Rare Today, Common Tomorrow: Strengthening Cervical Cancer Prevention in Low-Incidence Countries is Urgently Needed

Dear Editor, The worldwide incidence and mortality of cervical cancer are 14.1 and 7.1 per 100,000 women, respectively.[1] This means that every 47 seconds a woman is diagnosed with cervical cancer and every 90 seconds a woman dies of cervical cancer. The World Health Organization (WHO) launched the 90-70-90 strategy in 2020 with the goal of reducing the cervical cancer incidence worldwide below 4 per 100,000 women by 2030.[2] The 90-70-90 strategy encompasses: (1) vaccination: 90% of girls fully vaccinated with the HPV vaccine by age 15; (2) screening: 70% of women screened using a high-performance test by age 35, and again by age 45; and (3) treatment: 90% of women with precancer treated and 90% of women with invasive cancer managed.[2] There are already ten countries in the world where cervical cancer is a rare disease (<4 per 100,000) [Table 1]. Surprisingly, all these countries have low screening coverage and very low HPV vaccination coverage. They are all Muslim-majority countries with mixed income status. The mortality-to-incidence ratio (M/I ratio) in these countries is more than 50%, in contrast to Europe, where the ratio is 37% (mortality: 3.9, incidence: 10.6).[1] A high M/I ratio indicates that cancers are detected at advanced stages when they become symptomatic. Current projections indicate a concerning rise in cervical cancer mortality by 2040 compared to 2020: in Iraq (113.5%), Jordan (91.5%), and Lebanon (55%).[3]Table 1: Characteristics of countries where cervical cancer is currently a rare disease[ 1 , 3 , 5 , 8-15 ]The prevalence of HPV in Iran differs according to province and is estimated between 4.2% and 40.4%.[4,5] The prevalence of high-risk HPV infection among Iranian women has been increasing in recent years, especially in young age groups, and has become comparable to those in the rest of the world. The Westernization undoubtedly lies at the root of this change. Meta-analyses among Iranian women and unvaccinated women worldwide with normal cytology report HPV prevalence rates of 9% and 10.4%, respectively.[6,7] Due to societal changes that cannot be halted, the incidence of cervical cancer is expected to rise dramatically in countries with historically low incidence rates. For instance, the incidence rate in Kuwait is projected to increase by 48% by 2035.[3] Every effort must be made to prevent this rise in cervical cancer and other HPV-related cancers. Primary (HPV vaccination) and secondary (screening) prevention options have the capacity to achieve this. HPV vaccine awareness and acceptance in these countries should increase, together with the integration of the HPV vaccine into national immunization programs.[8,9] Similarly, secondary prevention programs should be implemented and fully integrated into national prevention strategies. Even in countries where cervical cancer is currently a rare disease, urgent adaptation of prevention programs is needed to avoid a dramatic rise in cervical cancer incidence and other HPV-related diseases. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.