Cervical cancer is the third most common cancer among women with an estimated 530,000 new cases and 275,000 deaths in 2008 (WHO, 2010).  Greater than 85 percent of the global burden occurs in developing countries and the highest-risk regions for cervical cancer are Eastern and Western Africa followed by Southern Africa, South-Central Asia, and South America (IARC, GLOBOCAN, 2010).  WHO (2006) offers four main reasons for the higher incidence and mortality of cervical cancer in developing countries: (1) lack of awareness about cervical cancer among the population, health care providers and policy makers; (2) absence or poor quality of screening programs for precursor lesions; (3) limited access to health care services; and (4) lack of functional referral systems.  Most women who die from cervical cancer are in the prime of their lives, and these losses are made more tragic by the fact that cervical cancer is considered one of the most preventable and treatable forms of cancer, as long as it is detected early and treated effectively (WHO, 2006).

Natural History of Cervical Cancer

Human Papillomavirus (HPV) infections are well established as the cause of cervical cancer and can be found in cervical lesions from cytologically normal women to women with varying stages of precancerous disease and invasive cervical cancer.  It takes about 10 to 20 years for precursor lesions caused by HPV to develop into invasive cancer (See WHO, 2006  for detailed background on cervical cancer etiology, progression, diagnosis, and treatment). While HPV is the cause of virtually 100 percent of cervical cancer cases, HPV types 16 and 18 are responsible for about 70 percent of cases, and the current HPV vaccines against types 16 and 18 have the capacity to substantially reduce cervical cancer incidence (WHO, 2010).  The primary transmission route for HPV infection is sexual intercourse. HPV infection has been found in up to 73 percent of healthy men in some regions and, as with other sexually transmitted infections, HPV is more readily transmitted from men to women than from women to men (WHO, 2010).  Male circumcision and the use of condoms have demonstrated a significant protective effect against HPV transmission and offer another strategy for HPV prevention. While HPV infection is a necessary cause of cervical cancer, it is not a sufficient cause. Other cofactors in the progression from cervical HPV infection to cancer include: tobacco smoking, parity, oral contraceptive use, and co-infection with HIV.  Additional probable cofactors are infection with Chlamydia trachomatis and herpes simplex type-2, immune suppression, and certain dietary deficiencies (WHO, 2010).

Cervical Cancer Programming

During the 1994 ICPD in Cairo, countries made commitments to support a more integrated vision of reproductive health (RH) care that went beyond maternity and family planning to embrace a wider array of women’s health needs, including cancer prevention and treatment.  While significant advances have been made on a number of women’s RH issues, cervical cancer has not received sufficient attention in many countries. In 2005, a year before the US Food and Drug Administration approved the first preventative HPV vaccine, the World Health Assembly addressed the growing epidemic of cancers in the developing world with a resolution on cancer prevention and control that emphasized the need for comprehensive and integrated action.  Without urgent action, deaths due to cervical cancer are projected to increase by almost 25 percent from 2005 to 2015 (WHO, 2006). Reduction of cervical cancer through addressing risk factors, adequate screening, and treatment will contribute to the Millennium Development Goals, specifically # 5: Improve maternal health.      

Well-designed and implemented cervical cancer screening and HPV vaccination programs can lower cervical cancer incidence and mortality. WHO (2006) delineates four basic components for cervical cancer control: (1) primary prevention; (2) early detection through increased awareness and screening programs; (3) diagnosis and treatment; and (4) palliative care for advanced disease.  Because of its complex etiology, diagnosis, and treatment requirements, cervical cancer control necessitates high degrees of national policy and program coordination, as well as effective communication and referrals among health providers at all levels of the health care system. Given the expanded focus over the past decade on programs targeting cervical cancer and HPV infection, there is an increasing need for well-designed systems for needs assessments, monitoring and evaluation (M&E).  

The Alliance for Cervical Cancer Prevention (ACCP), a consortium of five international organizations with the shared goal of working to prevent cervical cancer in developing countries, has adapted a framework for cervical cancer program M&E (ACCP, 2004).  The framework details various inputs, outputs, outcomes and impacts, all linked to the process of assessment and planning.  Program inputs (e.g., staff, training, equipment) contribute to attaining outputs, such as accessible and reliable client-centered screening, treatment, and other supportive care services. Quality services accessed by a large proportion of the target population can achieve outcomes including high coverage screening and treatment, which in turn can impact and reduce the burden of cervical cancer. Sources of recommended indicators include those accompanying the ACCP (2004) M&E framework, PATH (2000) selected evaluation indicators, WHO (2009) HPV vaccine coverage and impact monitoring indicators, and cervical cancer indicators from the WHO/UNFPA (2008) list for achieving universal access to RH care. The WHO/ICO Information Center on HPV and Cervical Cancer regularly reports on selected country level and age-specific cervical cancer and HPV surveillance indicators collected by IARC/GLOBOCAN.

Indicator Selection

The eight core indicators selected for this database cover policy, training, screening, and program impact as measured by the cervical cancer mortality rate.  Indicators for adolescent girls’ diagnosis and treatment for STIs and for vaccination with three doses of the HPV vaccine by age 15 are included in the database technical area on Adolescent and Youth Sexual and Reproductive Health.  Moreover, information collected on sexual and RH behaviors related to risk for HPV infection and cervical cancer can help inform the design and targeting of effective strategies.  The establishment of well-functioning information systems is vital to successful M&E and, ideally, information from facility-based records should be linked to regional or national databases to allow aggregation of data on key indicators.  Where available, national cancer registries can be used to monitor cervical cancer incidence and mortality rates.

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References:

Alliance for Cervical Cancer Prevention (ACCP), 2004, Planning and Implementing Cervical Cancer Prevention and Control Programs: A Manual for Managers, https://www.who.int/reproductivehealth/publications/cancers/a92126/en/

International Agency for Research on Cancer (IARC), GLOBOCAN, Online Database Geneva: WHO. http://screening.iarc.fr/

PATH, 2000, Planning Appropriate Cervical Cancer Prevention Programs, Seattle, WA: PATH. https://screening.iarc.fr/doc/cxca-planning-appro-prog-guide.pdf

WHO, 2010, Human Papillomavirus and Related Cancers: Summary Report Update, Nov. 10, 2010, World,  Geneva: WHO. https://www.unav.edu/documents/16089811/16216616/HPVReport2010.pdf

WHO, 2009, Report of the meeting on HPV Vaccine Coverage and Impact Monitoring, Geneva: WHO. http://whqlibdoc.who.int/hq/2010/WHO_IVB_10.05_eng.pdf

WHO / UNFPA, 2008, National-level monitoring of the achievement of universal access to reproductive health: conceptual and practical considerations and related indicators, Geneva: WHO. http://whqlibdoc.who.int/publications/2008/9789241596831_eng.pdf

WHO, 2006, Comprehensive Cervical Cancer Control: A Guide to Essential Practice, Geneva, WHO. https://www.who.int/cancer/publications/9241547006/en/

WHO, 2005, The 58th World Health Assembly resolution on cancer prevention and control (WHA58.22), Geneva: WHO. http://www.who.int/cancer/media/news/WHA58%2022-en.pdf