research topics on cervical cancer

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• v.32(6); 2020 Dec 31

Cervical cancer: Epidemiology, risk factors and screening

Shaokai zhang.

1 Department of Cancer Epidemiology, Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Henan Engineering Research Center of Cancer Prevention and Control, Henan International Joint Laboratory of Cancer Prevention, Zhengzhou 450008, China

Luyao Zhang

Youlin qiao.

2 Department of Epidemiology, National Cancer Center, Chinese Academy of Medical Sciences, School of Population Medicine and Public Health, Peking Union Medical College, Beijing 100021, China

Cervical cancer is one of the leading causes of cancer death among females worldwide and its behavior epidemiologically likes a venereal disease of low infectiousness. Early age at first intercourse and multiple sexual partners have been shown to exert strong effects on risk. The wide differences in the incidence among different countries also influenced by the introduction of screening. Although the general picture remains one of decreasing incidence and mortality, there are signs of an increasing cervical cancer risk probably due to changes in sexual behavior. Smoking and human papillomavirus (HPV) 16/18 are currently important issues in a concept of multifactorial, stepwise carcinogenesis at the cervix uteri. Therefore, society-based preventive and control measures, screening activities and HPV vaccination are recommended. Cervical cancer screening methods have evolved from cell morphology observation to molecular testing. High-risk HPV genotyping and liquid-based cytology are common methods which have been widely recommended and used worldwide. In future, accurate, cheap, fast and easy-to-use methods would be more popular. Artificial intelligence also shows to be promising in cervical cancer screening by integrating image recognition with big data technology. Meanwhile, China has achieved numerous breakthroughs in cervical cancer prevention and control which could be a great demonstration for other developing and resource-limited areas. In conclusion, although cervical cancer threatens female health, it could be the first cancer that would be eliminated by human beings with comprehensive preventive and control strategy.

Introduction

Cervical cancer is the second common female malignant tumor globally which seriously threatens female’s health. Persistent infection of high-risk human papillomavirus (HPV) has been clarified to be the necessary cause of cervical cancer ( 1 , 2 ). The clear etiology accelerated the establishment and implementation of comprehensive prevention and control system of cervical cancer. In May 2018, the World Health Organization (WHO) issued a call for the elimination of cervical cancer globally, and more than 70 countries and international academic societies acted positively immediately ( 3 - 6 ). Thereafter, in November 17, 2020, WHO released the global strategy to accelerate the elimination of cervical cancer as a public health problem to light the road of cervical cancer prevention and control in future which mean that 194 countries promise together to eliminate cervical cancer for the first time ( 7 ). At this milestone time point, we reviewed the update progress of cervical cancer prevention and control in epidemiology, risk factors and screening, in order to pave the way of cervical cancer elimination.

Epidemiology for cervical cancer

Cervical cancer is one of the leading causes of cancer death among women ( 8 ). Over the past 30 years, the increasing proportion of young women affected by cervical cancer has ranged from 10% to 40% ( 9 ). According to the WHO and International Agency for Research on Cancer (IARC) estimates, the year 2008 saw 529,000 new cases of cervical cancer globally. In developing countries, the number of new cases of cervical cancer was 452,000 and ranked second among malignancies in female patients ( 10 ). Conversely, the number of new cases of cervical cancer was 77,000 in developed countries and ranked tenth among female malignancies.

In 2018 worldwide with an estimated 570,000 cases and 311,000 deaths, cervical cancer ranks as the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women ( 11 ). However, approximately 85% of the worldwide deaths from cervical cancer occur in underdeveloped or developing countries, and the death rate is 18 times higher in low-income and middle-income countries compared with wealthier countries ( 12 ). Cervical cancer ranks second in incidence and mortality behind breast cancer in lower Human Development Index (HDI) settings; however, it is the most commonly diagnosed cancer in 28 countries and the leading cause of cancer death in 42 countries, the vast majority of which are in Sub-Saharan Africa and South Eastern Asia ( 13 ). The highest regional incidence and mortality rates are seen in Africa ( 14 ). In relative terms, the rates are 7−10 times lower in North America, Australia/New Zealand, and Western Asia (Saudi Arabia and Iraq) ( 15 ).

In China, cervical cancer is the second largest female malignant tumor ( 11 ). According to the data from National Cancer Center in 2015, there were 98,900 new cases and 30,500 deaths of cervical cancer ( 16 ). In the past 20 years, the incidence and mortality of cervical cancer have been increasing gradually in China ( 17 ).

Between 2004 and 2007, the Chinese scientific research team, cooperated with WHO/IARC and the Cleveland Medical Center in the United States in 8 rural and urban areas (Xiangyuan county of Shanxi Province, Yangcheng county of Shanxi Province, Xinmi county of Henan Province, Hotan Prefecture of Xinjiang Uygur Autonomous Region, Shanghai City, Beijing City, Shenzhen City of Guangdong Province, and Shenyang City of Liaoning Province), carried out a population-based multicenter HPV type distribution study among females aged 15−59 years old, clarifying the dominant HPV types of rural and urban populations in China, as well as female HPV infection status and age distribution ( 18 ). Studies have confirmed that persistent infection of high-risk HPV is closely related to the occurrence of cervical cancer. There are 14 types of high-risk HPV, namely HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68 and 73. A multi-center cross-sectional survey study showed that the infection rate of high-risk HPV in China is about 14.3%, and the dominant types are HPV16 (2.9%), HPV52 (1.7%), HPV58 (1.5%), HPV33 (1%) and HPV18 (0.8%), and showed double peaks during adolescence and perimenopause ( 19 ). Globally, HPV16 has the highest infection rate, HPV18 is the second most common type, while HPV 33 is common in Asia, and HPV52 and HPV58 have relatively low infection rates. This shows that compared with the global HPV epidemiology, HPV epidemiology in China has both similarities and differences.

Subsequently, the Chinese scientific research team conducted a cross-sectional multi-center cervical cancer and precancerous HPV genotyping study based on 19 hospitals in 7 geographic regions (Northeast China, North China, Northwest China, Central China, East China, Southwest, and South China). Through the pathological laboratory procedures of strict quality control, it was found that the dominant HPV types in cervical cancer tissue were HPV16, 18, 31, 52 and 58, respectively, and that HPV16 and 18 were the most carcinogenic, which could cause more than 84.5% of cervical cancer ( 20 ). The above research on HPV dominant types from different perspectives provides solid scientific evidence and support for the future research and application of preventive HPV vaccine and in vitro diagnostic technology, epidemiological research and health economics research in the Chinese population.

Risk factors for cervical cancer

A number of risk factors for cervical cancer are linked to exposure to the HPV ( 21 , 22 ). Invasive cancer development process could prolong up to 20 years from the precursor lesion caused by sexually transmitted HPV ( 23 ). However, there are also other numerous risk factors (such as reproductive and sexual factors, behavioral factors, etc) for cervical cancers which include sexual intercourse at a young age (<16 years old), multiple sexual partners, smoking, high parity and low socio-economic level ( 24 , 25 ).

Sexually transmitted infections (STI)

The primary cause of pre-cancerous and cancerous cervical lesions is infection with a high-risk or oncogenic HPV types. Most cases of cervical cancer occur as a result of infection with HPV16 and 18. High-risk types, especially HPV16, are found to be highly prevalent in human populations ( 22 ). The infection is usually transmitted by sexual contact, causing squamous intraepithelial lesions. Most lesions disappear after 6−12 months due to immunological intervention. However, a small percentage of these lesions remain and can cause cancer.

The results of a meta-analysis showed that the highest prevalence of HPV occurs at the age of 25 years, which could be related to changes in sexual behavior ( 26 ). In a meta-analysis study, the bimodal distribution of cervical cancer in some regions has been studied. In this distribution, immediately after sexual intercourse, an outbreak of HPV can be observed, which is followed by a plateau at adult age; the second peak again is observed after 45 years old ( 27 ). Permanent infection with one of the high-risk types of HPV over time leads to the development of cervical intraepithelial neoplasia (CIN). The major mechanisms through which HPV contributes to carcinogenesis involve the activity of two viral oncoproteins, E6 and E7, which interfere with major tumor suppressor genes, P53 and retinoblastoma. In addition, E6 and E7 are associated with changes in host DNA and virus DNA methylation. Interactions of E6 and E7 with cellular proteins and DNA methylation modifications are associated with changes in key cellular pathways that regulate genetic integrity, cell adhesion, immune response, apoptosis, and cellular control ( 28 ).

Human immunodeficiency virus (HIV)

The risk of developing infection from high-risk HPV types is higher in women with HIV ( 29 ). The results of the studies on the relationship between HIV and cervical cancer suggested a higher rate of persistent HPV infection with multiple oncogene viruses, more abnormal Papanicolau (Pap) smears, and higher incidence of CIN and invasive cervix carcinoma among people with HIV ( 23 ). Women infected with HIV are at increased risk of HPV infection at an early age (13−18 years) and are at high risk of cervical cancer. Compared with non-infected women, HIV positive patients with cervical cancer are diagnosed at an earlier age (15−49 years old) ( 30 ).

Reproductive and sexual factors

Sexual partners.

Factors relating to sexual behavior have also been linked to cervical cancer. One study found that an increased risk of cervical cancer is observed in people with multiple sexual partners ( 31 ). Moreover, many studies have also suggested that women with multiple sexual partners are at high risk for HPV acquisition and cervical cancer ( 32 , 33 ). From the meta-analysis, a significant increased risk of cervical diseases was observed in individuals with multiple sexual partners compared to individuals with few partners, both in non-malignant cervical disease and in cervical cancer ( 34 ). The association remained exist even after controlling for the status of HPV infection, which is a major cause of cervical cancer. Also, early age at first intercourse is a risk factor for cervical cancer ( 35 ).

Oral contraceptive (OC) pills

OC pills are known to be a risk factor for cervical cancer. In an international collaborative epidemiological study of cervical cancer, the relative risk in current users increased with an increase in the duration of OC use. It has been reported that the use of OC for 5 years or more can double the risk of cancer ( 36 ). And in a multi-center case-control study, among women who tested positive for HPV DNA, the risk of cervical cancer increased by 3 times if they have used OC pills for 5 years or more ( 37 ). In addition, a recent systematic review & meta-analysis also suggested that OC pills use had a definite associated risk for developing cervical cancer especially for adenocarcinoma. This study concluded that use of OC pills is an independent risk factor in causing cervical cancer ( 38 ).

Cervical cancer screening

With the background of cervical cancer elimination worldwide, cervical cancer screening plays an increased role in the comprehensive prevention and control besides HPV vaccination, especially those methods that demonstrated excellent clinical performance.

Overview of cervical cancer screening methods

The screening methods for cervical cancer are mainly as following: traditional Pap smear, visual inspection with acetic acid & Lugol’s iodine (VIA/VILI), liquid-based cytology (LBC) and HPV testing. The disease burden of cervical cancer has been significantly reduced in developed countries by Pap smear, mainly in the United States, since 1950s. However, the accuracy of traditional Pap smear could be easily affected by following factors: the level of cytological room, professional technicians, sampling method, slide quality, dyeing skills, and cytological personnel experience. In developed countries with high standard experimental conditions and technical level, the sensitivity of cytology is as high as 80%−90%, in contrast, in resource-limited regions, it could be as low as 30%−40%. To overcome the limitations of traditional Pap smear in cervical cancer screening, LBC was developed and approved by Food and Drug Administration (FDA) in 1996 for clinical-use purpose. Compared with the traditional Pap smear, the sensitivity of LBC was significantly improved. Meanwhile, organized and practicable LBC screening program has also been established in developed countries which could ensure cervical cancer screening strategy is carried out continuously and effectively.

Cervical cancer screening has been facilitated since the cause clarified. HPV-based testing is a pivotal part for cervical cancer screening besides cytology-based tests.

The detection of high-risk HPV in cervical lesion biopsies and exfoliated cells has evolved from restriction endonuclease cleavage patterns and hybridization techniques to polymerase chain reaction (PCR)-based system ( 39 ) and most recently next-generation sequencing (NGS) assays ( 40 ). Currently, HPV genotyping is primarily based on the detection of individual types by various methods that utilizing the highly conserved L1 gene and PCR-based methods. These PCR methods employed consensus primers that could target and amplify different sized fragments such as 455 bp with the MY09/11|PGMY system ( 41 ), 150 bp with the GP5+/6+ system ( 42 ), or <100 bp with SPF10 ( 43 ). And another point that is worth noting is that all these techniques remained the most validated methodology to identify and characterize clinically relevant HPV ( 44 - 46 ).

Additionally, the type-specific probes are always to be used to achieve HPV genotyping, besides DNA sequencing ( 46 , 47 ). Other types of assays may be type-specific with immediate discrimination and quantitation of specific HPV types in an “onetube” assay. These methods employ real-time (RT)-PCR techniques, coupled with beta-globin detection for internal quality control utilizing specialized detection systems ( 48 ).

Cervical cancer malignant pathways are tightly correlated to the viral E6 and E7 oncoprotein activities which could also contribute to the accumulation of cellular genomic mutations and viral integration ( 47 ). Therefore, identification of HPV E6/E7 mRNA has been shown to be promising in cervical cancer screening. And most of the assays utilized reverse transcriptase PCR or nucleic acid sequence-based amplification to identify E6/E7 genome fragments ( 49 ).

Recently, the correlation between increased HPV CpG site methylation levels and high-grade cervical lesions has also been demonstrated in numerous studies and has facilitated the development of quantitative assays targeted CpG methylation ( 50 , 51 ). . Studies indicate that NGS assays can provide single-molecule CpG methylation levels to help unravel the mechanism of methylation in cervical cancer development ( 39 , 50 ).

The application of HPV detection has accelerated the transition of cervical cancer screening from morphology to molecular biology. HPV testing was initially used as a triage method for the reflex triage of population with atypical squamous cells of undetermined significance (ASC-US). In 2014, FDA approved HPV detection for the use in cervical screening. Thereafter, HPV detection plays an increasingly important role in the practice of cervical cancer screening. At present, more than 425 HPV testing has been developed worldwide, of which more than 150 is from China. To restrict and standardize HPV testing market, China released guidelines for the clinical performance evaluation for HPV testing against clinical endpoints in 2015. In other countries, it is also necessary to set similar regulations in consideration that 59.7% of HPV tests on the global market without a single peer-reviewed publication ( 49 ). To improve the coverage of cervical cancer screening, HPV testing that is rapid, simple, inexpensive could be more popular and can further promote the application in practice. In 2008, care HPV was developed in China, which demonstrated excellent performance in screening, although it was easy to use, cheap, fast and friendly to the laboratory requirements ( 52 , 53 ). In 2018, the care HPV achieved the pre-qualification certification issued by WHO, which was expected to benefit more people in developing countries and resource-poor areas such as Africa and Southeast Asia ( 54 ). In addition, the cost-effective reflex triage, referral of women, and management strategies appropriate to various resource level areas were also in evaluation ( 55 - 58 ).

In recent years, with the rapid development of science and technology, the application of artificial intelligence (AI) based products is booming. In cervical cancer prevention and control, AI also showed to be promising in cytology-based screening and colposcopy examination based on the image pattern recognition ( 59 , 60 ). These AI-based technology or system can intelligently identify lesions and assist medical staff in clinical examination and diagnosis which could alleviate difficulties in diagnosis in primary clinics.

Screening practice in China

In China, cervical cancer screening started since 1990s, although late compared with Western countries, China still achieved great breakthroughs. Common screening methods were introduced into China for the first time after clinical performance evaluation in high-risk areas which included HPV DNA detection (Hybrid Capture II, HC2), LBC and visual inspection with VIA/VILI ( 61 - 63 ). At the same time, these studies also further made it clear that “one or more HPV tests in a lifetime for cervical cancer screening could be feasible in developing countries” which had important impact on the clinical practice of cervical cancer screening in China and even in the world.

In July 2019, the State Council issued the “Healthy China Action (2019−2030)” plan, emphasizing the need to move forward the diagnosis and treatment and optimize the allocation of medical resources, from the treatment-centered to the health-centered, and to improve health level of the whole people. The program also clearly points out that cervical cancer screening coverage rate needs to reach more than 80% by 2030 ( 64 ), indicating the importance and severity of cervical cancer prevention and control.

Finally, the achievements of scientific research should be able to be developed into products and applied in practice. Based on the experience and study findings, two “National Demonstration Base for Early Diagnosis and Treatment of Cervical Cancer” were set up in Shenzhen Maternal and Child Health Hospital (City type) and Xiangyuan Maternal and Child Health Hospital (Rural type) in Shanxi Province in February 2005 ( 65 ). Thereafter, National Health and Family Planning Commission of China and China Women’s Federation launched cervical cancer and breast cancer screening program for women aged 35−64 years old in rural areas in 2009 ( 66 ), which was also one of the major public health service projects in China organized by national government. Different screening and management strategies have been set up for various resource-level regions. Up to 2017, the project has offered cervical cancer screening for 73.99 million women. Currently, the project has covered 1,501 counties ( 67 ). Meanwhile, China has developed effective cervical cancer prevention and control network which covered screening, diagnosis to treatment, follow-up and rehabilitation step by integrating government support and leadership, multi-sectors’ cooperation, professional personnel support and whole society participation. In 2017, Chinese Preventive Medicine Association released the “Guideline for Comprehensive Prevention and Control of Cervical Cancer” to further promote the standardized and development of cervical cancer prevention and control in China ( 68 ).

The priority of public health measures for cancer prevention and control reflects the government and society’s attention to public’s health, especially in resource-limited areas, and also reflects the civilization and progress of a country and society.

A large number of studies around the world have confirmed that cervical cancer could be prevented and controlled well by screening and early treatment. And it has been widely recognized if only considering the effect of cancer screening. However, the screening methods or solutions with the best effect may be not the best one. In the case of limited health resources, it is necessary to analyze and compare the input and output of different programs from the perspective of health economics which included how to scientifically determine the initial age of screening and time interval, select appropriate screening programs according to local health resources, and focus on cancer intervention in order to maximize the use of limited health resources. And then, we could determine the screening solution that not only has a good effect of disease prevention and control, but also is in line with the principle of cost-effectiveness.

Conclusions

The disease burden of cervical cancer has decreased significantly in developed countries and regions in last decades, however it is still serious in less developed countries and regions, and effective preventive measures in these areas still face serious challenges. At present, there are various available prevention and control measures that are cost-effective and scientific evidence-based to meet the needs of areas with different economic levels. It is gratifying to note that the globe has achieved a strategic consensus on the elimination of cervical cancer and also has developed and released the global strategy to accelerate the elimination of cervical cancer. Although the global elimination of cervical cancer has a long way to go, it is believed that through large-scale continuous promotion and widely use of existing effective prevention and control measures, cervical cancer will become the first cancer eliminated by human beings.

Acknowledgements

This study was supported by grants from the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (No. 2017-I2M-B&R-03 and No. 2016-I2M-1-019).

Conflicts of Interest : The authors have no conflicts of interest to declare.

Cervical Cancer Research

For some people with early-stage cervical cancer, a surgical procedure called a simple hysterectomy may be a safe and effective alternative to treatment with a radical hysterectomy, results from the SHAPE trial show.

It may be worthwhile for some individuals between ages 65 and 69 to get tested for HPV, findings from a Danish study suggest. Specifically, the testing may help prevent cervical cancer among those who haven’t had cervical cancer screening for at least 5 years.

One dose of the HPV vaccine was highly effective in protecting young women against infection from high-risk HPV types, a study in Kenya found. A single dose would make HPV vaccines more accessible worldwide, reducing cervical cancer’s global burden.

The rates of timely cervical cancer screening fell between 2005 and 2019, researchers found, and disparities existed among groups of women. The most common reason for not receiving timely screening was lack of knowledge about screening or not knowing they needed screening.

Fewer women with early-stage cervical cancer are having minimally invasive surgery, including robotic, as part of their treatment, a new study shows. The shift toward more open surgeries follows the release of results from the LACC trial in 2018.

Widespread HPV vaccine use dramatically reduces the number of women who will develop cervical cancer, according to a study of nearly 1.7 million women. Among girls vaccinated before age 17, the vaccine reduced cervical cancer incidence by 90%.

Updated cervical cancer screening guidelines from the American Cancer Society recommend HPV testing as the preferred approach. NCI’s Dr. Nicolas Wentzensen explains the changes and how they compare with other cervical cancer screening recommendations.

In a new study, an automated dual-stain method using artificial intelligence improved the accuracy and efficiency of cervical cancer screening compared with the current standard for follow-up of women who test positive with primary HPV screening.

More than a decade after vaccination, women who had received a single dose of the HPV vaccine continued to be protected against infection with the two cancer-causing HPV types targeted by the vaccine, an NCI-funded clinical trial shows.

Women with cervical or uterine cancer who received radiation to the pelvic region reported side effects much more often using an online reporting system called PRO-CTCAE than they did during conversations with their clinicians, a new study shows.

A research team from NIH and Global Good has developed a computer algorithm that can analyze digital images of the cervix and identify precancerous changes that require medical attention. The AI approach could be valuable in low-resource settings.

A new test can help to improve the clinical management of women who screen positive for HPV infection during routine cervical cancer screening, an NCI-led study has shown.

FDA has approved pembrolizumab (Keytruda) for some women with advanced cervical cancer and some patients with primary mediastinal large B-cell lymphoma (PMBCL), a rare type of non-Hodgkin lymphoma.

By comparing the genomes of women infected with a high-risk type of human papillomavirus (HPV), researchers have found that a precise DNA sequence of a viral gene is associated with cervical cancer.

Investigators with The Cancer Genome Atlas (TCGA) Research Network have identified novel genomic and molecular characteristics of cervical cancer that will aid in subclassification of the disease and may help target therapies that are most appropriate for each patient.

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Cervical Cancer: Latest Research

ON THIS PAGE: You will read about the scientific research being done to learn more about cervical cancer and how to treat it. Use the menu to see other pages.

Doctors are working to learn more about cervical cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the best diagnostic and treatment options for you.

Improved detection and screening methods. Because cervical cancer is highly treatable when detected early, researchers are developing better ways to detect precancer and cervical cancer. For example, fluorescent spectroscopy is the use of fluorescent light to detect changes in precancerous cervix cells.

Human papillomavirus (HPV) prevention. As discussed in the Screening section, HPV vaccines help prevent infection from the HPV strains that cause most cervical cancers. Gardasil is also approved by the U.S. Food and Drug Administration (FDA) for boys and men ages 9 through 26 to prevent genital warts. Researchers are looking at the impact of the HPV vaccine on boys to reduce the risk of HPV transmission.

Immunotherapy. As explained in Types of Treatment , immunotherapy is a systemic therapy using medication designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. For people who already have cervical cancer, a therapeutic vaccine is being developed. This type of vaccine helps "train" the immune system to recognize cervical cancer cells and destroy them. Learn more about immunotherapy .

Fertility-preserving surgery. Research continues to focus on improving surgical techniques and finding out which patients can be treated successfully without losing their ability to become pregnant and have children. Learn more about fertility preservation .

Targeted therapy. As explained in Types of Treatment , targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. Targeted drugs called angiogenesis inhibitors that block the action of a protein called vascular endothelial growth factor (VEGF) have been shown to help people live longer if they have cervical cancer that has spread to other parts of the body. VEGF promotes angiogenesis, which is the formation of new blood vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of angiogenesis inhibitors is to “starve” the tumor. Learn more about angiogenesis inhibitors and targeted treatments .

Combination therapy. Some clinical trials are exploring different combinations of immunotherapy, radiation therapy, and chemotherapy.

Palliative and supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current cervical cancer treatments to improve comfort and quality of life for patients.

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Cervical cancer articles within Nature Reviews Clinical Oncology

Review Article | 17 May 2024

Epidemiology of HPV-associated cancers past, present and future: towards prevention and elimination

Lessons from the prevention of cervical cancer, the first cancer type deemed amenable to elimination, can provide information on strategies to manage other cancers. Infection with human papillomavirus (HPV) causes virtually all cervical cancers and an important proportion of other cancer types. The authors of this Review discuss the epidemiology of HPV-associated cancers and the potential for their elimination, focusing on the cofactors that could have the greatest effect on prevention efforts and health equity.

• Talía Malagón
• , Eduardo L. Franco
•  &  Salvatore Vaccarella

Research Highlight | 02 April 2024

Pembrolizumab plus chemoradiotherapy effective in locally advanced cervical cancer

• Peter Sidaway

Research Highlight | 06 March 2024

Non-inferiority of simple versus radical hysterectomy in low-risk cervical cancer

• Diana Romero

Research Highlight | 18 December 2023

Neoadjuvant chemoimmunotherapy is effective in locally advanced cervical cancer

Research Highlight | 25 February 2022

Benefit with cemiplimab in cervical cancer

Research Highlight | 06 October 2021

Pembrolizumab tunes up chemotherapy in cervical cancer

Research Highlight | 29 January 2021

SCRT for early stage cervical cancer

• David Killock

In Brief | 20 December 2018

TIL infusions effective in HPV-associated cancers

Research Highlight | 21 November 2018

Less invasive is not always better

News & Views | 11 April 2017

Novel molecular subtypes of cervical cancer — potential clinical consequences

The Cancer Genome Atlas Research Network recently published the most comprehensive, multi-omic molecular characterization of cervical cancers performed to date. The data reveal novel disease subtypes, and provide new insights into the aetiology and pathogenesis of cervical cancer. Importantly, the information obtained has potentially major clinical implications.

• Chris J. L. M. Meijer
•  &  Renske D. M. Steenbergen

Research Highlight | 13 October 2015

Therapeutic HPV vaccine holds promise

Opinion | 01 September 2015

HPV-FASTER: broadening the scope for prevention of HPV-related cancer

Human papillomavirus (HPV)-screening technologies and HPV vaccination are revolutionizing the management of cancers related to this virus, in particular, cervical neoplasms. At present, however, the effectiveness of these modalities is not optimal, owing to the limited scope of HPV-vaccination and cervical screening programmes. In this Perspectives, an international panel of experts describes for the first time a new campaign, termed 'HPV-FASTER', which aims to broaden the use of HPV vaccination coupled with HPV testing to women aged up to 30 years, and in some settings up to 50 years, with the aim of accelerating the reduction in the incidence of HPV infections and cervical cancer. The authors describe the evidence supporting this approach and details on how it might be implemented, discuss the opportunities—particularly in low-resource settings—and challenges associated with the strategy, and highlight key research gaps that need to be addressed in future studies.

• F. Xavier Bosch
• , Claudia Robles
•  &  Jack Cuzick

In Brief | 23 June 2015

Less than three doses of HPV-16/18 prevents HPV infection

News & Views | 02 June 2015

Squamocolumnar junction ablation—tying up loose ends?

Despite the commercialization of HPV vaccines, cervical cancer remains a major cause of death, especially in developing countries. Recent data implicate a discrete population of cells within the cervical squamocolumnar junction in the pathogenesis of cervical precancerous lesions, indicating that ablation of these cells might reduce the rate of cervical cancer in high-risk populations.

• Michael Herfs
•  &  Christopher P. Crum

News & Views | 24 February 2015

New standard of care—HPV testing for cervical cancer screening

High-risk human papillomavirus (hrHPV) types cause cervical cancer. Hence, a negative hrHPV test provides excellent reassurance against cervical precancer and cancer, superior to a negative cervical smear (Papanicolaou or Pap) test. Screening first for hrHPV might improve the accuracy and positive predictive value of secondary Pap testing in hrHPV-positive women, and thus guide decisions on what care is needed.

• Philip E. Castle

Research Highlight | 17 February 2015

Survival benefit and quality of life

• Lisa Hutchinson

Research Highlight | 09 December 2014

From ENA 2014

News & Views | 08 April 2014

Further delineating bevacizumab's response spectrum

The use of antiangiogenic drugs, such as bevacizumab, represents an appealing intervention against cancer. However, not all malignancies are equally responsive to such treatment. Recent trials demonstrate the efficacy of this drug for advanced-stage cervical cancer and, despite limitations, bevacizumab provides an important clinical respite for most patients with progressive glioblastoma.

• David A. Reardon
•  &  Patrick Y. Wen

Year in Review | 21 January 2014

Screening comes of age and treatment progress continues

In 2013, studies confirmed that HPV infection of target cells predisposes to cervical (pre)cancer. In developed countries, HPV screening revealed superior protection than cytology screening. In India, visual inspection of the cervix after acetic acid application significantly reduced cervical cancer mortality after 12 years. Improved survival for women with advanced disease was observed after adjuvant bevacizumab.

•  &  Peter J. F. Snijders

In Brief | 30 July 2013

Declining use of brachytherapy for cervical cancer in USA

Research Highlight | 18 June 2013

Advances in cervical cancer screening and treatment

• Rebecca Kirk

Review Article | 04 June 2013

Clinical trials of human papillomavirus vaccines and beyond

Highly efficacious vaccines are available to protect against persistent human papillomavirus (HPV) infection and, therefore, the associated neoplasias (most notably cervical cancer). This Review article discusses the two approved vaccines in terms of their structure, mode of action, efficacy, cross-reactivity with non-vaccine HPV types, safety and use in vaccination programmes.

• Matti Lehtinen
•  &  Joakim Dillner

News & Views | 11 September 2012

Cervical cancer—should we abandon cytology for screening?

Convincing data have shown that human papillomavirus (HPV)-DNA testing predicts the development of high-grade cervical cancer better than cytology. However, for HPV-positive women, triage with cytology testing should be performed before colposcopy. The question on how to proceed if the cytology test in HPV-positive women is negative remains unclear.

•  &  Johannes Berkhof

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More evidence supporting human papillomavirus testing

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• Published: 31 January 2017

Women’s knowledge and attitudes towards cervical cancer prevention: a cross sectional study in Eastern Uganda

• Trasias Mukama 1 ,
• Rawlance Ndejjo   ORCID: orcid.org/0000-0001-9263-557X 1 ,
• Angele Musabyimana 2 ,
• Abdullah Ali Halage 1 &
• David Musoke 1  

BMC Women's Health volume  17 , Article number:  9 ( 2017 ) Cite this article

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Cervical cancer is a leading cause of morbidity and mortality among women in Uganda, often due to late disease diagnosis. Early screening for the cancer has been shown to be the most effective measure against the disease. Studies conducted elsewhere have reported the lack of awareness and negative attitudes towards cervical cancer as barriers to early screening. This study assessed the knowledge and attitudes of Ugandan women about cervical cancer prevention with the aim of informing prevention and control interventions.

This study was conducted in Bugiri and Mayuge districts in eastern Uganda. It was a cross-sectional community based survey and collected data by means of a questionnaire. A total of 900 women aged 25–49 years participated in the study. Women’s knowledge and attitudes towards cervical cancer prevention were assessed and scored. Data were analysed using STATA 12.0 software. Bivariate and multivariate analyses were carried out to establish the relationship between knowledge levels and demographic characteristics.

Most (794; 88.2%) of the respondents had heard about cervical cancer, the majority (557; 70.2%) having received information from radio and 120 (15.1%) from health facilities. Most women (562; 62.4%) knew at least one preventive measure and (743; 82.6%) at least one symptom or sign of the disease. The majority (684; 76.0%) of respondents perceived themselves to be at risk of cervical cancer, a disease most (852; 94.6%) thought to be very severe. Living in peri-urban areas (AOR = 1.62, 95% CI: 1.15 – 2.28), urban areas (AOR = 3.64, 95% CI: 2.14 – 6.19), having a higher monthly income (AOR = 0.50, 95% CI: 0.37 – 0.68) and having had an HIV test (AOR = 1.99, 95% CI: 1.34–2.96) were associated with level of knowledge about cervical cancer prevention.

Although general knowledge about cervical cancer prevention was relatively high among women, and attitudes mostly encouraging, specific knowledge about screening was low. There were also undesirable perceptions and beliefs regarding cervical cancer among respondents. There is therefore need for more education campaigns to bridge identified knowledge gaps, and scale up of cervical cancer screening services to all women to increase service uptake.

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Cervical cancer is the second most common cancer among women in the developing world and is responsible for 230,200 deaths and 444,500 cases annually [ 1 – 3 ]. It is a major cause of morbidity and mortality in resource-poor settings where access to cervical cancer screening and vaccination is limited [ 4 , 5 ]. Over 80% of cervical cancers in sub-Saharan Africa are detected in late stages, predominantly due to lack of information about the disease and lack of screening services [ 4 , 5 ]. Consequently, women with cervical cancer in this region are not identified until they are at an advanced stage of disease which is associated with low survival rates [ 6 ]. East Africa has the highest age-standardised incidence rates for cervical cancer at 42.7 per 100,000 women per year [ 2 ]. In Uganda, an estimated 33.6% of women in the general population harbour human papillomavirus, a necessary cause of cervical cancer, and 44 per 100,000 women develop the disease every year [ 7 ]. With 3,915 women diagnosed with cervical cancer annually, Uganda ranks 14 th among countries with the highest incidence rates [ 7 ]. Amongst Ugandan women of reproductive age, the risk of developing cancer is high.

Although Uganda lacks a cervical cancer screening policy, the ministry of health’s strategic plan for cervical cancer prevention and control aimed to reach 90% of Ugandans with information education and communication materials about cervical cancer and to screen up to 80% of eligible women aged 25–49 years [ 8 ]. These efforts led to establishment of cervical cancer screening centres in national and regional referral hospitals, private-not-for-profit and private-for-profit hospitals. This notwithstanding, access to cervical cancer screening services remains limited especially for rural women. The success of a cervical cancer screening programme depends on access and uptake, the quality of screening tests, the adequacy of follow-up, and diagnosis and treatment of pre-cancerous and cancerous lesions detected.

Available evidence so far suggests that cervical cancer services have not been optimally utilised in Uganda. For instance, a recent study conducted in central Uganda found that only 7% of women had ever been screened for cervical cancer [ 9 ] while another in Eastern Uganda reported 4.8% [ 10 ]. Several factors, both individual and attitudinal influence women’s decision to undergo cervical cancer screening [ 9 ]. Studies show that having sufficient knowledge about cervical cancer and screening programmes increase acceptance, and uptake of available screening services [ 11 – 13 ]. Although knowledge plays a critical role in influencing a woman’s decision to screen, some women, nevertheless do not undergo screening. For example, studies conducted among health workers, who are expected to be knowledgeable, have also found low screening uptake rates [ 14 , 15 ]. Therefore, women’s attitudes towards cervical cancer and screening are equally important. Attitude regarding perceived risk, screening methods used, perceived pain during screening have been suggested to influence decisions to undergo the procedure [ 9 , 12 , 15 ]. Data on the knowledge and attitudes of women towards cervical cancer prevention in eastern Uganda is limited. This study determined women’s knowledge and attitudes towards cervical cancer prevention as determinants for utilization of preventive services.

Study design and area

This was a cross-sectional study conducted using a community based questionnaire survey which collected quantitative data. The questionnaire was administered by research assistants to women who were found in their homes. The study was conducted in Bugiri and Mayuge districts in eastern Uganda. The districts are approximately 150 km from Kampala, the capital city of Uganda. Bugiri and Mayuge districts are predominantly rural with most residents involved in subsistence farming with emphasis on crop growing as the main economic activity. The districts are located along the shores of Lake Victoria and communities that border with the lake are involved in fishing. Other residents who live in small towns and trading centres within the districts are involved in small scale businesses. The majority of people in the districts reside in roofed mud and wattle houses. Bugiri is composed of nine sub-counties while Mayuge has seven sub-counties. Both districts have an estimated combined population of 856,152 people of whom 51.4% are females [ 16 ] and a combined area of 10,372 km square. Cervical cancer screening services in the two districts are provided by Bugiri district hospital which also serves other neighbouring districts. The district hospital provides intermittent cervical cancer screening services and treatment of those diagnosed with the disease. Two private health facilities, both located in Bugiri town, provide cervical cancer screening in Bugiri district and one private facility serves Mayuge district.

Study population and eligibility

The study involved females aged 25 to 49 years in the selected districts who had lived in the area for more than six months. The sampling units were households and only one participant was selected per sampled household.

Sampling procedure

A multi-stage sampling technique was used: five sub counties were randomly selected from each district. Five villages were then selected from each sub county using simple random sampling to obtain 25 study villages in each district. In order to select the households, systematic random sampling was used where the interval for selection of the households was determined by dividing the approximate number of households in a given village by the required number of respondents from each village. Lists of sub-counties and villages were obtained from district officials while village local leaders provided the estimates of numbers of households in their villages. Within households, simple random sampling was used to select a respondent whenever more than one eligible woman were present at the time of data collection.

Data collection

Data was collected using a questionnaire (see Additional file 1 ) that captured information on knowledge and attitudes of participants on cervical cancer prevention. The questionnaire, which was translated to Lusoga —the main language used in the study area—and back translated to English with any discrepancies addressed was pretested among a group similar to the study respondents. The survey questionnaire had five sections. The first section included questions on the participants’ demographic characteristics such as age, highest level of education attained, marital status, area of residence, and number of children, previous health seeking behaviours, and use and methods of contraception. The second section had questions on awareness and sources of information about cervical cancer prevention. The third section included ten questions that assessed the respondents’ specific knowledge about cervical cancer prevention measures, symptoms and screening methods. This section also assessed women’s knowledge of recommended age for cervical cancer vaccination, screening and the frequency of screening. Some questions required Yes/No/I don’t know responses while others required the participant to mention responses. The fourth section comprised of a list of ten questions on risk factors which comprised both factual and common myths about cervical cancer. The risk factors included multiple sexual partnerships, smoking, use of contraception, heredity, previous exposure to sexually transmitted diseases and early sex onset. A knowledge score was generated for the third and fourth sections with 1 point given for one correct response for a maximum possible 20 points. The last section included questions on attitudes and required respondents to state their level of agreement with statements about cervical cancer on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). This section had ten statements that assessed women’s perception of risk, severity of cervical cancer, perceived self-efficacy and the importance of cervical cancer screening.

Data entry and analysis

Data were entered and cleaned in Epidata 3.02 (EpiData Association, Denmark) and transferred to Stata SE statistical software (version 12.0 College Station, Texas) for analysis. Descriptive statistics were conducted to characterize the participants and provide frequencies on individual questions and attitudes. Bivariate analysis was conducted to determine the association between socio-demographic characteristics and knowledge about cervical cancer prevention. To obtain a binary outcome of knowledge, the mean knowledge score was determined and women who had scores above the mean were considered to be more knowledgeable while those who scored below were considered to have less knowledge. This formed the outcome variable which was coded as 1 for high knowledge and 0 for low knowledge and run against the socio-demographic characteristics to identify the predictors for high knowledge among the respondents. A multivariable model that adjusted for confounding was developed. Variables were added in the model based on a statistical significance of ≤ 0.15 at bivariate level and biological plausibility. Odds ratios and 95% confidence intervals were used as measures of association.

A total of 900 women responded to the questionnaire. The mean age of respondents was 32.9 years (Standard Deviation [SD] = 6.7) and most (530; 58.9%) had completed primary education. The majority of respondents were married (767; 85.2%), engaged in farming (499; 55.4%) and resided in rural areas (610; 67.8%) (Table  1 ).

Knowledge about cervical cancer and risk factors

Almost all women (898; 99.8%) had heard about cancer and the majority (794; 88.2%) had heard about cervical cancer. The main sources of information about cervical cancer were radio (557; 70.2%), health centres (120; 15.1%) and networks of friends and family members (104; 13.1%). The majority (854; 94.9%) of respondents stated that early detection of cervical cancer was helpful in its treatment while 671 (74.6%) knew that the disease was curable if detected early. Among the respondents, 625 (69.4%) said that cervical cancer could be prevented with 562 (62.4%) correctly stating at least one preventive measure of the disease. Only 7 (0.01%) respondents knew the recommended frequency for cervical cancer screening and 743 (82.6%) stated at least one symptom of the cancer (Table  2 ). Overall 499 (55.4%) of the women had high knowledge about cervical cancer and its risk factors.

Knowledge about the risk factors for cervical cancer was high with most (706; 78.4%) respondents stating that having multiple sexual partners, being infected with the human papilloma virus (HPV) (760; 88.4%) and starting to have sexual intercourse at a young age (665; 73.9%) increased a woman’s risk of developing cervical cancer. Most women (713; 79.2%) also thought that using contraceptives for a long time increased one’s risk of developing the cancer (Table  3 ).

The most known measures to prevent cervical cancer among women were early screening (414; 46%) and vaccination (300; 33.3%). Others (83; 9.2%) thought that measures such as safe male circumcision, using condoms and avoiding multiple sexual relationships could prevent cervical cancer. Only three (0.3%) thought that nothing could be done to prevent cervical cancer while 154 (17.1%) did not know any method of preventing the disease. Regarding knowledge about signs and symptoms of cervical cancer, abdominal pain (520; 57.8%), vaginal bleeding (390; 43.3%) and smelly vaginal discharge (298; 33.1%) were the commonly known (Fig.  1 ). More than half of respondents (489; 54.3%) did not know any methods used for screening for cervical cancer. Other respondents knew liquid-based cytological screening (22.8%), HPV test (21.2%) and the Pap smear test 117 (13%) as methods for cervical cancer screening.

Knowledge about signs and symptoms of cervical cancer, N  = 900. Others** include; vaginal itching, backache, vaginal sores and painful sex

Predictors of higher knowledge about cervical cancer prevention among women

At bivariate analysis, household income, area of residence and having ever had an HIV test were significantly associated with knowledge among respondents. When potential confounders were adjusted for, women who lived in urban and semi-urban areas were four times (adjusted odds ratio (AOR) = 3.64, 95% confidence interval (CI): 2.14 – 6.19) and two times (AOR = 1.62, 95% CI: 1.15 – 2.28) more likely to have high knowledge about cervical cancer than their rural counterparts respectively. Respondents who earned more than 40 US dollars per month were 50% less likely to be knowledgeable (AOR = 0.50, 95% CI: 0.37 – 0.68) while those who had ever had an HIV test were two times (AOR = 1.99, 95% CI: 1.34 – 2.96) more likely to be knowledgeable about cervical cancer compared to their counterparts (Table  4 ).

Attitudes towards cervical cancer prevention

Most women (852; 94.7%) thought that cervical cancer was a severe disease and the majority (684; 76.0%) believed that they were at risk of developing it. The majority (850; 94.4%) of respondents believed that cervical cancer screening was important and 706 (78.4%) knew that the chances of curing the disease were higher if diagnosed early. A significant number (747; 83.0%) believed that cervical cancer was symptomatic and therefore infected women would have signs and symptoms of the disease. Also, most respondents (556; 61.8%) believed that nothing could be done once someone is diagnosed with cervical cancer (Table  5 ).

This study found that most women were knowledgeable about cervical cancer symptoms, prevention measures and risk-factors. This is consistent with findings from a similar study conducted in northern Uganda [ 17 ]. This high awareness indicates that women may be in position to recognize cervical cancer basing on its symptoms and seek medical attention. Also, when women are aware of the causes and risk factors of cervical cancer and perceive themselves to be at risk, they are more likely to take up measures to prevent the acquisition of human papilloma virus hence avoid developing the disease. Indeed, previous studies have showed that awareness of cervical cancer symptoms and prevention measures, and perception of being at risk of the disease were associated with intention to go for screening and thus its early detection [ 12 , 18 – 20 ]. However, studies conducted among health workers in Uganda and Nigeria, who are expected to be knowledgeable, found low screening rates [ 14 , 21 ]. Cervical cancer awareness campaigns should focus on increasing knowledge of signs and symptoms and risk perception of the disease to encourage screening and facilitate its early detection.

This study found knowledge gaps that might inhibit women from undergoing cervical cancer screening. For instance, most women did not know the recommended age to start screening and even fewer knew the recommended frequency of screening for the disease. In addition, the belief that nothing can be done once one is diagnosed with cervical cancer was common and might hinder women from seeking screening services for fear of a positive diagnosis. Other studies have also reported gaps in knowledge among women in various settings [ 14 , 21 – 24 ]. In this study, radios, health workers and networks of significant others were the principal sources of information for most women. Also, previous Ugandan studies have showed that significant others such as paternal aunts are important sources of reproductive health information [ 23 ] and that men play an important role in influencing women’s decision to go for screening [ 9 ]. Likewise, health workers have been shown to be an important source of such information [ 13 , 25 ]. Education campaigns aiming at providing comprehensive knowledge about the disease should utilise radios and health workers and should focus on addressing identified knowledge gaps.

Having previously tested for HIV/AIDS and residing in an urban or peri-urban area were associated with high cervical cancer knowledge among women. This is possibly because people who have tested for HIV may have good health seeking behaviours and have had interaction with health facilities, a key source of cervical cancer related information. Also, town residents are in close proximity to these health facilities that provide cervical cancer services. These findings suggest that integrating HIV counselling and testing services with cervical cancer services would enhance awareness about the disease among women. A study conducted in Uganda showed that such integration, although might result into longer waiting hours at the health facilities, is to a large extent manageable by both health workers and women [ 26 ]. In our study, women who belonged to the lower socio economic category were more knowledgeable about cervical cancer prevention compared to those from the higher status. This finding is surprising and seemingly counterintuitive. However, it could reflect service utilisation trends in rural areas whereby long waiting hours and poor quality of services at health facilities may act as disincentives and hinder working women (higher income women) from seeking care yet these health facilities could be the major source of information on cervical cancer in rural settings. In a study by Jia conducted in China, women who had lower incomes had higher willingness to screen compared to their other counterparts [ 19 ] while a Botswanan study found that previous cervical cancer screenings was high among women of higher incomes [ 27 ]. Cervical cancer screening services should also extend to rural areas since a woman’s awareness of location of a service point is associated with acceptance and uptake of screening [ 10 – 12 ] and should also target women in the higher economic stratum.

Most women showed a positive attitude towards cervical cancer screening. For instance, most women thought that early disease diagnosis was helpful in disease treatment and that they were at risk of getting cervical cancer, which they believed was a severe disease. Women’s perception of being at risk of cervical cancer was earlier found to be associated with their intention to go for screening services [ 9 ]. Since earlier studies have showed that attitudinal factors such as not feeling susceptible to cervical cancer and having limited knowledge about the disease affect uptake of services [ 12 , 14 ], the fact that many women were generally knowledgeable about cervical cancer and had a positive attitude presents an opportunity for cervical screening programmes. Therefore, it is likely that if more screening opportunities are presented to women, many will screen for the disease and take up preventive measures. It is also worth noting that in some studies, even when the opportunity to screen was provided to women, they reported other barriers such as fear of a positive cervical cancer diagnosis, and other fears related to the screening procedures and vaginal examinations [ 12 , 28 ] and therefore programs should be designed to provide treatment for those diagnosed with cancer. Cervical cancer awareness and prevention programmes should continually seek to influence women’s perceptions about cervical cancer and screening.

We also found perceptions that might negatively impact providing care to cervical cancer patients and affect public health interventions. For example, a significant number believed that cervical cancer patients could transmit the disease and most women thought that long-term use of contraceptives could cause cervical cancer. The belief that use of contraceptives leads to cervical cancer has been documented in studies carried out in other regions of Uganda [ 17 , 24 , 29 ]. This perception could be due to the similarity between the side effects of some of the contraceptive methods and the gynecological signs of cervical cancer such as longer periods of menstrual bleeding. This perception might hinder women from utilising contraceptives, reducing effectiveness of measures towards reducing fertility rates, which are among the highest in the world.

Strengths and limitations

This was a community based study that involved women eligible for cervical cancer screening in eastern Uganda. The study provides insights into the knowledge and attitudes of women in rural areas towards cervical cancer prevention. This information is important for designing appropriate interventions to increase cervical cancer awareness and screening in such areas where it has been reported as very low by previous studies, whilst acting as a benchmark for evaluating such interventions. A limitation of this study is the lack of a standardised knowledge assessment questionnaire which limits the comparability of the findings across studies carried out in the region.

This study found relatively high knowledge about general cervical cancer prevention but specific knowledge about screening was very low. There were also positive attitudes towards cervical cancer prevention. Since high knowledge and positive attitudes themselves are not enough to ensure uptake of screening services, there is need to scale up such cervical cancer screening services so that more women can access them irrespective of where they reside. There is also need for more awareness campaigns to provide comprehensive information about cervical cancer screening to women in all areas and dispel any negative beliefs and perceptions.

Abbreviations

Acquired immune deficiency syndrome

Adjusted odds ratio

Confidence interval

Crude odds ratio

Human immunodeficiency virus

Human papilloma virus

Standard deviation

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Acknowledgments

We thank the study participants and research assistants for taking part in this study.

This work was supported by Training Health Researchers into Vocational Excellence in East Africa (THRiVE), grant number 087540 funded by the Wellcome Trust. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the supporting offices. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Data are available upon request from the corresponding author.

Authors’ contributions

TM and RN conceived the study, contributed to its design, data collection and analysis and drafted the manuscript. AM, AAH and DM contributed in designing the study, data analysis and critical review of the manuscript. All authors read and approved the final manuscript.

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The authors declare that they have no competing interests.

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Ethics approval and consent to participate

Ethical approval was obtained from Makerere University School of Public Health Higher Degrees Research and Ethics Committee and the study registered by the Uganda National Council for Science and Technology. Participation in the study was voluntary and participants provided written informed consent only after being explained to the details of the study, and the benefits and risks of participation.

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Trasias Mukama, Rawlance Ndejjo, Abdullah Ali Halage & David Musoke

Department of Community Health, School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda

Angele Musabyimana

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Correspondence to Rawlance Ndejjo .

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Additional file 1:.

Women’s knowledge and attitudes towards cervical cancer prevention. Description of file: Study questionnaire. (PDF 456 kb)

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Mukama, T., Ndejjo, R., Musabyimana, A. et al. Women’s knowledge and attitudes towards cervical cancer prevention: a cross sectional study in Eastern Uganda. BMC Women's Health 17 , 9 (2017). https://doi.org/10.1186/s12905-017-0365-3

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Received : 01 August 2015

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DOI : https://doi.org/10.1186/s12905-017-0365-3

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Cervical cancer

Introduction

News & events, assessment of barriers and interventions to improve cancer screening programmes in latin american and caribbean countries: outcomes of the canscreen5/celac project, cancer screening metrics: effective evaluation to balance benefits and harms, cancer screening in five continents (canscreen5): a global data repository for breast, cervical, and colorectal cancer screening programmes, why is brazil changing its hpv vaccine recommendations, infographics, world immunization week 2024: vaccination against hpv and hepatitis viruses.

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Cervical Cancer Awareness Month 2021 Questions and Answers (Q&A)

Every few years, IARC publishes the latest global data on cancer incidence and mortality. What do these figure show about cervical cancer? Which geographical areas are most affected, and why?

What are the main solutions to address this problem globally?

What is the WHO Cervical Cancer Elimination Initiative?

FDA approves self-collection screening for virus that causes cervical cancer

Women’s health advocates view the move as crucial to stamping out the preventable disease.

The Food and Drug Administration this week moved to expand screening for potentially lethal cervical cancer by allowing women to collect test samples themselves, a move that reproductive health advocates view as crucial to stamping out the preventable disease.

For the first time, women will be able to gather samples for testing in private rooms inside offices of primary-care doctors, at urgent-care clinics and even pharmacies — an advance that could presage home testing.

Advocates hope the method will make it easier for women of color and those living in rural and underserved communities to screen for human papillomavirus — HPV — which can lead to a cancer that afflicts 11,000 each year. It comes as the National Cancer Institute has ramped up study of self-collection, partnering with 25 medical schools and cancer centers across the country to gauge use of collecting vaginal samples at home and at health-care facilities.

“It provides women who might not have otherwise had the opportunity — or inclination — to get screened the chance do so,” said Erin Kobetz, associate director for community outreach and engagement at the University of Miami Sylvester Comprehensive Cancer Center, who has studied self-collection for HPV testing for nearly two decades. “Maybe it makes this idea, at least in the United States, of eliminating cervical cancer by 2030 a perceptible reality.”

The collection method was greenlit for the previously approved HPV test Onclarity, manufactured by BD (Becton, Dickinson and Company). The test is expected to be available in summer and will be part of a study of self-collection, the company said in a news release Wednesday.

Roche also received sign off for the self-collection method for its cobas HPV Test, and has been collaborating with the NCI’s study, the company said in a news release.

Meanwhile, the FDA could sign off on at-home collection in coming months. Teal Health created a device that lets women collect their own vaginal samples and send them to a laboratory for testing. Last week , the test received a special designation from the FDA that allows agency staffers to review certain devices faster.

Most primary-care physicians do not test for HPV. Typically, it’s performed by gynecologists, who collect samples for an HPV test or for a Pap smear for abnormal cervical cells. Often, the samples are taken during a pelvic exam.

The new method “opens the door to a less invasive testing option,” the company said. It will still require an order from a doctor, who will be required to explain the results. But the samples can be collected by a woman using a vaginal swab in a health-care facility “like you would a urine sample,” said Jeff Andrews, vice president of medical affairs for BD. The swab is then sent to a lab equipped to test the sample.

Andrews added the test is already covered by private insurance, Medicare and Medicaid, which typically pays clinical, hospital and other labs about $46 per screening. BD sells the tests to labs.

Self-collection won’t replace testing for HPV during routine pelvic exams, but it will add another way to improve earlier detection of the infection.

“This literally just opens up another option for a different demographic of people that might not feel comfortable, that might not have access [and] may not have time” to get tested otherwise, said Irene O. Aninye, chief science officer for the Society for Women’s Health Research, a group focused on advancing women’s health and promoting research.

The method has already proved successful in European countries and Australia.

Now, federal researchers are beginning to gather data on whether self-collection works well in the United States. NCI in January launched its initiative to study self-collection, aiming to answer critical questions.

“The study will provide us the data to know what’s the uptake like, what do people do with this information? How is it received in different clinical settings, and do people engage with their gynecologists in a different way? And then ultimately, do we see a difference in cervical cancer cases?” NCI director Kimryn Rathmell said.

In the United States, the FDA’s approval of the BD test is the culmination of decades of research. Kobetz began studying self-collection in Miami’s Little Haiti neighborhood, where women of Haitian heritage shied away from Pap smears for complex reasons, including the perception the tests were intrusive and concerns about intimacy and vulnerability, Kobetz said.

Her study found self-collection was accurate — women who participated in the study obtained enough cells to test for HPV and they “really found this to be an appropriate method for cervical cancer screening — and an easy one,” Kobetz said.

The goal is for at-home tests to become easily available, said William L. Dahut, chief scientific officer at the American Cancer Society. Doing so, he believes, would increase the number of people who get screened for HPV.

In 2006, the FDA approved the first vaccine to prevent HPV, but uptake varies widely by state. The shots have the potential to prevent more than 90 percent of HPV-attributable cancers, according to the Centers for Disease Control and Prevention. While vaccination significantly reduces the chance of infection, it doesn’t eliminate risk of cervical cancer, so it remains important for people to get screened, Dahut said.

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• Risk Factors
• Cervical Cancer Screening and Survivor Stories
• Face Your Health
• National Breast and Cervical Cancer Early Detection Program
• Gynecologic Cancers

Treatment of Cervical Cancer

• Cervical cancer can be treated in several ways. It depends on the type of cervical cancer and how far it has spread.
• Treatments include surgery, chemotherapy, and radiation therapy.
• If your doctor says that you have cervical cancer, ask to be referred to a gynecologic oncologist.

If your doctor says that you have cervical cancer, ask to be referred to a gynecologic oncologist—a doctor who has been trained to treat gynecologic cancers, including cervical cancer. This doctor will work with you to create a treatment plan.

Treatment options

The extent of disease is referred to as the stage. Information about the size of the cancer or how far it has spread is often used to determine the stage. Doctors use this information to plan treatment and to monitor progress.

Cervical cancer is treated in several ways. It depends on the kind of cervical cancer and how far it has spread. Treatments include surgery, chemotherapy, and radiation therapy.

• Surgery: An operation in which doctors cut out the cancer.
• Chemotherapy: Use of special medicines to shrink or kill the cancer. The drugs can be pills you take or medicines given in your veins, or sometimes both.
• Radiation therapy: Use of high-energy rays (similar to x-rays) to kill the cancer.

For more information, visit the National Cancer Institute's Cervical Cancer Treatment. This site can also help you find health care services.

Which treatment is right for me?

Talk to your cancer doctor about the treatment options available for your type and stage of cancer. Your doctor can explain the risks and benefits of each treatment and their side effects. Side effects are how your body reacts to drugs or other treatments.

Sometimes people get an opinion from more than one cancer doctor. This is called a "second opinion." Getting a second opinion may help you choose the treatment that is right for you.

Clinical trials

Clinical trials use new treatment options to see if they are safe and effective. If you have cancer, you may want to take part. Visit the sites listed below for more information.

• NIH Clinical Research Trials and You (National Institutes of Health)
• Learn About Clinical Trials (National Cancer Institute)
• Search for Clinical Trials (National Cancer Institute)
• ClinicalTrials.gov (National Institutes of Health)

Complementary and alternative medicine

Complementary and alternative medicine are medicines and health practices that are not standard cancer treatments. Complementary medicine is used in addition to standard treatments. Alternative medicine is used instead of standard treatments. Acupuncture and supplements like vitamins and herbs are some examples.

Many kinds of complementary and alternative medicine have not been tested scientifically and may not be safe. Talk to your doctor about the risks and benefits before you start any kind of complementary or alternative medicine.

• Understanding Cervical Changes: A Health Guide (National Cancer Institute)
• Complementary and Alternative Medicine for Patients (National Cancer Institute)

Cervical Cancer

Screening tests and the HPV vaccine can help prevent cervical cancer.

• Frontiers in Oncology
• Gynecological Oncology
• Research Topics

Cervical Cancer: Updates from the Mexican National Consensus

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About this Research Topic

Human papillomavirus is a leading cause of disease in low- and middle-income countries, particularly in women, causing an essential public health problem and a severe burden to healthcare systems. In 2020, the World Health Organization outlined a global strategy to accelerate the elimination of cervical ...

Keywords : HPV, cervical cancer, epidemiology, symbiotics, cancer treatment, immunotherapy

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Stem cells provide new insight into genetic pathway of childhood cancer

Scientists have discovered a new insight into the genetic pathway of childhood cancer, offering new hope for tailored treatments.

Researchers from the University of Sheffield have created a stem cell model designed to investigate the origins of neuroblastoma, a cancer primarily affecting babies and young children.

Neuroblastoma is the most common childhood tumour occurring outside the brain, affecting the lives of approximately 600 children in the European Union and the United Kingdom each year.

Until now, studying genetic changes and their role in neuroblastoma initiation has been challenging due to the lack of suitable laboratory methods. A new model developed by researchers at the University of Sheffield, in collaboration with the St Anna Children's Cancer Research Institute in Vienna, replicates the emergence of early neuroblastoma cancer-like cells, giving an insight into the genetic pathway of the disease.

The research, published in Nature Communications , sheds light on the intricate genetic pathways which initiate neuroblastoma. The international research team found that specific mutations in chromosomes 17 and 1, combined with overactivation of the MYCN gene, play a pivotal role in the development of aggressive neuroblastoma tumours.

Childhood cancer is often diagnosed and detected late, leaving researchers with very little idea of the conditions that led to tumour initiation, which occurs very early during fetal development. In order to understand tumour initiation, models which recreate the conditions that lead to the appearance of a tumour are vital.

The formation of neuroblastoma usually starts in the womb when a group of normal embryonic cells called 'trunk neural crest (NC)' become mutated and cancerous.

In an interdisciplinary effort spearheaded by stem cell expert Dr Ingrid Saldana from the University of Sheffield's School of Biosciences and computational biologist Dr Luis Montano from the St Anna Children's Cancer Research Institute in Vienna, the new study found a way in which to use human stem cells to grow trunk NC cells in a petri dish.

These cells carried genetic changes often seen in aggressive neuroblastoma tumours. Using genomics analysis and advanced imaging techniques, the researchers found that the altered cells started behaving like cancer cells and looked very similar to the neuroblastoma cells found in sick children.

The findings offer new hope for the creation of tailored treatments that specifically target the cancer while minimising the adverse effects experienced by patients from existing therapies.

Dr Anestis Tsakiridis, from the University of Sheffield's School of Biosciences and lead author of the study, said: "Our stem cell-based model mimics the early stages of aggressive neuroblastoma formation, providing invaluable insights into the genetic drivers of this devastating childhood cancer. By recreating the conditions that lead to tumour initiation, we will be able to understand better the mechanisms underpinning this process and thus design improved treatment strategies in the longer term.

"This is very important as survival rates for children with aggressive neuroblastoma are poor and most survivors suffer from side effects linked to the harsh treatments currently used, which include potential hearing, fertility and lung problems."

Dr. Florian Halbritter, from St. Anna Children's Cancer Research Institute and second lead author of the study, said: "This was an impressive team effort, breaching geographic and disciplinary boundaries to enable new discoveries in childhood cancer research."

This research supports the University of Sheffield's cancer research strategy. Through the strategy, the University aims to prevent cancer-related deaths by undertaking high quality research, leading to more effective treatments, as well as methods to better prevent and detect cancer and improve quality of life.

• Lung Cancer
• Breast Cancer
• Skin Cancer
• Brain Tumor
• Prostate Cancer
• Colon Cancer
• Stem cell treatments
• Cervical cancer
• Colorectal cancer
• Breast cancer
• Prostate cancer

Story Source:

Materials provided by University of Sheffield . Note: Content may be edited for style and length.

Journal Reference :

• Ingrid M. Saldana-Guerrero, Luis F. Montano-Gutierrez, Katy Boswell, Christoph Hafemeister, Evon Poon, Lisa E. Shaw, Dylan Stavish, Rebecca A. Lea, Sara Wernig-Zorc, Eva Bozsaky, Irfete S. Fetahu, Peter Zoescher, Ulrike Pötschger, Marie Bernkopf, Andrea Wenninger-Weinzierl, Caterina Sturtzel, Celine Souilhol, Sophia Tarelli, Mohamed R. Shoeb, Polyxeni Bozatzi, Magdalena Rados, Maria Guarini, Michelle C. Buri, Wolfgang Weninger, Eva M. Putz, Miller Huang, Ruth Ladenstein, Peter W. Andrews, Ivana Barbaric, George D. Cresswell, Helen E. Bryant, Martin Distel, Louis Chesler, Sabine Taschner-Mandl, Matthias Farlik, Anestis Tsakiridis, Florian Halbritter. A human neural crest model reveals the developmental impact of neuroblastoma-associated chromosomal aberrations . Nature Communications , 2024; 15 (1) DOI: 10.1038/s41467-024-47945-7

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