Cervical cancer prevention in upper middle-income countries

The manuscripts by Tota et al. and by Rossi et al., in this issue of Preventive Medicine provide ample evidence regarding the urgent need to switch to HPV based screening programs and how it will become even more imperative once HPV vaccinated girls reach the cervical cancer screening age. Worldwide primary prevention with vaccination is the final goal; but, in the coming 2 to 3 decades most of the prevention should be done through screening and treatment of precancerous lesions. Cervical cancer remains a major public health problem in upper-middle income countries (UMICs). Coverage of vaccination against HPV by the end of 2014 was estimated to be < 10% for girls and young women 10 to 20 years with nearly no vaccination among older women. Therefore, multiple cohorts of women will remain dependent on secondary screening for cervical cancer prevention in the coming decades. Several UMICs currently have cytology-based screening programs with limited effectiveness. In addition to the limitations of cytology, summarized by Tota et al., screening programs in UMICs have other problems that further reduce their effectiveness including low programmatic coverage due to poor accessibility to health services and loss to follow-up of women screening positive. Cervical cancer prevention programs in UMICs should be urgently transformed to become more cost-efficient and most importantly more effective in reducing cervical cancer burden. Introduction of HPV vaccination where it is not available and where available, assuring high vaccination coverage among girls is a must. Screening programs should switch to HPV testing immediately while simultaneously solving other program deficiencies.