1.1. Background
Cervical cancer is a leading cause of mortality among women. In 2020, an estimated 604 000 women were diagnosed with cervical cancer worldwide and about 342 000 women died from the disease. Cervical cancer is the most commonly diagnosed cancer in 23 countries and is the leading cause of cancer death in 36 countries. The vast majority of these countries are in sub-Saharan Africa, Melanesia, South America, and South-Eastern Asia (1).
In May 2018, Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO), issued a call to action for the elimination of cervical cancer. A WHO Global Strategy to accelerate the elimination of cervical cancer as a public health problem was presented and unanimously endorsed by the Seventy-third World Health Assembly in August 2020. Subsequently, WHO officially launched the Global Strategy to accelerate the elimination of cervical cancer on 17 November 2020.1
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The targets of the Global Strategy are to achieve, by 2030:
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90% of girls fully vaccinated with human papillomavirus (HPV) vaccine by age 15 years
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70% of women screened with a high-performance test by 35 years of age and again by 45 years of age
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90% of women identified with cervical disease receive treatment (90% of women with pre-cancer treated, and 90% of women with invasive cancer managed) (2).
In the context of this Global Strategy, countries are updating their protocols for the prevention of cervical cancer and for the care and treatment of affected women. Cervical cancer prevention also plays an integral role in reaching the Sustainable Development Goals (SDGs), both for health (SDG 3) and gender equality (SDG 5).
To prevent cervical cancer, women can be screened using various tests to identify those who have or are at risk of cervical pre-cancer (see Table 1.1). Cervical intraepithelial neoplasia (CIN) is characterized by cellular changes in the transformation zone of the cervix. CIN is typically caused by infections with HPV, especially the high-risk HPV types such as strains 16 and 18 (these two strains cause more than 70% of cervical cancers) (3, 4). CIN1 lesions – also referred to as low-grade squamous intraepithelial lesions – are morphological correlates of HPV infections. CIN2/3 lesions – also referred to as high-grade squamous intraepithelial lesions – are correlates of cervical pre-cancers that, if left untreated, may progress into cervical cancer (for further details, refer to Chapter 1 of WHO’s Comprehensive cervical cancer control guidance [5]).
The traditional method to screen women for cervical cancer has been cytology (the Papanicolaou test, also known as the Pap smear or smear test). When cytology results are positive, the diagnosis is confirmed by colposcopy, and appropriate treatment is informed by biopsy of suspicious lesions for histological diagnosis.
Newer screening tests introduced in the last 15 years include visual inspection with acetic acid (VIA), and molecular tests, mainly high-risk HPV DNA-based tests,2 which are suitable for use in all settings (Table 1.1). More recently, even newer tests and techniques have been developed: (i) other molecular tests such as those based on HPV mRNA, oncoprotein detection or DNA methylation; (ii) more objective tests performed on cytological samples such as p16/Ki-67 dual staining; and (iii) more advanced visual inspection tests based on artificial intelligence/machine learning platforms (e.g. automated visual evaluation of digital images) (6-9).
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