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.