This article was adapted from the forthcoming PRB report, Preventing Cervical Cancer Worldwide.

(November 2004) Whether daunted by the two-hour walk to the nearest clinic, put off by local myths, or hindered by poor health services, millions of women worldwide never undergo cervical cancer screening, and hundreds of thousands die of this preventable disease without ever knowing why they were ill.

In an effort to reduce illness and death from cervical cancer, organizations are now working to break down barriers to detecting and treating the disease’s early signs. To this end, the Alliance for Cervical Cancer Prevention (ACCP), a group of five international agencies with funding from the Bill and Melinda Gates Foundation, has assessed and promoted prevention approaches to cervical cancer that are inexpensive, safe, and widely acceptable.

Cervical Cancer Hits Poor Regions Hardest

The numbers of cervical cancer deaths around the world underscore the demand for such programs. The disease kills an estimated 274,000 women every year, affecting the poorest and most vulnerable and sending a ripple effect through families and communities that rely heavily on women’s critical roles as providers and caregivers.1

Every year, some 80 percent of the world’s new cervical cancer cases—and a similar proportion of the deaths from the disease—occur in developing countries.2 In many of these countries, cervical cancer is the leading cause of cancer deaths among women.

“Cervical cancer has a major impact on women, particularly women in developing countries,” says Jacqueline Sherris of PATH, an international nongovernmental organization based in Seattle and one of five ACCP partners working on new prevention approaches. “An important reason for the higher incidence in developing countries is the lack of effective screening programs to detect precancerous conditions and treat them before they progress to cancer.”

The regions hardest hit by cervical cancer are among the world’s poorest. Central and South America, the Caribbean, sub-Saharan Africa, parts of Oceania, and parts of Asia have the highest incidence rates—over 30 per 100,000 women. These rates compare with no more than 10 per 100,000 women in North America and Europe.3

Incidence rates are reported to be 69 per every 100,000 in Tanzania, 55 per every 100,000 in Bolivia, and 40 per every 100,000 in Papua New Guinea. The highest absolute number of cases is reported in Asia. In India, an estimated 132,000 new cases—or more than one-fourth of the worldwide total—are reported annually.

Women 35 Years and Older at Highest Risk

Cervical cancer results from the abnormal growth and division of cells at the opening of the uterus or womb—the area known as the cervix. The main underlying cause is the human papillomavirus (HPV), a sexually transmitted infection that is often without symptoms.

No cure exists for HPV. And while the infection remains stable or becomes undetectable in most cases, HPV can lead to precancerous conditions that progress to cancer over time.

While women may contract HPV when they are young, cervical cancer is most likely to develop in women 35 years or older. If not detected and treated in its early stages, the disease is nearly always fatal. Prevention of HPV would sharply reduce cervical cancer rates. Therefore, an HPV vaccine, now in the late stages of development, would contribute greatly to preventing new cases of cervical cancer.

A Lack of Effective Screening and Treatment in Developing Countries

Traditionally, global efforts to prevent cervical cancer have focused on screening women for abnormal cervical tissue, treating the condition before it advances, and providing appropriate follow-up care. To date, screening efforts have relied largely on the Pap smear, a test that has long been used to detect abnormal cell changes.

However, while the test has achieved tremendous success in industrialized countries that offer periodic, high-quality screening, Pap smear programs are complex and costly to run and have failed to reach a significant proportion of women in countries where health systems and infrastructure are poor.

The lack of effective screening and treatment strategies is a major reason for the sharply higher cervical cancer rates in developing countries. In these countries, mortality rates are reported at 11.2 per 100,000 women on average, almost three times the rate of developed countries.4 Nearly 40 percent of cervical cancer deaths in developing countries occur in South Central Asia, a heavily populated region that includes India, Pakistan, and Bangladesh.

Without access to viable programs, women from poor communities generally seek care only when they develop symptoms and the cancer is advanced and difficult to treat. Health care providers can do little to save their lives at this stage and even drugs for easing their pain may be unavailable.

Other barriers to prevention and treatment may include a lack of awareness of cervical cancer and of ways to prevent the disease, difficulty getting to clinics and hospitals, the need for multiple visits, and high costs associated with screening. In some communities, myths and misconceptions about the disease also pose barriers to prevention.

New Research Seeks to Make Prevention Available to All

Despite the barriers, cervical cancer can be prevented at low cost. Health care providers can use relatively simple technologies to screen women for precancerous conditions and treat abnormal tissue early.

Projects of the Alliance for Cervical Cancer Prevention in sub-Saharan Africa, Latin America, and South Asia have studied screening and treatment approaches—particularly for women in their 30s and 40s—with the understanding that many of these women may be screened only once or twice in their lifetimes.

Research has also focused on approaches that overcome logistical and social barriers and that markedly increase women’s access to prevention services. Among the most promising alternatives to the Pap smear are visual screening methods that require simple vinegar or iodine solutions and the eye of a trained health provider to spot abnormal tissue. Another alternative involves testing women for the presence of HPV on their cervices. While these approaches are still being evaluated, all have the potential to save more lives at lower cost than traditional approaches using Pap smears.

To be truly effective, however, cervical cancer prevention programs must link testing with appropriate treatment, including low-cost outpatient procedures. Relatively simple procedures can be used to either destroy or remove abnormal cervical tissue, depending on the severity, location, and size of the affected area.

Two such procedures are particularly appropriate in low-resource settings. Cryotherapy uses extremely low temperatures to destroy the abnormal tissue. The method needs no electricity and is effective even where physicians, health supplies, and infrastructure are severely limited.5

Another method, the loop electrosurgical excision procedure (LEEP), involves using a thin wire to remove the affected area. While LEEP requires more medical backup and equipment than cryotherapy, the procedure allows tissue to be removed for analysis, reducing the possibility that advanced cancer will go unnoticed.

Effective Prevention Programs Share Key Features

While many developing countries have had cervical cancer prevention programs in place for some time, they have failed to reduce death rates from the disease. The ACCP’s work provides new evidence on which to base program decisions, and demonstrates promising approaches that have the potential to reduce cervical cancer even in the poorest countries.

“The ACCP’s research has found that programs can safely and effectively screen and treat women in just one or two clinic visits, using low-cost techniques,” notes PATH’s Sherris. “In many settings, prevention programs can be integrated into routine health services, assuming adequate resources are available.”

Good prevention programs for cervical cancer share a number of key strategies:

  • Using locally understood messages to increase awareness of the disease;
  • Reaching a significant proportion of women in their 30s and 40s;
  • Motivating women to get tested at least once;
  • Making outpatient treatment widely available;
  • Arranging appropriate follow-up care; and
  • Evaluating impact.

The ACCP provides practical program tools for achieving these goals in low-resource settings. Steps to prevent cervical cancer can form part of an overall strategy to improve women’s health and to promote equity and a high quality of care through primary health care systems.

The Alliance for Cervical Cancer Prevention consists of EngenderHealth, the International Agency for Research on Cancer, JHPIEGO (a nonprofit international public health organization affiliated with Johns Hopkins University), the Pan American Health Organization, and PATH.


Yvette Collymore is a senior editor at PRB.


For more information

The Alliance for Cervical Cancer website: www.alliance-cxca.org.


References

  1. J. Ferlay et al., GLOBOCAN 2002: Cancer Incidence, Mortality and Prevalence Worldwide, IARC CancerBase No. 5. version 2.0, (Lyon: IARCPress, 2004), accessed online at www-depdb.iarc.fr/globocan/GLOBOframe.htm on Sept. 30, 2004.
  2. J. Ferlay et al., GLOBOCAN 2002.
  3. J. Ferlay et al., GLOBOCAN 2002. Incidence rates are adjusted to account for differences in age structure across countries.
  4. J. Ferlay et al., GLOBOCAN 2002. Mortality rates are adjusted to account for differences in age structure across countries.
  5. Alliance for Cervical Cancer Prevention, “Effectiveness, Safety, and Acceptability of Cryotherapy: A Systematic Literature Review,” Cervical Cancer Prevention Issues in Depth, No. 1 (Seattle: ACCP, 2003).