Dr Vanes­sa Har­ry

The evo­lu­tion of cer­vi­cal can­cer man­age­ment is wide­ly re­gard­ed as one of the great­est suc­cess sto­ries in mod­ern med­i­cine, il­lus­trat­ing how pre­ven­tion, ear­ly de­tec­tion, and pub­lic health pol­i­cy can dra­mat­i­cal­ly re­duce can­cer bur­den. Yet, this suc­cess has been un­even, with pro­found dis­par­i­ties be­tween high-in­come coun­tries and many low- and mid­dle-in­come coun­tries (LMICs).

His­tor­i­cal­ly, cer­vi­cal can­cer was one of the lead­ing caus­es of can­cer death among women world­wide. Man­age­ment in the ear­ly 20th cen­tu­ry fo­cused al­most en­tire­ly on treat­ing ad­vanced dis­ease, and sur­vival out­comes were poor. A ma­jor turn­ing point came in the 1940s with the in­tro­duc­tion of the Pa­pan­i­co­laou (Pap) smear. This sim­ple cy­to­log­i­cal test al­lowed clin­i­cians to de­tect pre-can­cer­ous changes in the cervix long be­fore can­cer de­vel­oped. For the first time, cer­vi­cal can­cer could be pre­vent­ed rather than mere­ly treat­ed.

Sci­en­tif­ic ad­vances in the late 20th cen­tu­ry fur­ther trans­formed un­der­stand­ing of the dis­ease. The dis­cov­ery that per­sis­tent in­fec­tion with high-risk hu­man pa­pil­lo­mavirus (HPV) is the nec­es­sary cause of al­most all cer­vi­cal can­cers rev­o­lu­tionised pre­ven­tion strate­gies. This led to the de­vel­op­ment of HPV-DNA test­ing, which is more sen­si­tive than cy­tol­ogy and al­lows for longer screen­ing in­ter­vals. Many coun­tries have now tran­si­tioned to HPV-based screen­ing, of­ten com­bined with self-sam­pling, im­prov­ing par­tic­i­pa­tion and de­tec­tion rates.

Per­haps the most trans­for­ma­tive ad­vance has been the de­vel­op­ment of pro­phy­lac­tic HPV vac­cines in the mid-2000s. Vac­ci­na­tion against high-risk HPV types has been shown to dra­mat­i­cal­ly re­duce HPV in­fec­tion, pre­can­cers and cer­vi­cal can­cer it­self. In coun­tries with high vac­cine up­take and ef­fec­tive screen­ing—such as Aus­tralia, the UK, and sev­er­al Nordic coun­tries—cer­vi­cal can­cer is pro­ject­ed to be­come a rare dis­ease, and in some pop­u­la­tions, near elim­i­na­tion is an­tic­i­pat­ed with­in decades.

Cer­vi­cal can­cer should be rare—so why are so many women still dy­ing?

De­spite these ad­vances, cer­vi­cal can­cer re­mains a ma­jor pub­lic health prob­lem in many LMICs, where most glob­al deaths oc­cur.

Here are some rea­sons why cer­vi­cal can­cer re­mains a ma­jor prob­lem in these re­gions:

• Lim­it­ed or ab­sent or­gan­ised screen­ing or Pap smear pro­grammes

• Lack of aware­ness of HPV vac­ci­na­tion and its ac­ces­si­bil­i­ty

• In­ad­e­quate lab­o­ra­to­ry ser­vices, re­fer­ral path­ways, and fol­low-up

• Low health ed­u­ca­tion and aware­ness

• Late pre­sen­ta­tion: many women present with ad­vanced dis­ease

• So­cioe­co­nom­ic bar­ri­ers: Pover­ty, ge­o­graph­ic iso­la­tion

• Stig­ma and cul­tur­al bar­ri­ers sur­round­ing gy­nae­co­log­ic care

• In­con­sis­tent fund­ing and po­lit­i­cal com­mit­ment

Cer­vi­cal can­cer pre­ven­tion

Cer­vi­cal can­cer is one of the most pre­ventable can­cers, yet it con­tin­ues to af­fect and claim the lives of far too many women. One of the main rea­sons is sim­ple but dan­ger­ous: cer­vi­cal can­cer usu­al­ly caus­es no symp­toms at all in its ear­ly stages. Feel­ing well does not mean every­thing is fine. This is why ed­u­ca­tion and pre­ven­tion are so im­por­tant.

What pre­ven­tion re­al­ly looks like

Pre­ven­tion is not a sin­gle test or a one-time vis­it to a clin­ic. True pre­ven­tion is a process that in­cludes ed­u­ca­tion, reg­u­lar screen­ing, HPV vac­ci­na­tion, and—most im­por­tant­ly—fol­low-up when re­sults are ab­nor­mal. When any one of these steps is missed, women re­main at risk.

Skip­ping a Pap test be­cause you feel healthy can be risky. Cer­vi­cal can­cer de­vel­ops slow­ly, of­ten over many years. Dur­ing this time, ab­nor­mal cells can be de­tect­ed and treat­ed long be­fore can­cer de­vel­ops—but on­ly if screen­ing is done.

Pap smears and HPV tests: What they are (and what they’re not)

A Pap smear looks at cells from the cervix to see if there are ear­ly changes that could be­come can­cer. It does not di­ag­nose can­cer in most cas­es—it de­tects warn­ing signs ear­ly, when treat­ment is sim­ple and ef­fec­tive.

An HPV test looks for high-risk types of the hu­man pa­pil­lo­mavirus that are known to cause cer­vi­cal can­cer. It does not mean you have can­cer, and it does not mean you have done any­thing wrong.

These tests are tools for pre­ven­tion, not la­bels or judge­ments.

HPV ex­plained sim­ply

HPV is ex­treme­ly com­mon. Most peo­ple—men and women—will get it at some point in their lives, of­ten with­out ever know­ing. It is spread main­ly through sex­u­al con­tact. In the ma­jor­i­ty of cas­es, the body’s im­mune sys­tem clears the virus nat­u­ral­ly with­in one to two years.

The prob­lem aris­es when high-risk HPV does not go away. Per­sis­tent in­fec­tion can slow­ly cause changes in the cells of the cervix. If these changes are not de­tect­ed and treat­ed, they can even­tu­al­ly turn in­to cer­vi­cal can­cer. This process usu­al­ly takes many years, which is why reg­u­lar screen­ing works so well.

HPV vac­ci­na­tion: Why it mat­ters

The HPV vac­cine pro­tects against the types of HPV most like­ly to cause cer­vi­cal can­cer. It works best when giv­en be­fore sex­u­al ac­tiv­i­ty be­gins, but it still of­fers ben­e­fit to many peo­ple who are al­ready sex­u­al­ly ac­tive or old­er.

The vac­cine does not treat ex­ist­ing HPV in­fec­tions, but it can pro­tect against types you have not yet been ex­posed to. Vac­ci­na­tion is a pow­er­ful lay­er of pro­tec­tion—but it does not re­place screen­ing. Women who are vac­ci­nat­ed still need reg­u­lar Pap or HPV tests.

Why ab­nor­mal re­sults are com­mon—and man­age­able

One of the biggest sources of fear around cer­vi­cal screen­ing is an “ab­nor­mal” re­sult. In re­al­i­ty, ab­nor­mal re­sults are very com­mon, es­pe­cial­ly in younger women, and most do not mean can­cer.

They of­ten re­flect tem­po­rary HPV in­fec­tion or mild cell changes that ei­ther re­solve on their own or can be treat­ed eas­i­ly. The dan­ger lies not in the ab­nor­mal re­sult, but in ig­nor­ing it.

The re­al risk: Dis­ap­pear­ing af­ter a test

Many women do the hard­est part; they get test­ed, but then fail to re­turn for re­sults or fol­low-up ap­point­ments. This is where pre­ven­tion breaks down. Cer­vi­cal can­cer de­vel­ops not be­cause ab­nor­mal­i­ties ex­ist, but be­cause they are not fol­lowed up.

Pre­ven­tion is a part­ner­ship be­tween women and the health sys­tem. Test­ing, vac­ci­na­tion, and fol­low-up must all work to­geth­er.

The bot­tom line

Cer­vi­cal can­cer is large­ly pre­ventable. Ed­u­ca­tion, reg­u­lar screen­ing, HPV vac­ci­na­tion, and prop­er fol­low-up save lives. Feel­ing fine is not enough—pre­ven­tion works qui­et­ly, long be­fore symp­toms ap­pear. When women un­der­stand this, cer­vi­cal can­cer no longer has to be a life-threat­en­ing dis­ease.