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 (3). 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 (4).

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 this comprehensive report, planned to be the first in a regular series, 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

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 (8)) HPV vaccination is already impacting cervical cancer rates in young women, whereas Sweden documented this impact more than a year ago with a population smaller than Australia’s with timely linked data (9). 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.

Unlike the previous report, we have been able to report on this the proportion of those with high-grade cervical abnormalities detected who are treated. To our knowledge, this is the first time that this has been reported in Australia. Reassuringly, treatment rates are relatively high, and there was a small increase in this rate for high-grade cervical disease detected in 2020, compared to 2019, in spite of the COVID-19 pandemic impacting health services more broadly.

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. This remains a critical gap in reporting, given the unacceptable persisting higher incidence and mortality from cervical cancer amongst Indigenous women. Despite national indicators designed to ensure quality, safety and effectiveness of the program, only cervical incidence and mortality data have been reported by Indigenous status over the life of the screening program, derived from State and Territory cancer registries rather than cervical screening program data. Estimates of participation in the program and screening outcomes for Indigenous women have relied on data collection at the local level and data linkage studies, which have provided some estimates but an incomplete picture of the national situation, and all pre-date the transition to HPV screening. 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. Five years into the renewed program, 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, 28% of screening participants recorded ‘not stated’ on the NCSR (Table A1.5, 2021 AIHW monitoring report)) (3), but results from these data are not yet available for publication. Longstanding systemic barriers to the collection and reporting of Indigenous status 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.