Cervical cancer is the 4th leading type of cancer amongst women in the world. Caused by human papillomavirus (HPV) infection, cervical cancer is highly preventable through the use of prophylactic measures like HPV vaccines and robust screening programmes.

Through the launch of the Global Strategy to Accelerate the Elimination of Cervical Cancer in late 2020, the World Health Organisation is tackling this disease with a three-fold strategy: vaccination, screening and treatment. To succeed, they will need to take a tailored approach to different countries in Asia Pacific, where incidence rates of HPV infection range from 6 per 100,000 women in Australia to 23.4 per 100,000 women in Indonesia.

The importance of awareness and acceptance

Many women in low- to middle-income countries have limited knowledge about HPV and cervical cancer. Health education remains a cornerstone of raising awareness amongst these communities of women, and can help address the social stigma that often comes with a sexually transmitted infection. By facilitating conversations about HPV in an open manner, women are more likely to attend screening exercises without fear of social stigma. After all, 80% of men and women are likely to experience a HPV infection in their lifetimes.

In terms of testing workflows, self-sampling is another approach to combating social stigma towards cervical cancer screening. This approach has the ability to reach women that are most vulnerable, such as those with limited access to healthcare or who are hesitant due to their immigration status. Research has shown an overwhelmingly positive attitude towards such a testing method, which has also been included in some countries’ clinical guidelines.

In Asia, several public health programmes are helping to raise awareness. Project Teal for example, is a programme in Hong Kong that brings together multiple healthcare partners and charities to provide co-testing to underprivileged women. Through active outreach, hundreds of women have been educated and screened in their phase I and II activities. They have since initiated phase III, which includes self-sampling. Armed with facts and personal experience, these women in turn could amplify the important messages about HPV through their communities.

Programme Rose [1] in Malaysia has a similar outreach approach and goals. Through the use of self-sampling in clinics and simple digital health tools, 91% of positive cases [2] returned for further screening with 99% expressing interest for routine testing. Self-sampling programmes benefit many communities, and could inspire action in other countries.

In addition to raising awareness and increasing acceptance amongst the general public, healthcare providers (HCPs) need to be educated on actively promoting HPV knowledge to parents or young women. By advocating for vaccination and screening, HCPs can assist parents’ decision making or guide a patient’s journey through testing.  Yet even amongst HCPs [3], vaccine and screening uptake is low.

Healthcare frameworks and funding differ amongst countries

National health infrastructures differ widely from country to country. This also contributes to the unequal landscape of vaccination and screening programmes in Asia Pacific. Australia remains one of the leaders in the region. In 1991, it launched a subsidised screening programme that achieved an uptake rate of almost 60% [4]. In 2007, just one year after HPV vaccines were authorised for use, it became one of the first countries in Asia Pacific to offer free vaccination, aiming their efforts at school children. Australia is now on track to eradicating cervical cancer. Some predict that incidence of the disease will be only 4 per 100,000 cases by 2035.

Other countries in the region have not moved so quickly, but help may be on the way. The Global Alliance for Vaccines and Immunisation (GAVI), for example, assists countries that are unable to implement such measures on their own. As of 2020, GAVI has provided vaccines to nearly 5 million teenage girls worldwide. This includes an initiative it launched in Myanmar in 2020 [5], despite monumental challenges posed by COVID-19 [6].

Vaccines are only part of the answer. Cervical cancer develops from a persistent HPV infection and could take up to 15 years to develop. Because of this time delay, routine testing every 3 – 5 years is a necessary measure for the early detection of abnormal cervical cytology or the presence of HPV DNA. Countries can and should prioritise HPV DNA testing and genotyping of high risk strains (e.g. HPV16/18) as primary screening.

HPV DNA testing and genotyping could have a significant impact in screening age-appropriate females due to the tests’ high performance and fewer resources needed (e.g. cytology based methods require highly specialised personnel that may not be available). This testing method could appeal to some healthcare frameworks – providing even just one screening in a woman’s lifetime is better than none at all.

The key to prevention

A highly preventable disease, 93% of all cervical cancer cases can be averted through vaccine administration and routine screening. Persuading the public and healthcare providers by way of educating them with real-life success stories is key to both prevention and disease management.

References:

[1] Programme Rose cervical screening test

[2] Woo Y. L. (2019). The feasibility and acceptability of self-sampling and HPV testing using Cepheid Xpert® HPV in a busy primary care facility. Journal of virus eradication, 5(Suppl 1), 10–11.

[3] Tay et al. (2015). Vaccine Misconceptions and Low HPV Vaccination Take-up Rates in Singapore, Asian Pac J Cancer Prev, 16 (12), 5119-5124.

[4] Human papillomavirus fact sheet, Australian Government Department of Health

[5] “Myanmar introduces cervical cancer vaccine nationally, despite COVID-19 challenges”. GAVI news

[6] Human papillomavirus vaccine: Supply and Demand Update, UNICEF report