In November 2020, following two years of consultation and development, WHO formally launched the ‘Global strategy to accelerate the elimination of cervical cancer as a public health problem'. The strategy provides a pathway to the global elimination of cervical cancer as a public health problem (target incidence of <4 per 100,000) within a century. It has been made possible by advances in the understanding of cervical cancer as a preventable cancer caused by oncogenic human papillomavirus (HPV) and new technology that can be implemented at the population level enabling 1) primary prevention through HPV vaccination and 2) more effective and accessible secondary prevention through HPV-based cervical screening, in the context of 3) effective treatment modalities being established for cervical precancer and early-stage invasive cancer. When vaccination and screening is combined with timely diagnosis and treatment services for cervical cancer, the end to the enormous global suffering caused by the fourth most common female cancer with a disproportionate burden in lower income settings, will finally be in reach. Under the WHO strategy, countries are invited to commit to achieving coverage targets by 2030 in the implementation of strategies for primary and secondary prevention in the context of comprehensive cancer treatment. These so-called '90/70/90' targets are:

1. 90% of girls fully vaccinated with HPV vaccine by age 15
2. 70%+ of women screened with a high-performance test (such as HPV) by age 35 and again by 45
3. 90%+ of women with screen-detected precancer and 90%+ of women with cervical cancer treated

Australia is a long-standing world leader in cervical cancer prevention and control, having achieved a halving of incidence and mortality through the cytology-based National Cervical Screening Program first implemented in 1991 (see Box for timeline); and the world’s first national HPV vaccination program in 2007 (see Box for timeline), which has seen rates of HPV infection and cervical precancerous lesions plummet (1). With the transition from cytology to HPV based screening in December 2017 (projected to further reduce cervical cancer incidence rates by 20-30%) and the introduction of the nonavalent HPV vaccine in 2018 (protecting against ~90% of cancer-causing HPV types), Australia is expected to be the first country to achieve WHO’s definition of cervical cancer elimination as a public health problem, potentially as early as 2028 (2). In November 2023, Australia launched its national strategy for the elimination of cervical cancer as a public health problem (3) with a focus on equity and 2030 scale up targets extended beyond the WHO targets to aim for 90% of both girls and boys vaccinated, 70% of women aged 25-75 years screened every 5 years and a 95%  target for treatment of precancer and cancer.

Australia has also been a world leader in research and surveillance documenting the impact of control programs for cervical cancer. Since 2018, Australian public health and clinical researchers have been collaborating in the NHMRC-funded Centre of Research Excellence in Cervical Cancer Control (C4). Partners include many investigators who have been collecting, analysing and reporting key epidemiological information about the occurrence of cervical cancer and its precursors. The resources of C4 and its partner organisations have been used in consultation with key stakeholders, to deliver our 3rd comprehensive report, on Australia’s progress towards the elimination of cervical cancer as a public health problem. The report is based on 11 key indicators grouped into 4 components (see Table 1) framed by the WHO ‘90/70/90’ 2030 scale up targets for elimination, derived from the most recently available data. Twin goals of the report are to monitor progress towards achievement of targets and to provide recommendations for improving the quality, availability and timeliness of indicator data. 

 

 

Italics indicate that these are the WHO 2030 scale up indicators

 

* Indicators are reported, whenever appropriate data were available, broken down by Indigenous status, 5-year age groups, socioeconomic groups (according to Socio-Economic Indexes for Areas [SEIFA] Index of Relative Socio-Economic Disadvantage for 2016 (5)); remoteness area (according to Australian Statistical Geography Standard [ASGS] for 2016 (7)), and jurisdiction. Socioeconomic groups, remoteness area and jurisdiction were assigned based on residential postcode, and for population denominators were estimated based on SA2.

 

Timeliness is an issue for cancer incidence data. The 4-5 year lag nationally in cancer incidence reporting has meant it is still unclear whether (as predicted by modelling (4)) HPV vaccination is already impacting cervical cancer rates in young women. There also remain limitations with data on high-grade disease due to ongoing under-enumeration of histopathology reports held in the NCSR, and known incomplete data for 2018.

For the cervical screening related indicators (including screening participation, colposcopy, precancer treatment and high-grade cervical disease detection), we were unable to report outcomes for Indigenous women. In some cases (screening participation), this was due to incomplete Indigenous status data, but in other cases because data were available for analysis but not publication. We are encouraged by the recent publication of some additional program data for Indigenous women in the 2023 program monitoring report given the unacceptable persisting higher incidence and mortality from cervical cancer amongst Indigenous women. We hope that we will be able to publish these indicators by Indigenous status in our next report. The move to a national screening register and program change to support the renewed program provided a tangible opportunity to correct this long-standing data and reporting deficiency. Data completeness has improved (although Indigenous status is under-reported to Medicare with variation by age group, gender and jurisdiction and, for last reported Indigenous status, 26.7% of screening participants recorded ‘not stated’ on the NCSR (21.6% 'not stated' for most recent and historical sources combined) (Table 4.1, 2023 AIHW monitoring report)) (1), but these data remain largely unpublished. Longstanding systemic barriers to the collection and reporting of Indigenous status still need to be overcome, whilst also acknowledging the barriers experienced by many Indigenous people to self-disclosure of their Indigenous identity given the ongoing impacts of colonisation and intergenerational trauma.

1 Australian Institute of Health and Welfare. National Cervical Screening Program monitoring report 2021. Cancer Series 134. Cat. no: CAN 141 Canberra: AIHW; 2021.

2 Hall MT, Simms KT, Lew JB, et al. The projected timeframe until cervical cancer elimination in Australia: a modelling study. Lancet Public Health 2019; 4(1): e19-e27.

3 Australian Centre for the Prevention of Cervical Cancer. National Strategy for the Elimination of Cervical Cancer in Australia. November 2023. Available at: https://www.health.gov.au/resources/publications/national-strategy-for-the-elimination-of-cervical-cancer-in-australia?language=en  

4 Hall MT, Simms KT, Lew JB, et al. Projected future impact of HPV vaccination and primary HPV screening on cervical cancer rates from 2017-2035: Example from Australia. PLoS One 2018; 13(2): e0185332.