Cervical cancer screening in developing countries at a crossroad: Emerging technologies and policy choices

Abstract

Cervical cancer (CC) represents the fourth most common malignancy affecting women all over the world and is the second most common in developing areas. In these areas, the burden from disease remains important because of the difficulty in implementing cytology-based screening programmes. The main obstacles inherent to these countries are poverty and a lack of healthcare infrastructures and trained practitioners. With the availability of new technologies, researchers have attempted to find new strategies that are adapted to low- and middle-income countries (LMIC) to promote early diagnosis of cervical pathology. Current evidence suggests that human papillomavirus (HPV) testing is more effective than cytology for CC screening. Therefore, highly sensitive tests have now been developed for primary screening. Rapid molecular methods for detecting HPV DNA have only recently been commercially available. This constitutes a milestone in CC screening in low-resource settings because it may help overcome the great majority of obstacles inherent to previous screening programmes. Despite several advantages, HPV-based screening has a low positive predictive value for CC, so that HPV-positive women need to be triaged with further testing to determine optimal management. Visual inspection tests, cytology and novel biomarkers are some options. In this review, we provide an overview of current and emerging screening approaches for CC. In particular, we discuss the challenge of implementing an efficient cervical screening adapted to LMIC and the opportunity to introduce primary HPV-based screening with the availability of point-of-care (POC) HPV testing. The most adapted screening strategy to LMIC is still a work in progress, but we have reasons to believe that POC HPV testing makes part of the future strategies in association with a triage test that still needs to be defined.

Keywords: Cervical cancer screening; Human papillomavirus testing; Low- and middle-income countries.

Figure 1

Visual inspection tests. A: Visual inspection test with 3%-5% acetic acid; B: Visual inspection test with Lugol’s iodine.

Figure 2

Decision making algorithm for human papillomavirus triage. ¹HPV testing done on a self-taken sample by women aged 30-50 years; ²Triage tests suitable for same-day Screen and Treat; ³Triage tests requiring a second visit for treatment. HPV: Human papillomavirus; VIA: Visual inspection test with 3%-5% acetic acid; VILI: Visual inspection test with Lugol’s iodine.