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The Case for Collective Commonwealth Action on Cervical Cancer

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The Case for Collective Commonwealth Action on Cervical Cancer GLOBAL CANCER INITIATIVES The case for collective Commonwealth action on cervical cancer Professor Isaac F Adewole (left), Gynaecologic Oncology Unit, Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Nigeria and Dr Ophira Ginsburg (right), High-Risk Cancer Genetics Program, Perlmutter Cancer Center, School for Global Health, Department of Population health, New York School of Medicine, New York, USA Cervical cancer remains a public health challenge, particularly in the low-income and middle-income countries (LMICs) of the Commonwealth due to inequity, injustice and ignorance. The stark reality is that the global call by the World Health Organization (WHO) for the elimination of cervical cancer is only feasible in a few Commonwealth member countries. However, robust collective action that is driven by the highest political leadership could create a pathway for countries with a high burden of cervical cancer and weak health infrastructure to meet the 2030 targets of the cervical cancer elimination agenda. Thus, there is the need for genuine partnerships in research, and policies that will fit the local needs of individual countries. Indeed, single dose HPV vaccination with a “screen and treat” approach for those with premalignant cervical diseases may be a good alternative strategy to the conventional protocol in most Commonwealth countries. It is important that member countries should support each other to generate local evidence, health workforce development, infrastructure and healthcare financing for cervical cancer prevention and treatment. This will ensure that no one is left behind. The time for action is now. Cervical cancer as a public health concern Effective cervical cancer strategy prevention and Cervical cancer, the second most common cancer among control is available women after breast cancer globally, has been described as Generally, persistence of high-risk human papillomavirus a disease that manifests inequity, injustice, and ignorance (HPV) infection is a necessary cause of cervical cancer, (1). Whilst most high-income countries, particularly in accounting for 99% of all cases (5). Although there might the West. had initiated the process of eliminating cervical be variation in the pattern of detectable HPV genotypes in cancer, the majority of low- and middle-income countries the invasive cervical cancer samples, HPV 16 and 18 have in the Commonwealth are experiencing an increasing or been reported in more than 70% (6, 7). Thankfully, there are static incidence and mortality of cervical cancer (2). Most efficient and cost-effective vaccines – Cervarix, Gardasil and of these high-burdened countries are members of the Gardasil 9 – that can be deployed and administered to young Commonwealth (3). Worldwide, it was estimated that every girls before sexual debut at the population level to prevent two minutes a woman dies from cervical cancer. Of the half HPV infection acquisition and persistence (8). Catch-up HPV a million cases of newly diagnosed cervical cancer and more vaccination for sexually active women has also been shown to than a quarter of a million women who die from cervical be useful. Many high-income countries have adopted a gender cancer annually, over 70% are in the low- and middle-income neutral policy of vaccinating girls and boys, as a strategy to countries (4, 5). Commonwealth countries account for 40% quickly promote community herd immunity against HPV (9). of the global cervical cancer incidence and 43% of cervical A recent review by the World Health Organization cancer mortality. Women in Commonwealth countries with (WHO) showed that only two countries in Africa (Rwanda a high HIV burden – South Africa, Tanzania and Zambia – are and Seychelles) have achieved 80% national HPV vaccine at increased risk of morbidity and mortality from cervical coverage, while many other countries have not introduced the cancer. Estimates suggests that the burden of new cases and vaccine (9–11). In addition to mass vaccination, screening for mortality from cervical cancer might increase by 55% and premalignant lesions and prompt treatment of early invasive 60%, respectively, in the Commonwealth member countries cancer are effective secondary and tertiary preventive if there is no appropriate investment (2, 5). strategies for cervical cancer, respectively (11). In an attempt 22 CANCER CONTROL 2020 Maturation Maturation GLOBAL CANCER INITIATIVES Cervical cancer deaths, cervix uteri (per 100,000) Cervical cancer deaths, cervix uteri (per 100,000) to ensure that cervical prevention Figure 1: Cervical cancer deaths, cervix uteri (per 100,000) System building blocks and control is accessible to all women, Leadership / Governance System building blocks } Goals/outcomes WHO prescribed a modified algorithm Improved health Leadership / Governance Access for cervical cancer (1). Again, a number Health care financing } Goals/outcomescoverage (level and equity) of countries in the Commonwealth, Improved health Health care financing Access Responsiveness Health workforcecoverage (level and equity) particularly in Africa, do not have national policies and or implementation Responsiveness Health workforce Medical products, technologies Financial risk protection Quality plans for screening services (1). safety Medical products, technologies Financial risk protection Information and research Improved efficiency Quality } safety The landscape of cervical cancer in Improved efficiency Information and research }Service delivery the Commonwealth The increasing burden of cervical Service delivery cancer in Commonwealth member countries does not appear to be due 5 and more Between Between Less than 1 No reported 3 and 5 1 and 3 Machines to a new histological type or increased >17 5 to 16.9 0 to 4.9 5 and more Between Between Less than 1 No reported aggressiveness of a variant HPV Gavi supported countries 3 and 5 1 and 3 Machines >17 5 to 16.9 0 to 4.9 subtype; it is largely as a result of the high >17 5 to 16.9 0 to 4.9 Source: Gavi 2018 ADHL Gavi supported countries prevalence of risky sexual behaviour, Mali Central Zambia >17 5 to 16.9 0 to 4.9 ADHL poor knowledge and health-seeking Figure 2: Overview of programmatic interventions over the life course to prevent hpv infection and Central cervical cancer Mali Zambia behaviours of women, lack of capacity to effectively implement national HPV Source: WHO Guidance Note: Comprehensive cervical infection screening services and prompt diagnosis e (not to scale) cancer control: A healthier future for girls and women. Geneva: World health Organization; 2013 and treatment of early stage cervical HPV infection evalenc e (not to scale) cancer (1, 12). For example, hospital- Nigeria Kenya based studies have shown that most evalenc Zimbabwe opulation pr Pre-cancer Nigeria Kenya women present in advanced stage (i.e., P Cancer Zimbabwe opulation pr Pre-cancer Figo Stage 2b and above) when a cure P 9 years 15Cancer years 30 years 45 years 60 years 3,is 2% no longer3, 2% envisaged3, 1% and the five-year Uncategorised Kenya 2, 1% Mauritius years yearsPRIMARY PREVENTIO yearsN SECO yearNDsARY PREVENTIO yeN ars TERTIARY PREVENTION China 9 15 30 45 60 6, 3%survival is low (1). Girls 9-13 years Women >30 years of age All women as needed 3, 2% 3, 2% Japan3, 1% Uncategorised Kenya 2, 1% • HPV vaccination Screening and treatment as Treatment of invasive cancer 13, Mauritiu6% Ins Nigeria, more than 7 out of 10 PRIMARY PREVENTION SECONDARY PREVENTIOneededN TERTIARY PREVENTION China Girls and boys, as appropriate at any age 6, 3% Kuwait Girls 9-13 years Women >30 years of age • “Screen and trAlleat” w withomen lo asw coneededst Japan women that present with cervical cancer • Health information and warnings • Ablative surgery 3, 2% Screening and treatment as technology VIA followed by 17, 8% • HPV vaccination about tobacco use* Treatment of invasive cancer 13, 6% United states needed cryotherapy • Radiotherapy South Africa Girls and boys, as appropriate at any age Kuwait for the first time at the gynaecological • Sexuality education tailored to • HPV testing for high risk HPV • Chemotherapy • “Screen and treat” with low cost • Ablative surgery 3, 2% • Health information and warningsage & culture technology VIA followed by types(e.g. types 16, 18 and others) 17, 8% about tobacco use* Unitedclinic states already have Stage III of the disease • Condom promotioncryotherapy/provision for • Radiotherapy South Africa 47, 23% • Sexuality education tailored tothose engaged in sexual activity • Chemotherapy Zambia 51, 25% • HPV testing for high risk HPV (13, 14). In this scenario, a cervical cancer age & culture • Male circumcisiontypes(e.g. types 16, 18 and others) United Kingdom • Condom promotion/provision for 47, 23% patient is usually described as a woman those engaged in sexual activity Zambia 51, 25% * Tobacco use is an additional risk factor • Male circumcision for cervical cancer. Unitedwith Kingdom postcoital or abnormal vaginal * Tobacco use is an additional risk factor bleeding, foul smelling vaginal discharge, for cervical cancer. and weight loss with or without urinary or feacal incontinence. This scenario, often the end stage with no insurance coverage for basic healthcare and cancer of the disease spectrum, reflects the lack of awareness and care (1). High out-of-pocket costs make access to cervical understanding about the disease, prevention and treatment and care very challenging since most treatment protocols include failure of the health system (12-14). In contrast,
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