Improving outlooks for cervical cancer patients
In 2022, an estimated 660,000 women were diagnosed with cervical cancer and around 350,000 patients died globally. As the fourth most prevalent cancer in women, recent research efforts have aimed to improve prevention, treatment, and screening programs, ultimately driving better outcomes. For instance, the recent international INTERLACE trial assessed the impact of adding six weeks of chemotherapy before the standard of care course of chemoradiation (a combination of chemotherapy and radiotherapy) with striking results. With this modified treatment regime, the risk of death from cervical cancer was slashed by a staggering 40% and the risk of relapse after treatment was cut by 35%, a promising advance that will help more people survive without their cancer returning.
Similarly, vaccinations of teenagers against human papillomavirus (HPV), the most common cause of cervical cancer, have reduced incidence by up to 90%, as indicated by a recent UK study. Despite this success, HPV has many different types and current vaccines miss multiple high-risk HPV types, making effective screening approaches essential.
While these advances are undoubtedly important steps forward in the fight against cervical cancer, combining better treatment with improved and inclusive cervical cancer screening programs for early detection are key to ensuring each woman benefits from the best outcomes possible.
The power of cervical screening
Extensive cervical screening efforts have already successfully reduced incidence and mortality by up to around 90% in the high-income settings of Western and Northern Europe. This was achieved with two main types of cervical cancer screens. One approach is called a Pap smear, which takes a sample of cervical cells followed by their analysis with a microscope in the laboratory to look for cellular changes before they turn into cancer. From January 1st, 2025, Belgium is shifting its screening to a more sensitive and tailored method that detects the presence of HPV, one of the leading causes of cervical cancer, with the aim to ensure better protection. From the age of 30, women will be screened for HPV every five years.
While some types of HPV cause non-cancerous warts, other types are thought to be responsible for around 90% of cervical cancers. Approximately 80% women will have had an HPV infection at some point in their lives by the age of 50. Where an HPV infection is present in the cervix, around 10% of women will develop long-lasting infections making them at risk of cervical cancer.
With both screening approaches, if abnormal cervical cells or HPV are detected, the patient undergoes monitoring or local removal of cells if the HPV infection doesn’t clear. Treatment of precancers involves visual inspection of the cervix, followed by hot or cold ablation of the cells or their surgical excision and sustained follow up.
However, despite the clear efficacy of screening, some countries and regions are struggling. Accumulating evidence suggests some approaches fail to encourage women in certain demographics to attend screening, increasing the risk of undetected cervical cancer.
Un(der)screening in Belgium and beyond
In 2021, in the Flanders region of Belgium, over one third of all women eligible for cervical cancer screening remained unscreened. This is despite an initiative started in 2013 to promote free, three-yearly screening with reminder letters. Those most likely to remain un(der)screened in Belgium are socioeconomically disadvantaged women, those with a lower education attainment, and older women.
This trend extends beyond Flanders and studies from other European countries identify female sex workers, substance users, and women with a migration background as most likely to be un(der)screened for cervical cancer.
Why are certain women un(der)screened?
To identify these un(der)screened populations and find out the cause of the low screening participation in Flanders, researchers from Ghent University performed interviews with healthcare professionals and community workers focusing on identifying the specific needs and barriers faced by these un(der)screened populations.
Key barriers were identified, including at the individual, the sociocultural, and the healthcare system level. For instance, individuals may have a lack of awareness of cervical cancer or the risk it poses. They might prioritize other issues, have financial limitations, or experience a language barrier, or emotional hurdle due to embarrassment or fear.
At the sociocultural level, individuals may experience stigma, traditional cultural pressures, have limited discussions of intimate health issues, or may be influenced by religion, family or partners. In terms of healthcare providers, there may be insufficient focus on prevention, an overburdening of general practitioners, poor communication, or limited access to specialist gynecologists.
Breaking barriers
The researchers identified that the un(der)screened group is very heterogeneous, making it challenging to find a one-size-fits-all approach that effectively reaches everyone in the hard-to-reach population. Only a tailored, multilevel strategy to overcoming these individual, sociocultural, and healthcare system barriers will likely reach and encourage these un(der)screened women to go for cervical screening. One place to start is to raise awareness of the screening program in multiple languages as lack of awareness or language barriers are significant hurdles for many un(der)screened women. Providing more nurses for screening will also support general practitioners in streamlining the screening process.
Efforts are also now underway in Belgium with the ScreenUrSelf trial to see if more women could be reached by self-sampling at home than with current organized screening. While study outcomes are yet to be published, results from questionnaires suggest that the majority of Flemish women interviewed were more likely to participate in cervical cancer screening if they had the option to self-sample.
When vaccination against HPV, inclusive and accessible cervical screening, and improved treatments are combined, the outlook for women with or at risk of cervical cancer is brighter than ever before. By increasing efforts to try to include hard-to-reach, or vulnerable women we might eventually reach a point where incidence decreases for all women in society.
