Health Inequity: Bold Action and Collaboration Needed to Eradicate Cervical Cancer in Canada

Dr. Anu Rebbapragada D(ABMM) FCCM

BD-Canada is pleased to share the following blog post, the third in our Canadian Health Inequities Blog Series. This series was developed to draw attention to health inequities across Canada, as we believe that increasing awareness can improve the health outcomes for those affected most. The first post in this series, How do Social Determinants Create Instances of Peripheral Arterial Disease in Canadians?, can be read here. The second post in this series, In Celebration of Her — Equity, Diversity, and Inclusion in Canadian Breast Cancer Screening, can be read here.

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January is Cervical Cancer Awareness Month, an opportunity to honour the experiences of the patients, caregivers and families affected by cervical cancer and shine a light on the actions needed to address inequities that have impeded eradication efforts.

Cervical cancer is one of the few cancers that is almost completely preventable through systematic screening programs, early detection with HPV testing and vaccination. As a clinical microbiologist, public health professional and woman who has specialized in sexually transmitted infection research, implementing advanced diagnostic testing, improving healthcare access and advocating for women’s health issues, the work of eradicating cervical cancer is very close to my heart.

Our generation holds the incredible potential to seize the opportunity to eradicate cervical cancer within our lifetime.

Here are my reflections on the pivotal pillars essential to achieving the Canadian Partnership Against Cancer’s (CPAC) goal to eliminate cervical cancer in Canada by 2040:

Infection with the human papillomavirus (HPV) can initiate a cascade of cellular changes that may progress to the development of cervical cancer. Innovations in testing methodology and organized cervical cancer screening programs have led to dramatic reductions in the number of deaths and cancer diagnoses in Canada. The greatest technological leap forward is the use of molecular HPV testing, which permits early detection and promotes prompt treatment prior to the development of pre-cancerous lesions. As an early warning system, HPV testing detects persistent viral infections with the greatest likelihood of progressing towards disease, unlike the standard Pap test, which can only identify abnormal cells at a later stage in the oncogenic cancer development pathway. Extensive evidence of the superior performance of HPV testing led multiple prominent health organizations, including the World Health Organization (WHO) and CPAC, to recommend HPV testing as the primary method for cervical cancer screening.   Growing international experience with the implementation of HPV-based cervical cancer screening compelled Quebec and Prince Edward Island to update their primary screening method to HPV testing. Other jurisdictions across Canada are also actively evaluating to convert from the more commonly used, cytology-based Pap test.

Despite the availability of promising innovations, recent statistics from the Canadian Cancer Society show cervical cancer is still the fastest-increasing cancer in the country for those with a cervix. There remain an estimated 1,450 diagnoses and 380 deaths from cervical cancer in Canada annually.  Most shockingly, the rate of cervical cancer diagnoses in Canada has increased by 3.7 per cent per year since 2015, after a 30-year decline beginning in the mid-1980s.

The underlying message from these statistics is clear:

• Innovations are irrelevant if they are not implemented promptly, responsibly and equitably.
• Relying on the traditional Pap test will not bring us to our goal of eliminating cervical cancer.
• We are not doing enough to break down barriers to ensure that all eligible Canadians are being routinely screened for cervical cancer.
• Continued education on screening and vaccination is essentially critical in the arsenal against cervical cancer by empowering women to take ownership of their health.
   

Access to screening has been identified as a key pillar in the CPAC’s cervical cancer elimination strategy. However, broad access to cervical cancer screening services in Canada is far from adequate; novel strategies must be boldly implemented to overcome longstanding challenges in how women access screening services.

Numerous barriers to cervical cancer screening exist in Canada. Recent estimates of screening participation indicate that between 25% to 40% of eligible Canadians are not routinely screened for cervical cancer, depending on province and age. This falls significantly below the CPAC goal of achieving a 90% screening rate for all eligible individuals by 2030, a looming target just six years away.

A significant barrier is limited access to a physician for the collection of a cervical sample, the necessary first step to perform HPV and/or Pap testing. The COVID-19 pandemic also had an immense impact on cervical cancer screening rates in Canada; clinic and lab staff shortages led to backlogs in the collection, testing and management of cases. Since 2020, cervical cancer incidence grew three-fold higher in vulnerable populations who have limited access to screening compared to the general population. Women in remote and rural areas, for example, are more likely to have limited access to physicians for cervical cancer screening. Research also shows that women with disabilities, Black women, women born outside of Canada, women who have experienced sexual trauma, and 2SLGBTQI+ people are significantly less likely to be screened for cervical cancer than the national average. As a result, cervical cancer cases are higher in some populations, including people living in rural or remote areas, people with low incomes, and First Nations, Inuit and Métis. Updated screening programs must take these barriers into account, as 50 per cent of late-stage cervical cancers are diagnosed in women who have not been screened routinely.

The early detection benefits of HPV testing are irrelevant if women face significant barriers just to access a physician and have no alternate means to collect a sample necessary to perform HPV testing. To effectively address these inequities and truly be bold in our goal to eradicate cervical cancer, Canada must embrace emerging evidence-based technology to ensure the long-term return on investment with our country’s cervical cancer screening program.

The implementation of HPV testing as the primary screening method for cervical cancer is an important first step toward the cancer eradication goal. However, a comprehensive program must also explore the benefits of all available tools for safe self-collection of quality samples and their secure transportation for HPV testing. A precedent already exists with the use of home-based self-collected samples for fecal immunochemical testing (FIT) for the colon (bowel) cancer screening program.

As a complement to updating collection methods, culturally sensitive outreach is essential to educate women about the safety, acceptability and accuracy of HPV testing with self-collected samples. Education fosters buy-in for embracing self-collection as an effective solution to overcome barriers like remote geographical location, physician shortages and personal restrictions.

Great strides have been made in developing and deploying new testing and treatment tools, dramatically reducing both incidence and mortality. However, there’s still a long journey ahead to reach our goal of eliminating cervical cancer in the next 16 years. While I believe this goal is feasible, it requires immediate and updated actions.

An evolved, practical approach to cervical cancer requires strategies that responsibly harness technologies that improve diagnostic quality, overcome persistent gaps that impede access to screening services, enhance personalized management pathways, and proactively prepare for emerging risks.

A robust strategic plan includes:

• Advanced HPV test design and automated platforms for accurate and efficient high-quality screening
• Tools to improve access to HPV testing services, particularly for “under screened” women who bear the greatest likelihood of harbouring undetected disease
  
• Multi-valent vaccines that target a broad panel of oncogenic high-risk HPV types
  
• Risk-based triage algorithms for personalized management based on updated epidemiological and clinical evidence on HPV type-specific disease progression
  
• Enhanced education to ensure higher vaccination and screening rates

We need to remember that there is a cost to doing nothing, even if it is not immediately perceived. Every missed screening incurs a cost to the patient, physician and health system. Paramount is the human cost of delayed detection and the unnecessary development of complications that necessitate complex invasive procedures and lost quality of life. Canadian provinces must take decisive action to implement a widespread, barrier-free and comprehensive cervical cancer screening program. The lives of this generation of women, the quality of life for those who depend on them and their contribution to society are dependent on a well-designed cervical cancer screening program.

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Dr. Anu Rebbapragada has led the implementation of advanced HPV diagnostic testing and has served as a key opinion leader and advisor on cervical cancer screening and HPV testing at various cancer agencies across Canada. Over the course of her 15-year career, Dr. Rebbapragada has conducted numerous studies on the epidemiology of high-risk HPV infections in different Canadian populations, the performance of various HPV detection tests and alternate sample collection options. She is at the forefront of developing strategies to improve diagnostic access and led a pilot program that evaluated the feasibility, acceptability and accuracy of utilizing self-collection to obtain specimens from under screened populations for HPV detection. Her research has generated numerous publications, grant funding and awards, including the Ontario Innovation Award to evaluate HPV vaccine effectiveness.

References:

1. Access Alliance Multicultural Health and Community Services. Addressing Cervical Cancer Screening Inequity among Newcomer Women via HPV Self-Sampling | Alliance pour des communautés en santé. www.allianceon.org. Accessed December 28, 2023. https://www.allianceon.org/fr/resource/Addressing-Cervical-Cancer-Screening-Inequity-among-Newcomer-Women-HPV-Self-Sampling
2. Canadian Partnership Against Cancer. Canadian Strategy for Cancer Control Doing Together What Cannot Be Done Alone.; 2019. Accessed December 28, 2023. https://s22457.pcdn.co/wp-content/uploads/2019/06/Canadian-Strategy-Cancer-Control-2019-2029-EN.pdf
   
3. Haward B, Tatar O, Zhu P, et al. Are Canadian Women Prepared for the Transition to Primary HPV Testing in Cervical Screening? A National Survey of Knowledge, Attitudes, and Beliefs. Current Oncology. 2023;30(7):7055-7072. https://doi.org/10.3390/curroncol30070512
   
4. Lofters A, Devotta K, Prakash V, Vahabi M. Understanding the Acceptability and Uptake of HPV Self-Sampling Amongst Women Under- or Never-Screened for Cervical Cancer in Toronto (Ontario, Canada): An Intervention Study Protocol. International Journal of Environmental Research and Public Health. 2021;18(17):9114. https://doi.org/10.3390/ijerph18179114
   
5. Persaud N, Sabir A, Woods H, et al. Preventive care recommendations to promote health equity. CMAJ. 2023;195(37):E1250-E1273. https://doi.org/10.1503/cmaj.230237
   
6. Subramaniam A, Fauci J, Schneider K, et al. Invasive Cervical Cancer and Screening: What are the Rates of Unscreened and Underscreened Women in the Modern Era? Journal of lower genital tract disease. 2011;15(2):110-113. https://doi.org/10.1097/LGT.0b013e3181f515a2