Cervical cancer burden and elimination readiness in the US-affiliated Pacific Islands: A structured narrative review

BACKGROUND: The US-Affiliated Pacific Islands (USAPI) experience a high burden of cervical cancer, but progress toward achieving cervical cancer elimination targets is difficult to assess due to limited and fragmented data on HPV vaccination, cervical cancer screening and cancer treatment access. This narrative review aims to synthesise evidence of disease burden, risk factors, and interventions to inform region-specific strategies. METHODS: We conducted a structured narrative review of published literature (MEDLINE, Embase, Global Health), cancer registry data, surveillance reports, and health system registries for six USAPI jurisdictions from 1990 to 2025. We collated information on HPV, cervical precancers and cancers, and related risk factors. Information on HPV vaccination, cervical cancer screening, and treatment, obtained from jurisdictional health system registries and reports, was used to assess the region's trajectory towards the elimination targets. FINDINGS: Cervical cancer incidence among women aged ≥ 20 years during 2007-2022 in the USAPI (age-standardized rate:17.2/100,000;95%CI:15.6-18.8) exceeded that of the US (10.8/100,000;95%CI:10.7-10.8), with large variation across jurisdictions, from 8.4/100,000 in American Samoa to 68.9/100,000 in Republic of the Marshall Islands (RMI). Approximately 75% of cases were diagnosed at Stage III + . HPV vaccination was introduced between 2007-2016, with coverages ranging from 44.2% in Federated States of Micronesia (FSM) to 92.7% in Commonwealth of the Northern Mariana Islands (CNMI). Four jurisdictions have implemented cytology-based screening, whereas RMI/FSM primarily rely on visual inspection with acetic acid. Screening coverage varies from 14.2% (CNMI, 2019) to 67.8% (Guam, 2020). Cancer treatment capacity is limited, with most jurisdictions lacking radiotherapy and relying on off-island referrals for advanced cases. INTERPRETATION: USAPI cervical cancer burden is substantially higher than the US, compounded by late-stage diagnoses and limited treatment capacity. Although vaccination coverage has improved, major gaps remain in screening, follow-up, and access to care. Strengthening health systems through scalable, resource-appropriate strategies will accelerate progress toward elimination.