Introduction
Where a woman lives, plus her socioeconomic status, largely determines whether she will develop cervical cancer, how early she presents to healthcare services, and her access to affordable, good quality diagnostic and treatment services 1. Cervical cancer is preventable because it has a long pre-invasive phase that is easily identified by clinical and histopathological examination. The incidence of this disease is therefore directly related to a nation’s medical infrastructure and the resources available for population-wide screening and the treatment of identified cancers. Prevention and early detection offer the most cost-effective, long-term strategy for the control of cancer, even in low resource settings. Proven and cost-effective interventions for cervical cancer are available, yet access to these are beyond reach for many women in low and middle-income countries (LMIC). These countries have fragmented health systems and are responsible for 86% of the world’s cervical cancer cases 2. Shockingly, only 5% of global spending on cancer is directed towards them 3. Without significantly increased screening and preventive treatment services, an estimated 19 million women will die from cervical cancer over the next 40 years 4. A key reason for the high mortality rate is the fact that women typically present with late stage or advanced disease. Under these circumstances, treatment is significantly compromised by multiple issues includingde novo and pharmacokinetic (poor drug delivery and penetration) resistance. In this review, we discuss the potential benefits that could be gained by use of a ‘screen and treat’ strategy using simple screening methods and locoregional therapies to detect and treat cervical cancers early. The aim would be reducing the number of women in LMIC presenting with advanced, drug resistant disease. It is therefore pertinent to review the magnitude of the problem in LMIC and evaluate the limitations of current treatments for cervical cancer.
The Scale of the Problem in Sub-Saharan Africa
In 2018, there were an estimated 570,000 cases and 311,000 deaths, from cervical cancer worldwide 5. It is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women worldwide. Cervical cancer is the most commonly diagnosed cancer in 28 countries and the leading cause of cancer death in 42 countries. The majority of these countries are in Sub-Saharan Africa and South-Eastern Asia, with the highest incidence rate in Swaziland, and the highest mortality rates found in Malawi, Zimbabwe, Guinea, Burkina Faso, and Mali 5. In these countries, incidence and mortality rates are seven to 10 times higher than in North America, Australia/New Zealand, Saudi Arabia and Iraq 5.
The development of a country can be measured using the Human Development Index (HDI), using its people and their capabilities as opposed to economic growth alone. HDI measures three basic dimensions of human development 6 (i) life expectancy at birth (ii) the average number of years of schooling achieved by adults aged 25 years and above and (iii) the gross national income per capita. There appears to be a direct relationship between the HDI of a country and incidence of cervical cancer. When the national incidence burden of cervical cancer is compared the country’s HDI level, cervical cancer makes up to a third of all cancers diagnosed (in both sexes) in many low HDI countries. By comparison, cervical cancer comprises less than 10% of all cancers in very high HDI countries 1. For this reason cervical cancer can be considered “a case study in health equity” 7 based on the unequivocal evidence that cervical cancer is a major problem in LMIC, especially Sub-Saharan countries. Among the most cost-effective strategies according to WHO’s Global Action Plan for the Prevention and Control of Non-Communicable Diseases (2013–20) 8. is screening with treatment of pre-cancerous lesions. However, access to these strategies varies depending on where a woman lives, her socioeconomic status and her agency. In 2020, the WHO assembly adopted the Global Strategy for Cervical Cancer Elimination, the aim of which is to eliminate cervical cancer by 2030 through three main approaches: vaccination with a target of 90% of girls fully vaccinated against HPV by the age of 15; screening with a target of 70% of women screened by the ages of 35 and 45; treatment with the target of 90% of women with pre-cancer treated and 90% of women with invasive cancer managed 9. This can only be achieved if comprehensive cancer control is implemented in LMICs, including universal access to early diagnosis and accessible treatment for cancer. Therefore, the need for effective strategies to reduce the incidence of cervical cancer, whilst boosting early detection, and the application of treatments (existing and novel) for this disease are imperative in LMIC.