Best Practice & Research Clinical Obstetrics & Gynaecology
4Alternative approaches to cervical cancer screening for developing countries
Introduction
Worldwide, cervical cancer is the third most common cancer among women and the fourth leading cause of cancer death in women worldwide.1 It is estimated that annually there are about 529,828 cases and 275,125 deaths from cervical cancer globally (Table 1).2 The numbers of cases and deaths from cervical cancer, however, underestimates its global effect, as cervical cancer occurs in relatively young women. Each death from invasive cervical cancer occurring before the age of 70 years accounts for an average of 17 potential years of life lost.3 Globally, the mortality : incidence ratio is 52%.4 About 3.4 million women-years of life before age 70 years are lost annually from cervical cancer worldwide.4 Marked global disparities exist in both the incidence of, and mortality from, cervical cancer.5 More than 85% of the cases of cervical cancer occur in developing countries where it accounts for 13% of all cancers in women (Table 1).2 Highest risk regions include Eastern and Western Africa, where the age-standardised incidence rates are over 30 per 100,000 (Fig. 1). 2 Other high-risk regions with age-standardised incidence rates of over 20 per 100,000 include South Africa, South-Central Asia, South America, Melanesia, Middle Africa, Central America and the Caribbean. Rates are lowest in Western Asia, Australia and New Zealand, and Northern America, where the age-standardised incidence rates are less than 6 per 100,000. India, the second most populous country in the world, accounts for 27% of all cervical cancer deaths globally. In large part, these global disparities in the burden of cervical cancer reflect differences in cervical cancer screening rates as well as rates of infection with high-risk types of HPV. Few developing countries have organised and quality assured cervical cancer-prevention programmes that allow the detection of high-grade cervical cancer precursors (referred to as cervical intraepithelial neoplasia (CIN) grade 2 and 3) and early invasive cervical cancers before the development of advanced disease.
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Requirements for a successful cytology-based screening program and barriers found in low-resource settings
Since the introduction of cervical cytology (e.g. the Papanicolaou test) in the 1950s, the approach to cervical cancer prevention in most developed countries has been to screen women for CIN 2,3 lesions and early invasive cervical cancers using cervical cytology. Screening is followed by an evaluation using colposcopy and cervical biopsy for women with cytological abnormalities.6 If a CIN 2,3 lesion or early invasive cancer is detected on the cervical biopsy, treatment is provided. This
Alternative approaches to cervical cancer prevention
Because cytology-based cervical cancer prevention programmes have proven so difficult to establish in low-resource settings, over the past 15 years there has been considerable interest in the global health community in developing new strategies for cervical cancer prevention specifically for low-resource settings. These include changing the screening test that is used as well as simplifying how we evaluate and treat screen-positive women.
Outcomes of large screening trials
Over the past decade, a number of screening trials evaluating a variety of different approaches have been conducted in low-resource settings. The results of these trials have frequently been conflicting, which emphases how hard it is to conduct large-scale screening programmes in low-resource settings and the difficulty of monitoring the effectiveness of screening using end points other than cancer incidence and mortality. The results of just three of the many trials are provided in this
Conclusion
Progress is clearly being made in developing alternative cervical cancer screening approaches that are appropriate for developing countries. Advances have been made in how we screen and how those tested positive after screening are evaluated and treated. Randomised-controlled trials carried out in developing countries clearly show reductions in CIN2+ prevalence and incidence, with both VIA-based and hrHPV-based screening programmes. Perhaps, more importantly, a recent Indian community
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