This article is part of the Global Policy Lab: Decoding Cancer.
Cervical cancer is at a crossroads: If no action is taken, the number of women dying from the disease is expected to increase substantially by 2030. But the cancer is caused by the human papillomavirus and highly treatable if the warning signs are caught early.
So the World Health Organization predicts its possible to effectively eliminate cervical cancer as a public health threat sometime between 2060 and 2100. WHO Director General Tedros Adhanom Ghebreyesus issued a call to action in May, urging countries adopt a combination of vaccination for young girls before they become sexually active and ramped-up screening programs.
How to beat the disease isnt always straightforward. There are tradeoffs, in particular between richer and poorer parts of the world.
Germany, the U.K. and Ireland, for example, have announced plans to expand the availability of the vaccine to boys, and the U.S. just approved immunization for people up to the age of 45. Those moves may make sense on a domestic level. But the expansions could make it harder for poor countries to vaccinate the young girls who need it most.
“If your country decides to do a gender-neutral vaccination program for girls and for boys, there would have to be double the amount of vaccine available” — Anshu Banerjee
Likewise, international aid programs have embraced vaccines in poor countries — but theres not enough international help for the (vast majority) of adult women today who are too old to benefit from the vaccine, but could be saved immediately by early screening programs.
These issues emerged in POLITICOs interview with three top WHO experts: Anshu Banerjee, director of maternal, newborn, child and adolescent health; Raymond Hutubessy, a health economist working on vaccines; and Nathalie Broutet, whos led the development of clinical guidelines for cervical cancer control and HPV.
The discussion took place on Wednesday, as Ireland mourned the death from cervical cancer of a top activist amid a scandal over its public screening program, in which pap smear results for hundreds of women were misread, leaving many of them to be diagnosed with cancer only after it was too late.
Does cervical cancer occur at equal rates around the world?
Anshu Banerjee: Clearly here we have inequities and disparities. For example, in sub-Saharan Africa in countries where theres a high HIV incidence, cervical cancer is much higher because of the co-infection with HIV and HPV. We see that progression towards cancer is much faster. In high income countries, because of the possibility to have good screening programs, its possible to reduce mortality due to cervical cancer.
Several European countries have been increasingly expanding the availability of the HPV vaccines to boys. Is there strong evidence to support this move? Does the WHO recommend this?
Raymond Hutubessy: The recommendation from WHO is a mix of criteria: Not only safety and effectiveness, but also implementation issues. The best option from a cost-effectiveness point of view, if you have limited resources, the recommendation is go first for girls.[Vaccinating] 70 to 80 percent of the girls in the population, that gives you the so-called herd immunity. If you do have more resources, then yes it also makes sense, not just against cervical cancer but also other related diseases and other cancers.
AB: If your country decides to do a gender-neutral vaccination program for girls and for boys, there would have to be double the amount of vaccine available. Looking at the current supply-demand situation, if globally we would like to make more progress, it would be better if the available vaccines at the moment would be used to vaccinate girls … until we have resolved the supply issue.
So these high-income countries offering gender-neutral vaccine programs are using vaccines that could potentially be going to young girls in lower-income countries?
RH: We have to allocate, and currently there are two major players. [The vaccinations] have to come from one pot, so yes, there are consequences if they will broaden the [eligibility for vaccination]. Having said that, we also know that there will be new players starting from 2021, 2022 who will also be able to provide more vaccines to the global market, in particular in Asia. The Indians and the Chinese are also working on their own HPV vaccine.
Nathalie Broutet: Its just a question of planning. The manufacturers are very clear on their production plans. If [the international vaccine program] Gavi has a certain number of countries in which theyre going to introduce the vaccine, [manufacturers] are going to produce a portion for each of these countries. The same thing for high-income countries: Theyd say, “Well, were going to vaccinate girls and boys,” and they do their forecast, and they plan their production.
RH: It takes at least four or five years in order to set up the production line, so these manufacturers need to know in advance. So if Ireland is going to change the policy to give the vaccine to boys, that needs to be communicated.
In light of what happened with screenings in Ireland, broadly, how confident should women be about cervical screenings, and how do you recommend that they deal with the potential for false results?
NB: Comparing the different tests shows the HPV test is the [highest] performing. Its very sensitive, its around more than 95 percent. You will not miss lesions. Cytology [or pap smears, the test used in Ireland] is a very specific test, so you are sure when you see something, its a lesion. But its not sensitive.
What happened in Ireland, its more a political issue and we dont want to comment on that because its really a lack of communication between the different stakeholders. So yes, we are confident with HPV tests.
Editors note: On Tuesday, Irelands government announced funding to switch from pap smears to HPV tests as the first choice for cervical cancer screenings.
As far as research, what are the main unanswered questions? Or do we pretty much know whats going on and have it down?
NB: There are three major issues that were looking at: One is the issue of the one-dose efficacy of the one-dose of the vaccine, which would reduce the cost. [Currently, two doses are recommended.] The other is the HPV test, to have cheaper and have more rapid point-of-care tests that can be used at the primary health care level. And then the treatment of pre-cancer lesions. [We need] more easy-to-use treatments. We can [achieve elimination] with what we have at the moment, but we could accelerate even more if we make this progress.
What are other key challenges?
AB: There has been an interest in supporting HPV vaccine introduction in low-income countries … and to reduce the price for HPV vaccines [for] middle-income countries.
The impact of the vaccination will only kick in after 15-20 years. The impact of the screening would be immediate. But we have seen that there has been less financial support to try to lower the price of the HPV test.
This interview has been edited for length and clarity.