‘’Prevention is better than cure” – this adage has been around for centuries, and remains to be a fundamental principle of modern medicine. As we celebrate world cancer prevention awareness month this February, we focus on cervical cancer, which has become one of the most preventable malignancies, thanks to effective primary and secondary prevention strategies.
Globally, cervical cancer incidence has reduced mainly due to primary prevention with Human papillomavirus (HPV) vaccination and improved secondary prevention through national screening programs for early detection. However, a huge disparity in the mortality rates remains among countries worldwide, with about 90% of cervical cancer deaths occurring in low- and middle-income countries (LMIC). In the Philippines, it is the second most common cancer among women, and survival rates remain low, since 75% of patients are diagnosed at advanced stages. The high mortality of cervical cancer patients reflects the poor accessibility of health care within the country.
Early detection is key to prevention
Cervical cytology, commonly known as Pap smear, is the gold standard for cervical cancer screening. However, lack of resources hinder its use in the majority of LMICs, including the Philippines which still utilizes the cheaper alternative of visual inspection with acetic acid (VIA) as the usual primary screening test. Despite this compromise, still only 1% of women aged 30 – 49 years in the country have been screened. Financial constraints, poor knowledge on screening, fatalistic attitudes towards cancer, stigma associated with cancer, fear of pain or discomfort and embarrassment during the procedure contribute to low cervical cancer screening uptake within the country.
Better to protect than to regret
Aside from the staggeringly low screening rate, the Philippines also suffers from inadequate HPV vaccination rates. HPV vaccination could prevent more than 90% of malignancies caused by HPV, including cervical cancer. Hence, the World Health Organization (WHO) advocates its introduction in national immunization schedules worldwide by the year 2030. However, vaccination adoption rates remain low in LMICs compared to high income countries, despite accounting for most of the global disease burden.
In the Philippines, a school-based HPV vaccination program for girls aged 9–14 was started in 2016. However, the scale of the program remains subnational, with only 60% of provinces covered. The country still ranks last on HPV program coverage among LMICs, with only 23% of the target population receiving their first, and 5% completing their final doses – a number far from the WHO goal to vaccinate 90% of girls by the age of 15.
Identification of eligible individuals is crucial in the successful implementation of any vaccination program. School-based strategies could be beneficial in countries with high school attendance. However, its coverage can be severely limited in countries like the Philippines, where nearly 20% of children are out of school, hence missing a significant proportion of the target population. Extending the program to the community-level to include out-of-school youth could hence be useful, in order to achieve higher target population coverage.
It is also essential to emphasize and reinforce timely vaccination of girls before they are sexually active. To further strengthen current evidence on how effective timely administration of HPV vaccines truly is, a recent groundbreaking study in Scotland has shown that no new cases of invasive cervical cancer were detected in all women born between 1988-1996 nationwide who received HPV vaccinations between the ages of 12 and 13.
A jab at success for a cervical-cancer free future
GAVI, The Vaccine Alliance (GAVI) was set up as a Global Health Partnership with the goal of creating equal access to new and underused vaccines for children living in most impoverished countries. In particular, Gavi aims to accelerate access to vaccines and strengthen countries’ health and immunization systems. The Philippines, despite classification as an LMIC, was ineligible for HPV vaccine financial support. The country had to work with UNICEF, the agency procuring vaccines from manufacturers on behalf of Gavi, to purchase US-based Merck’s quadrivalent vaccine Gardasil at approximately 14 USD per dose. Although lower than the private market price of 160 USD per dose, it was still three times more than the Gavi lowest global price of 4.50 USD per dose. It is therefore not surprising that socioeconomic disparities act as roadblocks to the nation’s vital preventive programs against HPV infection and cervical cancer.
Recently a new study found the quadrivalent HPV vaccine Cervavac, manufactured by Serum Institute of India (SSI), to be as safe and immunogenic as Gardasil. This new cheaper vaccine could play a pivotal role in meeting the global need for HPV vaccinations and improve coverage worldwide. Furthermore, once Cervavac is made available, it is hoped that the even more affordable pricing could also be extended to the Philippines, considering the burden of cervical cancer within the country. This would allow the Philippines to optimize its financial resources, focus more on preventive care, and become one step closer towards reaching its ultimate goal of cervical cancer reduction within the nation.
About the Authors:
Dr. Janine Audrei T. Pajimna is an internist based in the Philippines.
Dr. Giannina Alyana L. Orpilla is a physician based in the Philippines.
Dr. Mark Jason D.C. Milan is a pediatrician based in the Philippines.
Dr. Camille K. Pascasio is an internist based in the Philippines.
Dr. Lorenz Fort E. Revillas is a medical oncology fellow based in the Philippines.
Dr. Denise Joy C. Lopez is an endocrinology fellow based in the Philippines.
Dr. Nikolas Leandro R. Daguno is pediatrician based in the Philippines.
Competing interests: None
Handling Editor: Neha Faruqui