Cancer Research Division, Cancer Council New South Wales, Woolloomooloo, Sydney, NSW, Australia.
Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France.
Lancet Oncol. 2019 Mar;20(3):394-407. doi: 10.1016/S1470-2045(18)30836-2. Epub 2019 Feb 19.
Cervical screening and human papillomavirus (HPV) vaccination have been implemented in most high-income countries; however, coverage is low in low-income and middle-income countries (LMICs). In 2018, the Director-General of WHO announced a call to action for the elimination of cervical cancer as a public health problem. WHO has called for global action to scale-up vaccination, screening, and treatment of precancer, early detection and prompt treatment of early invasive cancers, and palliative care. An elimination threshold in terms of cervical cancer incidence has not yet been defined, but an absolute rate of cervical cancer incidence could be chosen for such a threshold. In this study, we aimed to quantify the potential cumulative effect of scaled up global vaccination and screening coverage on the number of cervical cancer cases averted over the 50 years from 2020 to 2069, and to predict outcomes beyond 2070 to identify the earliest years by which cervical cancer rates could drop below two absolute levels that could be considered as possible elimination thresholds-the rare cancer threshold (six new cases per 100 000 women per year, which has been observed in only a few countries), and a lower threshold of four new cases per 100 000 women per year.
In this statistical trends analysis and modelling study, we did a statistical analysis of existing trends in cervical cancer worldwide using high-quality cancer registry data included in the Cancer Incidence in Five Continents series published by the International Agency for Research on Cancer. We then used a comprehensive and extensively validated simulation platform, Policy1-Cervix, to do a dynamic multicohort modelled analysis of the impact of potential scale-up scenarios for cervical cancer prevention, in order to predict the future incidence rates and burden of cervical cancer. Data are presented globally, by Human Development Index (HDI) category, and at the individual country level.
In the absence of further intervention, there would be 44·4 million cervical cancer cases diagnosed globally over the period 2020-69, with almost two-thirds of cases occurring in low-HDI or medium-HDI countries. Rapid vaccination scale-up to 80-100% coverage globally by 2020 with a broad-spectrum HPV vaccine could avert 6·7-7·7 million cases in this period, but more than half of these cases will be averted after 2060. Implementation of HPV-based screening twice per lifetime at age 35 years and 45 years in all LMICs with 70% coverage globally will bring forward the effects of prevention and avert a total of 12·5-13·4 million cases in the next 50 years. Rapid scale-up of combined high-coverage screening and vaccination from 2020 onwards would result in average annual cervical cancer incidence declining to less than six new cases per 100 000 individuals by 2045-49 for very-high-HDI countries, 2055-59 for high-HDI countries, 2065-69 for medium-HDI countries, and 2085-89 for low-HDI countries, and to less than four cases per 100 000 by 2055-59 for very-high-HDI countries, 2065-69 for high-HDI countries, 2070-79 for medium-HDI countries, and 2090-2100 or beyond for low-HDI countries. However, rates of less than four new cases per 100 000 would not be achieved in all individual low-HDI countries by the end of the century. If delivery of vaccination and screening is more gradually scaled up over the period 2020-50 (eg, 20-45% vaccination coverage and 25-70% once-per-lifetime screening coverage by 2030, increasing to 40-90% vaccination coverage and 90% once-per-lifetime screening coverage by 2050, when considered as average coverage rates across HDI categories), end of the century incidence rates will be reduced by a lesser amount. In this scenario, average cervical cancer incidence rates will decline to 0·8 cases per 100 000 for very-high-HDI countries, 1·3 per 100 000 for high-HDI countries, 4·4 per 100 000 for medium-HDI countries, and 14 per 100 000 for low-HDI countries, by the end of the century.
More than 44 million women will be diagnosed with cervical cancer in the next 50 years if primary and secondary prevention programmes are not implemented in LMICs. If high coverage vaccination can be implemented quickly, a substantial effect on the burden of disease will be seen after three to four decades, but nearer-term impact will require delivery of cervical screening to older cohorts who will not benefit from HPV vaccination. Widespread coverage of both HPV vaccination and cervical screening from 2020 onwards has the potential to avert up to 12·5-13·4 million cervical cancer cases by 2069, and could achieve average cervical cancer incidence of around four per 100 000 women per year or less, for all country HDI categories, by the end of the century. A draft global strategy to accelerate cervical cancer elimination, with goals and targets for the period 2020-30, will be considered at the World Health Assembly in 2020. The findings presented here have helped inform initial discussions of elimination targets, and ongoing comparative modelling with other groups is supporting the development of the final goals and targets for cervical cancer elimination.
National Health and Medical Research Council (NHMRC) Australia, part-funded via the NHMRC Centre of Excellence for Cervical Cancer Control (C4; APP1135172).
宫颈癌筛查和人乳头瘤病毒（HPV）疫苗接种已在大多数高收入国家实施；然而，在低收入和中等收入国家（LMICs），疫苗接种覆盖率较低。2018 年，世界卫生组织（WHO）总干事宣布采取行动，将宫颈癌作为一个公共卫生问题消除。世卫组织呼吁在全球范围内采取行动，扩大疫苗接种、筛查和对癌前病变的治疗，早期发现和及时治疗早期浸润性癌症，并提供姑息治疗。尚未定义宫颈癌发病率的消除阈值，但可以选择绝对宫颈癌发病率来定义该阈值。在这项研究中，我们旨在量化扩大全球疫苗接种和筛查覆盖范围对 2020 年至 2069 年期间宫颈癌病例数的潜在累积影响，并预测 2070 年以后的结果，以确定宫颈癌发病率可能降至两个绝对值以下的最早年份，这两个绝对值可能被认为是可能的消除阈值——罕见癌症阈值（每年每 10 万名妇女有 6 例新病例，仅在少数几个国家观察到）和每年每 10 万名妇女有 4 例新病例的较低阈值。
在这项统计趋势分析和建模研究中，我们使用国际癌症研究机构（IARC）出版的《五大洲癌症发病率》系列中包含的高质量癌症登记数据，对全球范围内的宫颈癌进行了现有趋势的统计分析。然后，我们使用一个全面和广泛验证的模拟平台 Policy1-Cervix，对宫颈癌预防的潜在扩大规模情景进行动态多队列建模分析，以预测未来的发病率和宫颈癌负担。数据以全球、人类发展指数（HDI）类别和个别国家水平呈现。
如果不采取进一步干预措施，2020-69 年期间全球将诊断出 4440 万例宫颈癌病例，其中近三分之二发生在低 HDI 或中 HDI 国家。到 2020 年，迅速将疫苗接种覆盖率扩大到全球 80-100%，并使用广谱 HPV 疫苗，可以避免这一时期的 670-770 万例病例，但其中一半以上的病例将在 2060 年后避免。在所有 LMICs 中，70%的覆盖率实现了 35 岁和 45 岁的 HPV 筛查两次/终生，将提前预防效果，并在未来 50 年内避免总共 1250-1340 万例病例。从 2020 年开始，快速扩大联合高覆盖率的筛查和疫苗接种，将导致非常高 HDI 国家的宫颈癌年发病率在 2045-49 年降至每 10 万人不到 6 例，高 HDI 国家在 2055-59 年降至每 10 万人不到 6 例，中 HDI 国家在 2065-69 年降至每 10 万人不到 6 例，低 HDI 国家在 2085-89 年降至每 10 万人不到 4 例，而非常高 HDI 国家在 2055-59 年降至每 10 万人不到 4 例，高 HDI 国家在 2065-69 年降至每 10 万人不到 4 例，中 HDI 国家在 2070-79 年降至每 10 万人不到 4 例，低 HDI 国家在 2090-2100 年或以后降至每 10 万人不到 4 例。然而，到本世纪末，并非所有低 HDI 国家的发病率都能达到每 10 万人不到 4 例。如果在 2020-50 年期间（例如，到 2030 年疫苗接种覆盖率达到 20-45%，筛查覆盖率达到每年一次/终生 25-70%，到 2050 年增加到 40-90%的疫苗接种覆盖率和 90%的每年一次/终生筛查覆盖率，作为 HDI 类别之间的平均覆盖率），疫苗接种和筛查的覆盖范围逐渐扩大，到本世纪末，宫颈癌发病率将降低。在这种情况下，到本世纪末，非常高 HDI 国家的宫颈癌发病率将降至每 10 万人 0.8 例，高 HDI 国家降至每 10 万人 1.3 例，中 HDI 国家降至每 10 万人 4.4 例，低 HDI 国家降至每 10 万人 14 例。
如果中低收入国家不实施初级和二级预防方案，未来 50 年内将有超过 4400 万妇女被诊断患有宫颈癌。如果能迅速实施高覆盖率的疫苗接种，在三四十年后将对疾病负担产生重大影响，但更接近的影响将需要为不会受益于 HPV 疫苗接种的老年人群提供宫颈癌筛查。从 2020 年开始，广泛覆盖 HPV 疫苗接种和宫颈癌筛查，到 2069 年，有可能避免 1250-1340 万例宫颈癌病例，到本世纪末，所有国家的 HDI 类别都可能将宫颈癌年发病率降至每 10 万人每年约 4 例或更低。世界卫生大会将于 2020 年审议一项加速宫颈癌消除的全球战略，该战略将包括 2020-30 年期间的目标和指标。这里提出的研究结果有助于为消除目标的初步讨论提供信息，并且与其他小组正在进行的比较建模为最终确定宫颈癌消除的目标和指标提供支持。
澳大利亚国家健康与医学研究理事会（NHMRC），部分通过宫颈癌控制 NHMRC 卓越中心（C4；APP1135172）资助。
