Cervical cancer elimination possible if we choose equity

Despite being preventable, cervical cancer is a leading cause of death for women in low- and middle-income countries. Achieving elimination demands one thing above all: a global commitment to equity.

The WHO has issued a global call to action to eliminate cervical cancer within the next 100 years. Photo: NIAID

In 2018, Dr Tedros Adhanom Ghebreyesus, director of the World Health Organization (WHO), issued a global call to action to eliminate cervical cancer within the next 100 years. That future will remain out of reach and millions of women will die unless we confront one uncomfortable reality: inequity is killing them.

In the US, a teenage girl receives her third dose of the human papilloma virus (HPV) vaccine, the virus responsible for nearly all cervical cancer cases. Her mother, now in her mid-40s, clicks her phone open to a reminder text from her primary care provider about her upcoming Pap smear screening.

Meanwhile in Kenya, a mother in her late 30s with three young children dies of cervical cancer, never having heard of the HPV vaccine or Pap smear, innovations that would have saved her life. Her death is not a result of a medical failure, but a story of neglect on a global scale. And, without intervention, it will happen again.

Despite being entirely preventable, cervical cancer is the fourth most common cancer in women globally, according to the WHO, and the second most common, behind breast cancer, in low- and middle-income countries (LMICs).

The WHO launched a campaign in 2020 to end cervical cancer as a public health concern using a three-pillar strategy called the 90-70-90 targets: 90% of girls vaccinated for HPV by the age of 15, 70% of women screened for cervical pre-cancer twice in their lifetime, and 90% of women with cervical pre-cancer treated.

The roadmap is clear. The science is sound. Yet, the gap between what is possible and what is practised is dangerously wide.

Cervical cancer technology not shared equally

After the deaths of Henrietta Lacks, an African American woman in the US, in 1951 and Eva Perón, the first lady of Argentina, in 1952, both a result of cervical cancer in their early 30s, public awareness and scientific urgency around the disease intensified.

Two key screening and diagnostic technologies revolutionised cervical cancer prevention: the Pap smear and the colposcope. The Pap smear, developed by Dr George Papanicolaou, enabled early visualisation of abnormal cervical cells. The first colposcope was invented by Hans Hinselmann, providing magnified visualisation of the cervix and allowing physicians to acquire targeted biopsies. Though both were developed in the 1920s, neither saw widespread use until the 1950s or 1960s.

More recently, the discovery of HPV as the primary driver of cervical cancer led to HPV DNA testing technologies, greatly improving cervical dysplasia (abnormal cells) screening sensitivity. As a result of technological innovation and diffusion, many high-income countries have reached or are approaching elimination thresholds, proving cervical cancer elimination is possible.

Yet, the absence of such tools for Lacks and Perón, and for millions of women today, remains a powerful reminder that innovation means little without access. As a result, cervical cancer has become not just a disease, but a marker of disparity.

Cervical cancer screening for rural women

Innovative, community-centred programmes like the HOPE initiative in Cajamarca, Peru, offer a glimpse into an equitable future for cervical cancer prevention. HOPE is led by Universidad Peruana Cayetano Heredia in Lima and supported by technologies developed at Duke University’s Center for Global Women’s Health Technologies (GWHT) in Durham, North Carolina. The programme empowers women to take charge of their health through self-collected HPV tests, and equips midwives with technology-enabled mobile diagnostics, allowing for timely follow-up and immediate treatment.

Without new technologies, care would be restricted to central healthcare facilities, often hours of travel away from where women live. At its core is a simple idea with transformative impact: reach women where they are, with tools they can trust.

HOPE is enabled by local women, who serve as champions for cervical cancer screening. These “HOPE ladies” distribute HPV self-test kits to women within the community and help women schedule a follow-up visit at a local clinic if their HPV test is positive.

At the local clinic, women undergo a visual exam using the Pocket colposcope, one of GWHT’s pioneering technologies. The Pocket colposcope performs identically to a standard colposcope, but at a fraction of the cost, by bringing the colposcope camera close to the cervix, obviating the need for expensive optical lenses. A midwife performs the Pocket colposcopy exam and uploads images to a server for a gynaecologist to make a diagnosis in real time.

Under direction from the gynaecologist, the midwife will then perform treatment immediately or refer if advanced disease is found. To date, more than 4,000 women across five clinics in Cajamarca have undergone cervical cancer screening using this model, with more women being screened every day.

Training AI to detect cervical cancer

The team at GWHT is expanding the capabilities of the HOPE model by incorporating AI-assisted risk assessment. Using a growing dataset of cervical images, researchers are training AI models to distinguish between normal and potentially precancerous lesions with a high sensitivity. This will relieve overburdened health workers and expand diagnostic capacity to remote communities that lack reliable Wi-Fi or cellular connections required for telehealth diagnosis.

In places like the Andean Mountain region in Peru, such innovations could mean the difference between early intervention and late-stage, deadly cancer. The success of this redesigned healthcare delivery model requires all hands on deck, including engineers, computer scientists, healthcare providers, policymakers, and local community champions. Similar models are being implemented in communities across the globe.

Cervical cancer is the first, and only, cancer with a call for total elimination. It is also entirely preventable. Whether or not we eliminate cervical cancer will serve as a bellwether for how seriously we take healthcare inequity. If we act now, we can write a different story. A story where no woman dies simply because of where she was born. A story where elimination is not just a headline, but a shared human victory. We can end cervical cancer, but only if we choose equity.

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The opinions expressed are those of the authors and do not necessarily reflect the position of Re:solve Global Health.

Brian Crouch is an assistant research professor at Duke University, the assistant director of research at the Center for Global Women’s Health Technologies, and the chief technology officer at the Calla Health Foundation. His research focuses on democratising access to healthcare for women globally, with an emphasis on new treatments for breast and cervical cancer.

Nirmala (Nimmi) Ramanujam is the Robert W. Carr professor of engineering and professor of cancer pharmacology and global health at Duke University. In 2013 she founded the Center for Global Women’s Health Technologies to reshape women’s health through technology innovation. She founded the Calla Health Foundation to commercialise these technologies.