Affordable human papillomavirus screening needed to eradicate cervical cancer for all
Authors: Sara Krivacsy, Alice Bayingana, Agnes Binagwaho
Journal: The Lancet Global Health (2019)

Headlines claiming the impending eradication of cervical cancer and all the suffering it causes are proliferating. Technical innovations, political agendas, and grassroots advocacy have joined efforts to turn the hope for elimination into a possible, near-tangible reality. But a question remains: elimination of suffering for whom? Cervical cancer incidence and mortality have plummeted in high-income countries, largely because of effective human papillomavirus (HPV) vaccination and screening programmes. More than a year has passed since the Director-General of WHO announced a call to end the preventable devastation of cervical cancer for all.1Ghebreyesus TA Cervical cancer: an NCD we can overcome.https://www.who.int/reproductivehealth/DG_Call-to-Action.pdf?ua=1Date: May 19, 2018Date accessed: August 9, 2019Google Scholar However, in 2018, there were an estimated 570 000 cases and 311 000 deaths worldwide, approximately 90% of which occurred in low-income and middle-income countries.2Bray F Ferlay J Soerjomataram I Siegel RL Torre LA Jemal A Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.CA Cancer J Clin. 2018; 68: 394-424Crossref PubMed Scopus (51287) Google Scholar As much of the developing world faces an epidemiological transition towards chronic disease and is not ready to face it, the burden of cervical cancer mortality is expected to rise dramatically, particularly for those born in poverty. By 2030, WHO predicts a 27% rise in cervical cancer mortality in low-income countries compared with just a 1% increase in high-income countries. An opportunity to minimise the injustice of women in low-income countries having a substantially increased likelihood of dying from cervical cancer simply because of their place of birth can be found in the provision of affordable HPV screening tests. National cervical cancer management programmes require vaccination, screening, treatment, and palliation. If the vision of eradication promised by news headlines is to be realised, these components must all be fulfilled. Prophylactic HPV vaccination is a highly effective prevention strategy, but millions of women at risk have already been infected or have cancerous or precancerous lesions.3Jeronimo J Bansil P Lim J et al.A multicountry evaluation of careHPV testing, visual inspection with acetic acid, and papanicolaou testing for the detection of cervical cancer.Int J Gynecol Cancer. 2014; 24: 576-585Crossref PubMed Scopus (133) Google Scholar Thus, accessible screening programmes are essential. Advances in screening technologies assessed by a large body of research have shown that screening using HPV DNA testing is effective, cost-effective, and feasible in low-income settings. Overwhelming evidence indicates that HPV testing is more sensitive than conventional Pap testing for the detection of precancerous lesions.4Schiffman M Wentzensen N Wacholder S Kinney W Gage JC Castle PE Human papillomavirus testing in the prevention of cervical cancer.J Natl Cancer Inst. 2011; 103: 368-383Crossref PubMed Scopus (515) Google Scholar It also predicts a longer period of low risk of developing cancerous lesions, allowing for screening intervals to be lengthened—an important programmatic element in developing countries, where many women face barriers to accessing health centres. An improved HPV test that became available in 2014 has proven effective for low-income settings as it does not require air conditioning or running water and can be done by people with very little laboratory experience.3Jeronimo J Bansil P Lim J et al.A multicountry evaluation of careHPV testing, visual inspection with acetic acid, and papanicolaou testing for the detection of cervical cancer.Int J Gynecol Cancer. 2014; 24: 576-585Crossref PubMed Scopus (133) Google Scholar The vaginal sample can be self-collected or taken by a health-care provider, presenting an opportunity for community-based screening.3Jeronimo J Bansil P Lim J et al.A multicountry evaluation of careHPV testing, visual inspection with acetic acid, and papanicolaou testing for the detection of cervical cancer.Int J Gynecol Cancer. 2014; 24: 576-585Crossref PubMed Scopus (133) Google Scholar Another innovative HPV test uses PCR to test for 15 types of HPV and can give results in 1 h.5Einstein MH Smith KM Davis TE et al.Clinical evaluation of the cartridge-based GeneXpert human papillomavirus assay in women referred for colposcopy.J Clin Microbiol. 2014; 52: 2089-2095Crossref PubMed Scopus (63) Google Scholar Cost-effectiveness studies done in low-income and middle-income countries, including India, Kenya, Peru, South Africa, and Thailand, confirm the efficacy of HPV DNA screening and suggest a financial obligation to implement it.6Goldie S Gaffikin L Goldhaber-Fiebert J Cost-effectiveness of cervical-cancer screening in five developing countries.N Engl J Med. 2006; 355: 745Crossref Google Scholar, 7Campos NG Tsu V Jeronimo J Mvundura M Lee K Kim JJ When and how often to screen for cervical cancer in three low- and middle-income countries: a cost-effectiveness analysis.Papillomavirus Res. 2015; 1: 38-58Crossref Scopus (41) Google Scholar, 8Burger EA Ortendahl JD Sy S Kristiansen IS Kim JJ Cost-effectiveness of cervical cancer screening with primary human papillomavirus testing in Norway.Br J Cancer. 2012; 106: 1571-1578Crossref PubMed Scopus (62) Google Scholar Rwanda has achieved impressive HPV vaccination coverage and has a comprehensive cervical cancer programme. The country has joined the ranks of some high-income countries in almost attaining eradication.9Cousins S Why Rwanda could be the first country to wipe out cervical cancer.https://edition.cnn.com/2019/05/30/health/rwanda-first-eliminate-cervical-cancer-africa-partner/index.htmlDate: May 30, 2019Date accessed: August 9, 2019Google Scholar In 2014, a pilot screening programme was implemented, representing the largest cohort of women to date screened for HPV with a DNA test in a low-income setting. The programme was shown to be effective and feasible, saving and extending many lives. Yet, it was terminated after the pilot phase because of the cost of the test. The global HPV testing market is valued at nearly US$630 million and is expected to exceed $1130 million by 2025, driven mainly by favourable government policies in North America. More than three-quarters of market share will be held by North America and Europe, whereas the Middle East and Africa will hold less than 4%.10Persistence Market ResearchGlobal market study on human papillomavirus (HPV) testing: North America projected to remain the dominant regional market through 2025.https://www.persistencemarketresearch.com/market-research/human-papillomavirus-testing-market.asDate: July, 2017Date accessed: August 9, 2019Google Scholar If the global community is to extend its goal of minimising cervical cancer to the poor, screening services have to be made available. Global pricing of HPV testing must reflect the inequitable overall mortality burden and the capacity to pay. Innovative financing models for HPV tests that allow for community-based screening with minimal clinic visits and laboratory capacity must determine prices in a way that allows those most in need to access the tests. Hundreds of thousands of women will continue to die while unfavourable distribution of medical services continues. Eradication of cervical cancer could be near, but not until the global community stops ignoring the deaths of the bottom billion and takes serious action towards enabling universal screening. We declare no competing interests.