90-70-90 Target Eliminating Cervical Cancer Initiative

Cancer is the leading cause of morbidity and mortality worldwide. Global Cancer Statistic (GLOBOCAN) 2020 reports 19.3 million new cases of cancer and around 10 million cancer deaths across the globe. One-half of these cancer incidences and mortality is reported to happen in Asia alone. Female breast cancer is now the most often diagnosed cancer in women around the world, while cervical cancer is the fourth most frequent cancer. Global data reveal incidence of 604,237 cases and 341,843 deaths related to cervical cancer in 2020. Between 2018 and 2030, the number of cases is expected to rise from 570,000 to 700,000, with 310,000 to 400, 000 deaths.(1) Cervical cancer kills one woman every two minutes, and 9 in 10 such deaths occur in low and middle income countries, according to statistics.
Cervical cancer, however, is more common in low and low-middle income countries, prominently in sub-Saharan Africa. Cervical cancer is the most frequent cancer among Nepali women aged 15 to 44 years. As of 2021 estimates, cervical cancer has been identified in 2,244 women, and 1,493 have died as a result of the condition. Around 2% of women are infected with HPV 16 and 18, which are the causes for invasive cancer in 80% of women. Another essential information to remember is that, HIV-positive women are six times more likely to acquire this cancer.

The World Health Organization has recently launched an endeavor to eliminate cervical cancer from the planet. WHO urged countries worldwide in May 2018, and proposed action was approved in August 2020. The main goal of this initiative is to reduce the incidence of cervical cancer to below 4 per 100,000 women in each country. To attain this primary goal, each country has to meet the accompanying target by 2030. The expected benefit of this global strategy is to reduce the incidence of over 74 million new cancer cases and consequently save over 300,000 deaths by 2030.(1) The essential approach of the initiative are:

• Fully vaccinate 90% of girl children by the age of 15 against HPV.
• Screen 70% of women by age 35 and 45 using high performance test.
• Treat 90% of women with pre-cancer and manage those who have the cancer.
Cervical cancer is a type of cancer that affects the cells of the cervix, and is caused by long-term infection with the human papillomavirus (HPV). If diagnosed early, cervical cancer can be treated effectively. WHO has also issued a guideline for treatment and prevention of cervical cancer for women in the general population and HIV-positive women. “Screen and treat” and “screen triage and treat” are the two basic screening and treatment approaches.

Cervical cytology, also known as Papanicolaou test or Pap smear test, is the most common method used to screen women in many regions of the world. Liquid cytology was later developed and used. However, neither cytology test is entirely accurate. Dual staining to identify test with cell cycle regulatory protein P16 and cell proliferative marker Ki67 has emerged as a more sensitive cytology test that is also recommended as a triage test by WHO. For settings with limited resources, Visual Inspection with Acetic Acid (VIA) and Lugol’s Iodine (VILI) became more favorable to identify the cancer. Moreover, artificial intelligence and machine learning have been developed to produce more complex visual inspection tests with increased accuracy.

WHO currently recommends HPV DNA detection as a primary screen method for both“screen and treat” as well as “screen triage and treat” approach. DNA-based screening test became the most preferred method, as it would discover cases that would otherwise go undetected by traditional methods. Nepal, despite its limited resources, could benefit from a visual inspection- and cytology-based screening program, until a comprehensive national plan is devised that includes DNA-based HPV testing that is accessible to a wider range of people.

Overall, the effort is unique in that it is the first time WHO has undertaken a cancer elimination initiative. Nepal Society of Obstetricians and Gynecologist (NESOG) has already been successful in receiving an International Federation of Gynecology and Obstetrics (FIGO) grant for a project in Nepal aimed at eliminating cervical cancer. Despite the challenges, to further accelerate this initiative, we will require interest and support from a variety of stakeholders, such as health professionals, national societies, civil societies, local leaders, policymakers, and political leaders. This endeavor will also bring forth various opportunities, ranging from research initiatives, establishment of a national guideline, implementation of newer screening and diagnostic tests, and development and distributions of vaccines.

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