A Framework for Cervical Cancer Elimination in Low-and-Middle-Income Countries: A Scoping Review and Roadmap for Interventions and Research Priorities

Abstract

The World Health Organization announced an ambitious call for cervical cancer elimination worldwide. With existing prevention and treatment modalities, cervical cancer elimination is now within reach for high-income countries. Despite limited financing and capacity constraints in low-and-middle-income countries (LMICs), prevention and control efforts can be supported through integrated services and new technologies. We conducted this scoping review to outline a roadmap toward cervical cancer elimination in LMICs and highlight evidence-based interventions and research priorities to accelerate cervical cancer elimination. We reviewed and synthesized literature from 2010 to 2020 on primary and secondary cervical cancer prevention strategies. In addition, we conducted expert interviews with gynecologic and infectious disease providers, researchers, and LMIC health officials. Using these data, we developed a logic model to summarize the current state of science and identified evidence gaps and priority research questions for each prevention strategy. The logic model for cervical cancer elimination maps the needs for improved collaboration between policy makers, production and supply, healthcare systems, providers, health workers, and communities. The model articulates responsibilities for stakeholders and visualizes processes to increase access to and coverage of prevention methods. We discuss the challenges of contextual factors and highlight innovation needs. Effective prevention methods include HPV vaccination, screening using visual inspection and HPV testing, and thermocoagulation. However, vaccine coverage remains low in LMICs. New strategies, including single-dose vaccination could enhance impact. Loss to follow-up and treatment delays could be addressed by improved same-day screen-and-treat technologies. We provide a practical framework to guide cervical cancer elimination in LMICs. The scoping review highlights existing and innovative strategies, unmet needs, and collaborations required to achieve elimination across implementation contexts.

Keywords: cervical cancer; cervical cancer elimination; cervical cancer prevention; cervical cancer screening; human papillomavirus vaccination; scoping review.

Figure 1

Logic model for comprehensive, intersectoral cervical cancer prevention. ^aPolicies: develop and implement policies, legislation regulations, and registrations. ^bProcurement: develop and implement provision, production, procurement and training strategies. ^cDelivery: develop and implement delivery system, strategy for management, training, and maintain motivation among providers and distributors. ^dQuality: develop and implement an external and internal quality control system. ^eCapacity building: develop provider and health worker skills training, infrastructure and capacity building. ^fEnabling change: cultivate dialogue to promote adoption of innovative technologies and approaches (e.g., task-shifting/sharing) to simplify care delivery and break conflicts of interest. ^gCommunity engagement: demand promotion by empowering local stakeholders and advocacy. ^hBehavior change education: develop and implement intervention strategy for information, education, and communication for behavior change.