Abstract
India has the highest burden of cervical cancer in the world. To estimate the consequences of delaying implementation of organized cervical cancer screening, we projected the avertable burden of disease under different implementation scenarios of a screening program. We used an individual‐based microsimulation model of human papillomavirus (HPV) infection and cervical cancer calibrated to epidemiologic data from India to project age‐specific cancer incidence and mortality reductions associated with screening (once‐in‐a‐lifetime among women aged 30–34 years) with one‐visit visual inspection with acetic acid (VIA) and one‐ and two‐visit HPV DNA testing. We then applied these reductions to a population model to project the lifetime cervical cancer cases and deaths averted under different implementation scenarios taking place from 2017 to 2026: (1) immediate implementation of screening with currently available screening tests (one‐visit VIA, two‐visit HPV testing); (2) immediate implementation of screening with currently available screening tests, with a switch to point‐of‐care one‐visit HPV testing in 5 years; and (3) 5‐year delayed implementation of screening with current screening tests or point‐of‐care HPV testing. Immediate implementation of two‐visit HPV testing with a switch to one‐visit HPV testing averted 574,100 cases and 382,500 deaths over the lifetimes of 81.4 million 30‐ to 34‐year‐old women screened once between 2017 and 2026. Delayed implementation with a one‐visit HPV test averted 209,300 cases and 139,100 deaths. Delaying implementation of screening programs in high‐burden settings will result in substantial morbidity and mortality among women beyond the age for adolescent HPV vaccination.
Highlights
India has the largest burden of cervical cancer in the world, with an estimated 123 000 incident cases occurring annually.[1]
The disease is preventable through either prophylactic vaccination against human papillomavirus (HPV)Ͷ the sexually transmitted virus that causes cervical cancerͶ or screening and treatment of precancerous lesions caused by persistent HPV infection
Among immediate implementation strategies involving only currently available screening tests, immediate two-visit HPV testing was more effective than immediate visual inspection with acetic acid (VIA), averting an estimated additional 149,800 cases and 110,100 deaths
Summary
India has the largest burden of cervical cancer in the world, with an estimated 123 000 incident cases occurring annually.[1] This accounts for approximately 23% of cases worldwide, and 32% of cases in less developed countries.[1] Yet the disease is preventable through either prophylactic vaccination against human papillomavirus (HPV)Ͷ the sexually transmitted virus that causes cervical cancerͶ or screening and treatment of precancerous lesions caused by persistent HPV infection. While the introduction and scale-up of adolescent HPV vaccination programs would substantially reduce the number of cervical cancer cases in years to come, the full benefits of HPV vaccination will not be realized for more than 30 years; to date, there are several HPV vaccination demonstration projects in India, but the vaccine is not available through the national immunization program.[2] In the interim, screening is the only form of prevention for the two to three generations of women beyond the target age of adolescent vaccination. An estimated 3.1% of women in India reported receiving a Pap smear in the last 3 years.[3]
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