Crossroads of Primary and Secondary Cervical Cancer Prevention Strategies in Resource-Constrained Settings

Abstract

EditorialJ Cancer Prev Curr Res 2017, 7(4): 00246 cancer prevention. Besides, overtreatment of patients when clinicians fear future noncompliance leads to heightened patient anxiety and community mistrust of the health care system [1]. Nonetheless, lower socioeconomic status and inequalities represent fundamental problems which must be addressed in the new integrated strategies [3].More than 10 years have elapsed since the global launch of the first vaccine targeting an STI, namely the quadrivalent VLP HPV vaccine. Despite being highly successful, HPV vaccination programs have been particularly well executed in special settings where their implementation has been school-based [4]. The patchy coverage of vaccination target groups and the huge debate over HPV vaccination essentially stemmed from physicians and people's mixed attitudes towards vaccination, inaccurate information in the electronic and social media and the robust antivaccination movement among others. In hindsight, anecdotally some would argue that if the quadrivalent vaccine was globally marketed as an anti-wart vaccine without reference to cervical "precancer", it might have enjoyed more success.In the meanwhile, the inherent drawbacks of cytology (subjective nature, low sensitivity for detecting true cervical precancer requiring frequent re-screening) have been partially addressed with the wider implementation of HPV-related biomarkers which represent objective and more repetitive methods to screen for precancerous lesions [5]. Several DNA and mRNA HPV assays have gained FDA approval, other biomarkers (p16/Ki67 dual stain, viral genotyping, methylation markers) are being successfully used in daily clinical practice, and several others are still being validated in the assessment of HPV positive women [6]. This progress in HPV science has been the basis of calibrated cervical screening and triage options, and guidelines endorsed by the scientific committees. Therefore, the two approaches for controlling cervical cancer incidence have paved in parallel routes for a while; secondary prevention implementing cytology and HPV-related biomarkers for identifying precancer lesions, with subsequent resort to colposcopy; and HPV vaccination -virtually the incarnation of primary prevention. Even in the western world however, cervical screening is commonly opportunistic; or might be organized inconsistently across and within countries and regions. 7 In an excellent review addressing the flaws of secondary cervical prevention, the authors point at the differences between organized and opportunistic screening; in the former the basic principle is that the more women screened (as differentiated from the more tests done), the less morbidity and mortality from cervical cancer [7]. In contrast, opportunistic screening is often characterized by the over-screening of a minority of (some privileged) women, while those women most at risk tend to be screened rarely or not at all [7]. Thus, across all levels of screening coverage, increases in test sensitivity provide gre...