus that all programs eventually will need to move to HPV testing, which includes opportunities associated with self-collected samples.[10] New technology opportunities are emerging in the field of outpatient ablative treatments for precancerous cervical lesions.[11] Basu et al.[12] share the latest thinking on how to combine screening and preventive treatment methods for the optimal balance of effectiveness, acceptability, safety, and feasibility in low-resource settings.

In addition to new options for the screening process itself, several aspects of programmatic structures and strategies are addressed. Drummond et al.[13] discuss how recent advances in health information technology can address some of the challenges that beset data systems needed for both patient care and program monitoring. White et al.[14] draw on their experience integrating cervical cancer screening into existing family planning and HIV/AIDS services to delineate the potential opportunities such integration can create, as well as the challenges that must be overcome to reap the full benefits of this approach. Using their extensive modeling capabilities, Campos et al.[15] estimate the level of investment needed for vaccination and screening over the next 10 years and the potential health and economic impact of such investment in the 50 poorest countries. Wittet et al.[16] emphasize the importance of clear communication and strategic partnerships in strengthening advocacy for cervical cancer prevention. Holme et al.[17] capture the experience of five countries that have embarked on the process of scaling-up their screening programs, identifying challenges they have encountered and insights garnered that could be useful for other countries.

The final paper makes the argument that we now have sufficient tools and knowledge to deliver HPV vaccination, screening, and preventive treatment to even the most resource-constrained settings.[18] There is a limited window of opportunity over the next 10 years to prevent more than 5 million cervical cancer cases with very cost-effective interventions.[15] In 2011, cervical cancer screening and HPV vaccination were identified as “best buys” in the fight against noncommunicable diseases.[19] These efforts are timelier than ever, as the health and well-being of women and girls are considered essential to ending extreme poverty, promoting development and resilience, and achieving the Sustainable Development Goals.[20]

What Dr Mahmoud Fathalla said about maternal mortality is equally true of cervical cancer: “Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving.”[21] Preventing cervical cancer has been largely accomplished in wealthier countries; failing to use the tools and knowledge we now have at hand to accord women in low-resource settings the same life-saving opportunity is unthinkable. This Supplement describes the major achievements of the past decade and points out the way forward.
This paper and publication of the entire Supplemental issue were supported by funding from the Bill & Melinda Gates Foundation. We are grateful for their support, but the funder has had no role in selecting the authors or reviewing the papers. The findings and conclusions contained within this publication are those of the authors and do not necessarily reflect positions or policies of the Bill & Melinda Gates Foundation.
The author has no conflicts of interest to declare.
This Supplement focuses on cervical cancer prevention—recent progress, remaining challenges, and priorities for action and investment in the next 5–10 years.

Ending cervical cancer: A call to action
Sanchia Aranda, Seth Berkley, Sally Cowal, Mark Dybul, Tim Evans, Katja Iversen, Matshidiso Moeti, Babatunde Osotimehin, Stefan Peterson, Peter Piot, et al
First Published: 9 July 2017
Elimination of cervical cancer is now on the horizon if we rapidly scale up prevention in the low‐ and middle‐income countries that bear the highest burden of disease.

Progress in HPV vaccination in low‐ and lower‐middle‐income countries
Scott LaMontagne, Paul J.N. Bloem, Julia M.L. Brotherton, Katherine E. Gallagher, Ousseynou Badiane, Cathy Ndiaye
As of December 2016, 11 low‐ and lower‐middle‐income countries (LLMICs) have introduced or will soon introduce HPV vaccine nationally; another 32 LLMICs have conducted pilot or demonstration programs.

Optimizing secondary prevention of cervical cancer: Recent advances and future challenges
Gina Ogilvie, Carolyn Nakisige, Warner K. Huh, Ravi Mehrotra, Eduardo L. Franco, Jose Jeronimo
HPV‐based cervical cancer screening offers enormous promise toward the global elimination of cervical cancer, but key challenges need to be addressed to ensure women across the world benefit from this new technology.

Treatment of cervical intraepithelial lesions
Philip E. Castle, Dan Murokora, Carlos Perez, Manuel Alvarez, Swee Chong Quek, Christine Campbell
Treatment of precancerous cervical lesions has evolved and newer ablative options for low‐resource settings are being implemented. We review the evolution of treatments, current status, and future directions.

Management algorithms for cervical cancer screening and precancer treatment for resource‐limited settings
Partha Basu, Filip Meheus, Youssef Chami, Roopa Hariprasad, Fanghui Zhao, Rengaswamy Sankaranarayanan
Management algorithms for screen‐positive women in resource‐limited settings need to be pragmatically selected to ensure strong linkage between screening and treatment. Approaches based on limited number of visits are most efficient and cost‐effective.

Cervical cancer data and data systems in limited‐resource settings: Challenges and opportunities
Jennifer L. Drummond, Martin C. Were, Silvina Arrossi, Kara Wools‐Kaloustian
This article draws on authors’ experiences and current literature to describe outstanding challenges and recent advances in implementation of cervical cancer data systems, and to offer recommendations for next steps.

Integrating cervical cancer screening and preventive treatment with family planning and HIV‐related services
Heather L. White, Alejandra Meglioli, Raveena Chowdhury, Olivia Nuccio
Integrating cervical cancer prevention services into existing sexual and reproductive health programs can improve “screen and treat” coverage in countries with high cervical cancer burden.

The health and economic impact of scaling cervical cancer prevention in 50 low‐ and lower‐middle‐income countries
Nicole G. Campos, Monisha Sharma, Andrew Clark, Kyueun Lee, Fangli Geng, Catherine Regan, Jane Kim, Stephen Resch
A 10‐year roll‐out of HPV vaccination for girls and cervical cancer screening for women in 50 low‐ and lower‐middle‐income countries could prevent 5.2 million cancer cases, and is estimated to be very cost‐effective.

Advocacy, communication, and partnerships: Mobilizing for effective, widespread cervical cancer prevention
Scott Wittet, Jenny Aylward, Sally Cowal, Jacqui Drope, Etienne Franca, Sarah Goltz, Taona Kuo, Heidi Larson, Silvana Luciani, Emmanuel Mugisha, et al
Advocacy and communications interventions can help overcome current low levels of access to cervical prevention services in low‐resource settings, especially when implemented through strong partnerships speaking with a common voice.

Scaling up proven innovative cervical cancer screening strategies: Challenges and opportunities in implementation at the population level in low‐ and lower‐middle‐income countries
Francesca Holme, Sharon Kapambwe, Ashrafun Nessa, Partha Basu, Raul Murillo, Jose Jeronimo
Governments in low‐ and lower‐middle‐income countries should consider implementing population‐based cervical cancer screening as soon as possible following a successful pilot program. We discuss these efforts in five countries, including progress, remaining challenges, and recommendations.

The investment case for cervical cancer elimination
Vivien Davis Tsu, Ophira Ginsburg
The inequitable burden of cervical cancer could be eliminated with solutions already available. Sustained political commitment and strategic investments in the next few years could make this a reality.