Research Article: Coverage of Cervical Cancer Screening in 57 Countries: Low Average Levels and Large Inequalities

Date Published: June 17, 2008

Publisher: Public Library of Science

Author(s): Emmanuela Gakidou, Stella Nordhagen, Ziad Obermeyer

Abstract: Emmanuela Gakidou and colleagues find that coverage of cervical cancer screening in developing countries is on average 19% compared to 63% in developed countries.

Partial Text: Cervical cancer is the second most common cancer in women and a leading cause of mortality worldwide, with 273,000 deaths estimated in 2002 [1]. Eighty-three percent of cases occur in the developing world, where cervical cancer accounts for 15% of female cancers, as compared to just 3.6% in developed countries [1].

Figure 1 shows levels of coverage of cervical cancer screening for the 57 countries, and Table 1 summarizes these results. The population-weighted means of crude coverage and effective coverage of cervical cancer screening across all included countries are 68% and 40%, respectively. In the 30 developing countries surveyed, these rates are much lower: 45% and 19%, respectively. (Former communist countries are considered developed for purposes of this analysis.) There is wide variation in the level of effective coverage across countries, from over 80% in Austria and Luxembourg to 1% or less in Bangladesh, Ethiopia, and Myanmar. In many countries, a large proportion of women have had pelvic examinations, but the exam was not accompanied by laboratory tests or was not done in the three years preceding the survey. In Georgia, for example, 67% of women have had a pelvic exam, but only 11% had had one in the preceding three years and accompanied by a Pap smear; likewise in China, crude coverage is 70%, but effective screening coverage is only 23%. (Estimates of coverage by age group and wealth quintile for all included countries are provided in Table S2.)

The results of this study illustrate that a wide range of current screening practices exists across countries; this makes it unlikely that any one strategy will prove to be effective globally. Choices regarding cervical cancer prevention strategies must be adapted to the current situation and the constraints of individual countries—indeed, multiple strategies may need to be pursued within the same country. In this regard, it may be useful to consider countries in three broad groups, based on current screening coverage rates, each facing different policy choices with regard to cervical cancer prevention.

Effective coverage rates for cervical cancer screening services are very low outside of developed countries, and women at the highest risk of developing cervical cancer are among the least likely to be screened. Coverage rates decline with advancing age, when cervical cancer incidence rates are the highest. Poor women, who likely have higher exposure to known cervical cancer biological risk factors such as smoking and unsafe sex [62], also show much lower coverage rates. Improving the effective coverage of cervical cancer screening or developing alternative ways to decrease cervical cancer mortality worldwide would have a considerable impact on decreasing the disease’s burden as well as overall health inequalities. No one strategy will work everywhere, making it important to consider multiple strategies across—and likely within—countries.