AFJOG

GUIDELINES BACKGROUND Epidemiology Cervical cancer is almost completely preventable through effective primary (prophylactic HPV vaccine) and secondary prevention (screening) but it remains a major public health problem in South Africa. The age-standardised incidence rate in 2020 was estimated at 35.3 per 100 000 South African women, almost three times the global average of 13.3 per 100 000 women. 1 Estimates show that, in South Africa, currently more than 10 000 new cervical cancer cases are diagnosed each year and it was the leading cause of female cancer deaths in 15 to 44-year-olds in with a mortality rate of 19.6 per 100 000 women in 2020. 1 Many factors contribute to the high cancer rates including historic and persistent wealth disparities (SA has one of the highest Gini indices in the world), a high rate of people living with HIV and competing health priorities. Primary prevention through HPV vaccination The lack of progress in cervical cancer prevention is particularly concerning in an era when effective primary and secondary preventative strategies are available. Primary prevention through school-based HPV vaccination was introduced in 2014 and initially, relatively high rates of coverage were achieved for the first dose with a significant drop off with a second dose. 2 Only girls are vaccinated in the SA school-based program and the coverage has decreased dramatically during the COVID pandemic with only 3% of the target population receiving the vaccine in 2020. 3 HPV vaccination coverage to achieve herd protection must remain the most important focus. Increasing the cohorts for vaccination (all genders and more age cohorts) provides the best hope for reducing new cervical cancer cases. Other primary preventative strategies including controlling the HIV pandemic and reduction in smoking are also extremely important priorities. Vaccination of all young people against oncogenic HPV types must remain a high priority. HPV, HIV & prevalence Persistent viral infection with high-risk human papillomavirus (hrHPV) genotypes causes nearly all cervical cancers. 4 Data from South Africa estimate that 64.2% of invasive cervical cancers can be attributed to HPV16 or HPV18, and 3.2% of women with normal cytology test positive for HPV16/18. 1,5 Like in most other geographies, HPV 16 and 18 are the most important oncogenic strains detected in invasive cervical cancer in SA, which means that all the currently available vaccines will be effective in preventing cervical cancer caused by these types and many high-grade precancerous lesions. Besides protecting against HPV 16 and HPV 18 there is also a vaccine that protects against HPV types 16, 18, 31, 33, 45, 52 and 58 that would provide wider protection. 6 Women living with human immunodeficiency virus (HIV) (WLWH) have a six-fold increased risk of developing pre- cancerous cervical lesions and cervical cancer, as well as a higher probability of early-age disease compared to HIV- negative women. 7 Women in South Africa have high rates of HIV and HPV infection resulting in high rates of precancer with low screening coverage. 8 Current estimates are that nearly 25% of South African women in their reproductive age (15–49 years) are living with HIV. 9 World Health Organisation Call to Action In May 2018 the World Health Organization (WHO) announced a global strategy, the “Call to action to eliminate cervical cancer as a public health problem”. All regions of the world are encouraged to reach an incidence rate of below 4 per 100,000 women per year. There are three pillars of action. • Vaccination of 90% of girls by the age of 15 with an effective HPV vaccine • Screening of women with a high-performance test by the age of 35 years and again at 45 years • To achieve treatment of 90% of women with pre-cancer or invasive cancer Following the announcement of this global strategy, a panel of experts published an updated WHO Guideline for Screening and Treatment of Cervical pre-cancer lesions for Cervical Cancer Prevention. 10 These guidelines recommend HPV DNA detection as the most preferred method of screening rather than cervical cytology or visual inspection methods. The WHO also recommends the adoption of self-sampling; however, the exact methodology is not yet defined. The guidelines recommend different strategies for screening a low-risk population and for at-risk populations MH Botha 1 , M Mabenge 2 , M Makua 3 , ML Mbodi 4 , LJ Rogers 5 , M Sebitloane 6 , TH Smith 7 , FH Van der Merwe 8 , AWilliamson 9 , J Whittaker 10 , G Dreyer 11 1 Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, Stellenbosch, South Africa 2 Department of Obstetrics and Gynaecology, Walter Sisulu University, Mthatha, South Africa 3 Maternal and Reproductive Health, National Department of Health, South Africa 4 University of Witwatersrand & Charlotte Maxeke Academic hospital, Johannesburg, South Africa 5 Department of Obstetrics and Gynaecology, University of Cape Town and Groote Schuur Hospital, SAMRC Gynaecological Cancer Research Centre, Cape Town, South Africa 6 Department of Obstetrics and Gynaecology, University of KwaZulu-Natal, Durban, South Africa 7 Wits Donald Gordon Medical Centre, Johannesburg, South Africa 8 Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, Stellenbosch, South Africa 9 Institute of Infectious Disease and Molecular Medicine/ SAMRC Gynaecological Cancer Research Centre/ Division of Medical Virology, Department of Pathology, University of Cape Town, Cape Town, South Africa 10 Lancet laboratories, Cape Town, South Africa 11 Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa Cervical Cancer Screening Guidelines for South Africa African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 1 | 2023 | 35