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Cervical Cancer Screening and Prevention in Low- and Middle-Income Countries: 2020


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Cervical cancer is a worldwide public health problem. The incidence of the disease is particularly high in low- and middle-income countries, where low coverage of prevention strategies and high risk of infection persist. To reduce morbidity and mortality, improved screening and prevention are urgently needed.

Across eastern, western, middle, and southern Africa, cervical cancer is a leading cause of cancer-related death in women, and the disease burden in sub-Saharan Africa is increasing. High incidence of cervical cancer also persists in South Asia and Latin America, largely attributed to high rates of infection with the human papillomavirus (HPV) as well as human immunodeficiency virus transmission.

Sailaja Kamaraju, MD, MS

Sailaja Kamaraju, MD, MS

Sailaja Kamaraju, MD, MS, and colleagues highlighted two prominent cervical cancer prevention and control strategies: (1) vaccination to prevent HPV infection, and (2) screening of high-risk HPV for early detection and treatment of precancerous lesions.1 Despite evidence of the effectiveness and affordability of these interventions, political commitment and allocation of resources remain inadequate. To facilitate action, the World Health Organization has called on member states to increase investment in evidence-based interventions and eliminate the disease as a public health problem.

Vaccinations

To prevent infection, national immunization programs are essential. As such, it is recommended these programs include HPV vaccination. As HPV infections causing precancerous lesions are most aggressive in immunocompromised patients, immunization measures should be prioritized in these populations. Although two to three doses over a 6- to 12-month period are best practice among all patients, evidence suggests that even a single dose may protect against cervical neoplasia.

Supported by high vaccine coverage, community sensitization, and strong governmental commitment, a number of countries in sub-Saharan African have begun to implement HPV vaccination as a cost-effective measure for primary prevention of cervical cancer. In addition, in India and China, new HPV vaccines are undergoing evaluation, with licenses expected in India as early as 2021.

Screening

Testing for high-risk HPV enables early detection and treatment of cervical precancerous lesions, thereby reducing cervical cancer morbidity and mortality. In 2013, Surendra S. Shrasti, MD, MBBS, DPH, et al showed the effectiveness of a low-cost, innovative screening intervention to reduce cervical cancer mortality in India: visual inspection with acetic acid.2

Characterized by real-time results, this type of screening enables a single-visit approach, maximizing compliance to treatment. Using affordable materials and locally trained providers, the approach further enables strong coverage, particularly in low-resource settings. Such screening has already been implemented in several sub-Saharan African countries. Challenges related to quality assurance remain, though significant reduction in cervical cancer mortality has been observed through even a single round of visual inspection with acetic acid screening for HPV. 

References

1. Kamaraju S, et al: Cancer prevention in low-resource countries: An overview of the opportunity. Am Soc Clin Oncol Educ Book 40:1-12, 2020.

2. Shastri S, et al: Effect of VIA screening by primary health worker: Randomized controlled study in Mumbai, India. J Natl Can Inst 106:dju009, 2014.


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