Regional variations and inequalities in testing for early detection of breast and cervical cancer: evidence from a nationally representative survey in India.

BACKGROUND: The burden of cancer in India has been rising, yet testing for early detection remains low. This study explored inequalities in the uptake of breast cancer (BC) examination and cervical cancer (CC) among Indian women, focusing on socioeconomic, regional, and educational differences. METHODS: Data from the 2019-21 National Family Health Survey (n=353,518) were used to assess the uptake of BC examination and CC testing. Inequalities were quantified using the slope index of inequality (SII), relative index of inequality (RII), and relative concentration index (RCI). SII measured absolute inequality, while RII and RCI assessed relative inequality between disadvantaged and advantaged groups. RESULTS: The ever uptake of tests for early detection of BC and CC were low at 9 and 20 per 1,000 women, respectively. Higher uptake was observed among women from the richest households compared to the poorest (SII: 1.1 for BC and 1.8 for CC). The magnitude of relative socioeconomic inequalities was more pronounced in rural areas (RCI: 22.5 for BC and 21.3 for CC) compared to urban areas. Similarly, higher-educated women were 4.84 times (RII: 4.84) and 2.12 times (RII: 2.12) more likely to undergo BC examination and CC testing, respectively, compared to non-educated women. The northeastern region exhibited greater socioeconomic inequality, while the western region showed more education-based inequality. CONCLUSION: The lower uptake of BC examination and CC testing and the marked inequalities underscore the need for targeted interventions to improve access and utilization of testing services, especially among lower-educated women, and those in rural areas.

Disparities and Determinants of Testing for Early Detection of Cervical Cancer among Nepalese Women: Evidence from a Population-Based Survey.

BACKGROUND: Cervical cancer presents a considerable challenge in South Asia, notably in Nepal, where screening remains limited. Past research in Nepal lacked national representation and a thorough exploration of factors influencing cervical cancer screening, such as educational and socioeconomic disparities. This study aims to measure these gaps and identify associated factors in testing for early detection of cervical cancer among Nepalese women. METHODS: Data from the 2019 Nepal Noncommunicable Disease Risk Factors survey (World Health Organization STEPwise approach to noncommunicable risk factor surveillance), involving 2,332 women aged 30 to 69 years, were used. Respondents were asked if they had undergone cervical cancer testing through visual inspection with acetic acid, Pap smear, or human papillomavirus test ever or in the past 5 years. The slope index of inequality (SII) and relative concentration index were used to measure socioeconomic and education-based disparities in cervical cancer test uptake. RESULTS: Only 7.1% [95% confidence interval (CI): 5.1-9.9] Nepalese women had ever undergone cervical cancer testing, whereas 5.1% (95% CI: 3.4-7.5) tested within the last 5 years. The ever uptake of cervical cancer testing was 5.1 percentage points higher (SII: 5.1, 95% CI: -0.1 to 10.2) among women from the richest compared with the poorest households. Education-based disparities were particularly pronounced, with a 13.9 percentage point difference between highly educated urban residents and their uneducated counterparts (SII: 13.9, 95% CI: 5.8-21.9). CONCLUSIONS: Less than one in ten women in Nepal had a cervical cancer testing, primarily favoring higher educated and wealthier individuals. IMPACT: Targeted early detection and cervical cancer screening interventions are necessary to address these disparities and improve access and uptake.

Feasibility, accuracy and acceptability of self-sampled human papillomavirus testing using careHPV in Cambodia: a cross-sectional study.

OBJECTIVE: Self-sampled human papillomavirus (HPV) testing is a potential option for cervical cancer screening, but research is scarce in Cambodia. We evaluated the feasibility, accuracy, and acceptability of self-sampled HPV testing using careHPV. METHODS: A cross-sectional study including women aged 20-49 years attending 2 national hospitals in the capital city was conducted. Women underwent both self-sampling and clinician-sampling of specimens, and were then asked to complete an acceptability questionnaire. The paired samples were analyzed for high-risk HPV by careHPV and genotyped by polymerase chain reaction (PCR). RESULTS: A total of 375 women were eligible for inclusion. Based on PCR, 78.9% were negative for HPV in both self and clinician-samples, 9.9% had a complete HPV type match, and 6.1% had all HPV types in clinician-samples also detected in self-samples. In 5.1%, one or more HPV types identified in the clinician-samples were missed in self-samples. When using careHPV, the overall agreement between the 2 sampling methods was 95.7% (95% confidence interval [CI]=95.8-95.6) with good concordance (κ=0.66, 95% CI=0.56-0.76). Nearly 90% of the women preferred clinician-sampling over self-sampling, citing greater comfort, ease, and speed. CONCLUSION: Self-sampled HPV testing using careHPV could be an option for cervical cancer screening in Cambodia; however, it requires periodic quality control of handling procedures. In addition, women's health education regarding the accuracy of self-sampled HPV testing and the importance of follow-up in cases of positive results is needed.

Feasibility of monitoring Global Breast Cancer Initiative Framework key performance indicators in 21 Asian National Cancer Centers Alliance member countries.

Background: The Global Breast Cancer Initiative (GBCI) Framework, launched by the World Health Organisation (WHO) in 2023, emphasises assessing, strengthening, and scaling up services for the early detection and management of breast cancer. This study aims to determine the feasibility of monitoring the status of breast cancer control in the 21 Asian National Cancer Centers Alliance (ANCCA) countries based on the three GBCI Framework key performance indicators (KPIs): stage at diagnosis, time to diagnosis, and treatment completion. Methods: We reviewed published literature on breast cancer control among 21 ANCCA countries from May to July 2023 to establish data availability and compiled the latest descriptive statistics and sources of the indicators using a standardised data collection form. We performed bivariate Pearson's correlation analysis to measure the strength of correlation between stage at diagnosis, mortality and survival rates, and universal health coverage. Findings: Only 12 (57%) ANCCA member countries published national cancer registry reports on breast cancer age-standardised incidence rate (ASIR) and age-standardised mortality rate (ASMR). Indonesia, Myanmar, and Nepal had provincial data and others relied on WHO's Global Cancer Observatory (GLOBOCAN) estimates. GLOBOCAN data differed from the reported national statistics by 5-10% in Bhutan, Indonesia, Iran, the Republic of Korea, Singapore, and Thailand and >10% in China, India, Malaysia, Mongolia, and Sri Lanka. The proportion of patients diagnosed in stages I and II strongly correlated with the five-year survival rate and with the universal health coverage (UHC) index. Three countries (14%) reported national data with >60% of invasive breast cancer patients diagnosed at stages I and II, and a five-year survival rate of >80%. Over 60% of the ANCCA countries had no published national data on breast cancer staging, the time interval from presentation to diagnosis, and diagnosis to treatment. Five (24%) countries reported data on treatment completion. The definition of delayed diagnosis and treatment completion varied across countries. Interpretation: GBCI's Pillar 1 KPI correlates strongly with five-year survival rate and with the UHC index. Most ANCCA countries lacked national data on cancer staging, timely diagnosis, and treatment completion KPIs. While institutional-level data were available in some countries, they may not represent the nationwide status. Strengthening cancer surveillance is crucial for effective breast cancer control. The GBCI Framework indicators warrant more detailed definitions for standardised data collection. Surrogate indicators which are measurable and manageable in country-specific settings, could be considered for monitoring GBCI indicators. Ensuring UHC and addressing health inequalities are essential to early diagnosis and treatment of breast cancer. Funding: Funding for this research article's processing fee (APC) will be provided by the affiliated institution to support the open-access publication of this work. The funding body is not involved in the study design; collection, management, analysis and interpretation of data; or the decision to submit for publication. The funding body will be informed of any planned publications, and documentation provided.

Towards elimination of cervical cancer - human papillomavirus (HPV) vaccination and cervical cancer screening in Asian National Cancer Centers Alliance (ANCCA) member countries.

About 95% of cervical cancers worldwide are caused by human papillomavirus (HPV). Cervical cancer is preventable and curable if it is detected and treated early. We reviewed the latest national cervical cancer indicators, and barriers to HPV vaccination and cervical cancer screening in 21 Asian National Cancer Centers Alliance (ANCCA) member countries. Half (n = 11, 52%) of the countries have introduced HPV vaccination for girls as part of their national vaccination programme, three countries reported coverage of over 90%. Most ANCCA member countries have cervical cancer screening programmes, only five countries reported screening uptake of over 50%. The barriers to HPV vaccination coverage and cervical cancer screening participation have been identified. Ensuring health service accessibility and affordability for women, addressing sociocultural barriers, and strengthening the healthcare system and continuum of care are essential to increase HPV vaccination and cervical cancer screening coverage.

A Review of the Implementation Status of and National Plans on HPV Vaccination in 17 Middle-Income Countries of the WHO Western Pacific Region.

The World Health Organization's Western Pacific Region is responsible for one-fourth of the global cervical cancer burden, and nearly 90% of that burden is concentrated in middle-income countries (MICs). Applying a conceptual model of implementation of population-based interventions, we synthesized the current implementation status of human papillomavirus (HPV) vaccination and national plans that form the basis of its implementation in 17 MICs. We gathered information from a range of governmental documents, published studies, and global databases. For all available national cancer-related plans and immunization plans, we examined the description of HPV vaccination. We found that, as of July 2021, only four countries (24%) had a mature HPV vaccination program with a high first-dose coverage; three (18%) had introduced HPV vaccination, but needed further efforts to scale it up, seven (41%) had not been able to introduce it after conducting demonstration projects, and three (18%) did not have any experience in HPV vaccination. In the national plans, most of the countries recognized the importance of HPV vaccination, but only 10 (59%) provided an implementation strategy on how it would be introduced or scaled up. Countries with a mature program were more likely to have their implementation strategy detailed in their national cancer control plan. Successful implementation of HPV vaccination requires overcoming known challenges and having a clear national plan. Positioning HPV vaccination clearly in the overall national cancer control plan may be key to accelerating its nationwide implementation.

What is the current status of Japan's efforts to meet global goals and targets to eliminate cervical cancer?

Following the global call to action by the World Health Organization (WHO), the world is currently moving to eliminate cervical cancer as a public health problem. To eliminate the cancer within this century, which is defined as an age-adjusted cervical cancer incidence rate (ASIR) below 4 per 100,000 women, WHO recommends all countries to achieve "90-70-90" targets for human papilloma virus (HPV) vaccination, cervical cancer screening, and treatment of precancer and cancer by 2030. In Japan, ASIR has been rising since the late 1990s to 11.1 per 100,000 women, and this rise is particularly prominent in women of reproductive age. HPV vaccination coverage is as low as 0.3%, largely due to the Governments ongoing suspension of proactive recommendations for the vaccine. Given the absence of centralized, population-based cervical cancer screening program and a nationwide surveillance system for systematic monitoring, the exact screening participation rate and treatment rate are difficult to estimate. A national survey suggested that only around 40% of women between the ages of 20 and 69 years underwent cervical cancer screening within the last two years. National policies and systems for HPV vaccination and screening should be updated in a more efficient way as new evidence and innovations become available. In the wake of powerful global momentum, actions must be taken now to further enhance cervical cancer control and ensure that Japanese girls and women are no longer left behind.

The cooperation between professional societies contributes to the capacity building and system development for prevention and control of cancer in low- and middle-income countries: the practice of Cervical Cancer Prevention and Control Project in Cambodia.

Globally, an estimated 570,000 women are newly diagnosed with cervical cancer, and 311,000 women die every year, with approximately 90% of the cases occurring in low- and middle-income countries (LMICs). Cervical cancer is the most common cancer in women in Cambodia, with age-standard incidence rate of 13.5/100,000 and mortality rate of 10.1/100,000. This paper introduces the educational and managerial interventions of Cambodia Cervical Cancer Project 2015-2018 by two professional societies of Cambodia and Japan. It can be categorized into three phases: health education and screening; diagnosis and treatment of precancerous lesions; and pathology service. Human papillomavirus test-based cancer screening and treatment of precancerous lesions were successfully initiated. Key factors contributed to optimal outcomes are partnership between two professional societies with strong commitment, and a comprehensive and stepwise quality-focused approach. A complementary role and joint society initiatives is a novel approach and substantial in sustainability for developing a system of cervical cancer management. This effort might serve as a good example how professional societies can contribute to capacity building and system development for prevention and control of cancer in LMICs.

Examining policy cohesion for cervical cancer worldwide: analysis of WHO country reports.

INTRODUCTION: Cervical cancer is controllable through appropriate interventions such as vaccination, screening, treatment, early diagnosis and palliative care. The greatest burden of cervical cancer lies in low-income countries (LIC) where most of these services are missing or developed asymmetrically. Indeed, it is important to have not just an expansion, but a symmetric and concordant development of each service. Therefore, policies of countries should be aligned to provide concordant services and achieve the best outcomes with available resources. This is called 'policy cohesion' and for the first time in literature we will analyse cervical cancer policy coherence in all the 194 WHO member states. METHODS: The study is based on the 2017 WHO Non-Communicable Disease Country Capacity Surveys (NCD CCS). Although the survey covers multiple non-communicable diseases, in this report we will only discuss those results pertaining to cervical cancer, analysing the cervical cancer policy cohesion of 194 WHO member states, divided by WHO region and World Bank income group. RESULTS: Human papilloma virus vaccination exists in 53% of countries. 76% of countries offer cervical screening: among these countries, treatment, early diagnosis guidelines and palliative care are missing in 13%, 13% and 40%, respectively. In the African region, this discord is even more profound: 32%, 17% and 60%, respectively. CONCLUSION: Especially in those settings where resources are limited, early detection guidelines, treatment and palliative care should be implemented along with secondary prevention strategies. Symmetric development of concordant cervical cancer services maximises cervical cancer control efficacy.

How to reduce the impact of cervical cancer worldwide: Gaps and priority areas identified through the essential cancer and primary care packages: An analysis of effective interventions.

BACKGROUND: Cervical cancer is a preventable cancer; therefore, countries should provide strategic, evidence-based health services to reduce its incidence and impact on their populations. Two packages of health services that group together all the services related to cervical cancer, the Essential Cancer Package (9 interventions) and the Primary Care Package (5 interventions), are defined in this article with the aim of assessing the global status of the availability of health services and their coverage in 194 countries worldwide. METHODS: The study was based on the 2017 World Health Organization (WHO) Noncommunicable Disease Country Capacity Survey. Although the survey covered multiple noncommunicable diseases, this report examined only those results pertaining to cervical cancer in the 194 WHO member states divided by WHO region and World Bank income. RESULTS: Only 21% of the countries reported providing all 9 interventions of the Essential Cancer Package, with the highest proportions being found in Europe (45.3%) and among high-income countries (HICs; 54.3%). As for the Primary Care Package, only 19.1% of countries provided all 5 interventions, with the highest proportions being found in Europe (39.6%) and among HICs (45.5%). CONCLUSIONS: The complete development and appropriate coverage of each service listed in both the Essential Cancer Package and the Primary Care Package are essential to reduce the impact of cervical cancer worldwide, and they should be integrated into all cancer control planning efforts.