Cervical cancer prevention for all women: Why now?

In the past 25 years, the view of cervical cancer has changed from resigned acceptance of a seemingly inevitable and inequitable blight to guarded optimism that we are on the brink of eliminating this dreaded disease that has taken so many women in the prime of their lives. The projections in GLOBOCAN 2012 that the estimated 285 000 annual deaths in 2015 would grow to nearly 385 000 by 2030, with 95% of those deaths in lowerincome countries, were based on the assumption that incidence and mortality rates would continue unchanged.1 That assumption is now being called into question on both scientific and social justice grounds.2 Much of the recent change is due to stunning advances in our understanding of the role of human papillomavirus (HPV) in the development of cervical (and other) cancer and of the virus itself and related biomarkers, which enabled the creation of HPV vaccines and screening tests. But these technologies alone do not tell the whole story, since they would be meaningless without the programmatic knowledge of how best to deploy them in the lowresource settings that need them most. Also essential has been the parallel development of a growing contingent of global and national advocates calling for allocation of adequate financial and human resources and implementation at scale of evidencebased strategies for prevention and effective management of cervical cancer. Multilateral agencies such as WHO and UNFPA, international and national nongovernmental organizations (NGOs), coalitions such as Cervical Cancer Action, federations such as the Union for International Cancer Control and FIGO, and donors such as the Bill & Melinda Gates Foundation have joined forces to set norms, strengthen capacities, generate knowledge, and build community demand and political support. An effort to make screening for cervical cancer available in lowresource settings was started in 1991 by PATH, an international nonprofit NGO devoted to improving the health of women and children through innovation. The modest goal was to identify a screening method that was more feasible than the Papanicolaou test that had become standard in highincome countries and had dramatically reduced previously high rates of cervical cancer through organized, regularly repeated screening.3 Over the next decade and a half, several organizations, including PATH, generated persuasive clinical and operational evidence that visual inspection with acetic acid (VIA) could be an effective screening modality, despite its shortcomings of user variability and moderate sensitivity.4 In the past 5–8 years, the pace of scientific discovery has accelerated, and the body of programmatic experience with cervical cancer prevention in Africa, Asia, and Latin America has grown dramatically. More than 20 lowand middleincome countries (LMICs) have introduced HPV vaccine in either pilot or national programs.5 Three LMICs in Central America are introducing HPV testing using selfcollected specimens in their routine national screening programs,6 while others in Africa and elsewhere are conducting pilot programs with this method. Countries in Africa and Asia are building service platforms using VIA for screening and cryotherapy for managing precancerous lesions, in line with recent WHO recommendations.7 As best practices emerge through systematic evaluation, new challenges and remaining gaps are also more clearly delineated. This Supplement to the International Journal of Gynecology and Obstetrics (IJGO) comes at a critical juncture for cervical cancer prevention. Decisions that are made (or not made) now will affect several generations of women.