BARRIERS TO IMPLEMENTING CERVICAL CANCER SCREENING IN UKRAINE: THE PATH FORWARD

The demographic situation in Ukraine is critical. Eleven years of the russo-Ukrainian war, including the full-scale invasion of Ukraine by the russian federation in 2022, had devastating consequences for the country’s population structure. Among them are the large-scale emigration of women and children and a notable deterioration in public health indicators. In particular, the incidence of various diseases, including cancer, is rising [1]. Cervical cancer (CC) has remained a significant public health challenge in Ukraine over the past decade. In certain regions, it is still the leading cause of mortality among women of reproductive age. The critical situation stems from the low effectiveness of opportunistic screening (characterized by limited coverage and a lack of quality control) and the absence of an organized, population-based screening program [2]. According to the WHO data (last updated in September 2022), screening coverage among women aged 30–49 in Ukraine remains low, failing to reach 40% [3]. As a result, most CC cases are diagnosed at late stages, complicating treatment and reducing the likelihood of recovery. The consequences of the russian full-scale invasion, including trauma, sexual violence, and an increased number of surgical interventions, have exacerbated the situation, contributing to a higher risk of HIV transmission. Among women living with HIV, CC is the most common malignancy. In 2023, the share of newly diagnosed advanced CC cases in Ukraine reached 36%, more than double the rate in 2013 (16.1%) [4; 5]. Despite wartime challenges, Ukraine’s medical community has actively joined the WHO Global Initiative to eliminate CC, implementing both primary and secondary prevention measures within the ongoing humanitarian crisis. A significant step forward was taken in 2024 with the approval by the Ministry of Health of Ukraine of the National Standard of Medical Care, Clinical Guideline, and Organizational Procedure for Cervical Cancer Screening and Early Detection. This was the first document at the national level to recommend the introduction of primary HPV screening, including the option for self-sampling, in line with WHO guidance. It outlines recommended testing methods and follow-up algorithms in the case of a positive HPV test result. For the first time, HPV self-sampling was officially endorsed as a promising tool to increase screening coverage [6; 7]. HPV self-sampling is widely acknowledged as an effective alternative to clinician-collected samples. A meta-analysis by Arbyn et al. (2018) demonstrated that PCR-based HPV tests on self-collected samples yield a sensitivity of 99% (95% CI: 0.97–1.02) for detecting CIN2+ lesions, comparable to tests performed by clinicians [8]. Furthermore, incorporating self-sampling into active invitation strategies more than doubles screening participation (OR = 2.33; 95% CI: 1.86–2.91). Currently, at least 12 European countries have integrated self-sampling into their national screening programs [9]. Denmark’s experience is particularly illustrative, with an 80% reduction in un(der)screened women within 10 years of implementing self-sampling [10]. However, implementing CC screening in Ukraine, particularly through HPV self-sampling, faces significant barriers. Low awareness and psychological barriers A study currently underway at the Department of Oncology and Medical Radiology at Danylo Halytsky Lviv National Medical University surveyed 67 women aged 25–43 (mean age: 35.45±1.02) who sought medical care for various reasons at healthcare facilities in Lviv. The survey revealed significant knowledge gaps regarding HPV. Only half of the respondents (51.1%) knew that HPV is sexually transmitted, while just a third (27.7%) correctly stated that not all HPV infections lead to CC. Another 14.9% mistakenly believed there is a cure for HPV. These findings underscore the need for enhanced public education efforts. Psychological and logistical barriers also play a significant role. About one-fifth of women surveyed (20%) did not consider it necessary to visit a gynecologist for screening in the absence of symptoms; 10% did not attend screening due to not being sexually active at the moment; and 6% avoided examinations out of fear of contracting sexually transmitted infections. Logistical challenges, such as inconvenient or costly travel to healthcare facilities, were cited by 2% of respondents. It is important to note that the survey included only those women who had already accessed healthcare services, thus overcoming at least basic logistical barriers. A substantial share of the target population (women with no access to medical care or who avoid it due to psychological reasons) remains unaccounted for. These findings highlight the need for public awareness campaigns and improved access to screening initiatives. Structural barriers Even with the existence of a legal framework regulating CC screening in Ukraine, there is still no clear algorithm for implementing HPV self-sampling as a method of cervical screening. Specifically: The target population has not been clearly defined; There is no standardized approach to implementation (e.g., offerings through physicians, mail delivery, etc.); Although one HPV self-sampling device (Quintip) is registered in Ukraine, it is not widely available. Thus, despite regulatory recognition, HPV self-sampling remains largely unimplemented in practice. Recommendations for overcoming barriers To ensure the successful implementation of CC screening, particularly via HPV self-sampling, in Ukraine, the following steps are necessary: Expanding awareness-raising campaigns: Education of women about HPV and the benefits of self-sampling through media, family doctors, and civil society organizations; Informing healthcare providers: Training family physicians and gynecologists on the benefits and use of self-sampling; Development of clear implementation guidelines: An annex to the current Standard of Medical Care should be explicitly developed for self-sampling. It should define target groups (e.g., women who have never been screened), engagement strategies (e.g., direct offer by family doctors), preferred test types (prefer PCR), and follow-up algorithms for HPV-positive results; Improving the accessibility of self-sampling kits: Promoting their integration into primary healthcare settings. HPV self-sampling is a scientifically validated, effective, and acceptable screening method for women that can substantially increase coverage in Ukraine. However, low public awareness, psychological barriers, lack of infrastructure, and regulatory gaps continue to hinder its implementation. Drawing on international experience and local data, Ukraine can overcome these obstacles by developing clear guidance, launching educational campaigns, and coordinating efforts across government agencies, professional communities, and civil society.