“In this history of mankind, cervical cancer is probably going to be the first cancer to be eliminated.”
A commanding opening statement by Dr Partha Basu presenting on the World Health Organization’s global initiative to eliminate cervical cancer at the recent CervScreen project meeting of the International Agency for Research on Cancer (IARC), the HSE’s National Screening Service, the Department of Health and project stakeholders.
Head of Early Detection, Prevention and Infections Branch with IARC, Dr Basu said in some countries cervical cancer elimination will happen in a number of years because we know the natural history of the disease very well. The majority of cervical cancers are caused by the human papillomavirus, or HPV. There are different types of HPV, and Dr Basu explained that a study at IARC has shown that 70% of cervical cancers are caused by HPV types 16 and 18, with five other common HPV types (45, 33, 58, 31, 52) responsible for another 20%.
“Having an infectious etiology” – a cause for the disease - Dr Basu said “has given us two wonderful opportunities to prevent this cancer” – by vaccinating against HPV, and by using a test in screening that detects the virus.
“We don’t want women to die of a preventable cancer.”
The WHO’s elimination initiative “is one of the best global advocacy messages for cervical cancer prevention” with a very clear target, Basu explained. Modelling studies have shown that the global incidence of cervical cancer, which is now at 20 per 100,000 women, can be reduced to below 4 per 100,000 women. “It cannot be made zero” he said, but if we can achieve the three intermediate elimination targets – 90% of girls are vaccinated against HPV; 70% of women are screened for HPV twice in their lifetime; and ensuring 90% of the screen-detected pre-cancers are treated – “it is possible to achieve that target [of 4 per 100,000] within a few decades.”
A WHO modelling study based on data from 78 countries in low- and middle-income regions of the world where cervical cancer is most prevalent shows that if we can ensure vaccination of 90% of pre-adolescent girls, we can reduce the median incidence of cervical cancers from 19.8 per 100,000 women to 2.1 per 100,000 in 100 years, and 61 million cases of cervical cancer can be prevented.
The study shows that along with vaccination, adding two lifetime HPV screenings of women can reduce the median incidence to 0.7 per 100,000 and prevent a further 12.1 million cases of cervical cancer.
With only 18% of adolescent girls vaccinated globally, and with low-quality and low-volume screening in most low- and middle-income countries, Dr Basu says “there is a price we are paying for our inaction.”
“Ireland has already shown it is capable of achieving the 90% vaccination target.”
Ireland was one of the first countries to introduce HPV vaccinations through the national immunisation programme in 2010. The 9-valent vaccination, which protects against 9 types of HPV, has also been introduced in Ireland since 2019. This offers protection against 5 more types of HPV compared to the 4-valent vaccine. Wider coverage and uptake of the vaccine will reduce cervical cancer incidence further in Ireland.
While Ireland has already shown it is capable of achieving the global 90% vaccination target, uptake of the HPV vaccination programme was impacted from 2016 after misinformation circulated across Europe. The response to this in Ireland involved identifying and engaging with key stakeholders, establishing parental views about the HPV vaccine, engaging in social media listening and analysis, revising information materials and website content, enhancing co-operation between schools, teachers and parents associations, and supporting and empowering frontline healthcare providers.
The steps that were taken in Ireland to mitigate this crisis, Dr Basu said “is global best practice in crisis management in any health programme”. Included in the new IARC report as best practice communications, Dr Basu recommended that Ireland produce a best practice document in crisis management relevant to HPV vaccinations.
“When I look at the Irish data, it gives me a lot of confidence in the programme in Ireland.”
In Ireland, the incidence of cervical cancer is around 11 per 100,000. Prior to the introduction of Ireland’s cervical cancer screening programme in 2008, the incidence of cervical cancer was rising. Since the introduction of CervicalCheck the data shows a steep decline in cervical cancer incidence – an average 2.8% reduction annually between 2009 and 2019. Presenting this Irish context, Dr Basu said for Ireland to achieve the WHO elimination targets “it is a priority to ensure that this decline continues” and the focus must be on both HPV vaccination and screening.
The WHO global elimination target is to screen 70% of women for HPV twice in their lifetime. In Ireland there is almost 80% coverage in cervical cancer screening, with most counties exceeding 70% coverage. Women aged 25 to 29 are screened every 3 years, and those aged 30 to 65 are screened every 5 years. There are over 4,000 registered sampletakers across the country and around 250,000 to 300,000 women are being screened every year.
Since the establishment of CervicalCheck in 2008 up to March 2020, 64,000+ pre-cancers (CIN) have been detected and treated in Ireland. On a conservative estimate, Dr Basu said, that equates to the prevention of thousands of cervical cancers - “a hugely important message to communicate to all stakeholders.”
Screening is not all about coverage. Screening programmes need to be well organised with a robust quality assurance framework that ensures screened-positive women are appropriately taken care of. The global elimination target is to ensure 90% of screen-detected pre-cancers are treated and in several European countries, many women who have a positive screen don’t attend for colposcopy. However, in Ireland less than 10% of screened-positive women don’t come for colposcopy “and is a huge achievement for the programme” Dr Basu said. “When I look at the Irish data, it gives me a lot of confidence in the programme in Ireland.”
With new scientific advancements in screening, Dr Basu believes there are opportunities to improve, including recognising the potential role of self-sampling in cervical screening programmes. While HPV-positive women need to be recalled for cytology testing after self-sampling, technologies are changing with molecular tests potentially improving HPV testing so the same sample could eventually be used for assessment.
Concluding the presentation, Dr Basu said Ireland is already very much aligned to the Europe Beating Cancer Plan and with the EU commitment to eliminate cervical cancer caused by HPV.
Speaking about the new IARC report on best practice recommendations in cervical screening programmes, he said it will support the global cervical cancer elimination initiative and considers it “a gift to the world from Ireland.”
More about Ireland’s roadmap to Cervical Cancer Elimination
Ireland is one of the first countries in the world to publicly announce its commitment to the WHO Cervical Cancer Elimination initiative. In January 2023, during Cervical Cancer Prevention Week, Ireland published a roadmap to eliminate cervical cancer as a public health problem.
The HSE is working in partnership with the National Immunisation Office, the National Cancer Control Programme and the National Cancer Registry Ireland to progress the WHO global targets. A wider strategic group is overseeing the work with input from patient advocacy representatives.
Ireland will announce its target date for elimination in November 2023.