The Patient Experience Across the Cervical Cancer Care Pathway
Cervical cancer is highly preventable, with HPV vaccination as primary prevention and screening for cervical pre-cancer as secondary prevention. In LMICs, neither form of prevention is commonly available. Even when screening is available, there is low uptake. Screening in LMICs, when available, is typically by visual inspection of the cervix at a PHC facility. This can trigger a decision to treat cervical pre-cancer lesions. Because this method has poor sensitivity and specificity, it can result in both under- and over-treatment. WHO guidelines recommend molecular diagnostics as a screening step to detect HPV DNA and additional testing as a triage step before treatment. These recommended methods often require patients to be referred or patient samples transferred to a different facility at the PHC level or higher, delaying treatment and causing loss to follow-up. The patient experience described below focuses on the LMIC context. Missed pre-cancer detection is currently a critical roadblock in preventing cervical cancer.
WHO Guidelines
WHO guidelines provide recommended standards for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention (including screen-and-treat as well as screen, triage, and treat approaches), without specifying at what level of health facilities these services should be provided.
Primary Prevention
The HPV vaccine is highly effective at preventing infection by virus strains most commonly associated with cervical cancer. Learn moreChallenges
The high cost of the HPV vaccine is a significant barrier for widespread use in LMICs. While Gavi-supported countries can procure the vaccine at subsidized prices that UNICEF procures (as low as $4.50 per dose as of March 2025), the cost burden often falls on the health system rather than individuals. This is especially true at the PHC level, which may also lack the infrastructure required to store and distribute vaccines, including cold-chain systems. Furthermore, the stigma around sexually transmitted infections including HPV (for which the WHO recommends 90% of girls be fully vaccinated by age 15) can hinder the acceptance and uptake of the vaccine.
Screening
Cervical pre-cancer screening is not common in LMICs, but when it is available, it typically happens at a PHC facility where women undergo a pelvic exam including visual inspection with acetic acid (VIA). After acetic acid solution is applied to the patient’s cervix, abnormal cells appear visibly white. When molecular diagnostics for HPV are not readily available in the health system, this test can serve as detection of cervical pre-cancer, leading to treatment as the next step (after additional tests to guide treatment when they are available). In some settings, cervical pre-cancer screening is integrated at PHC clinics as part of a broad set of women’s health care.WHO guidelines recommend molecular diagnostics as a screening step to detect HPV DNA indicating an HPV infection (and this can improve the accuracy of a follow-on VIA test). In LMICs, these diagnostic tests are typically not at the PHC level, so cervical samples collected by care providers are sent to higher level facilities or central laboratories for testing for the presence of the virus. There are existing tools for self-collection of cervical samples, such as cervicovaginal swabs. Although they are not in routine use in LMICs, self-collection could help lower the barriers to bringing routine molecular testing and a same-day test-and-treat process to the PHC level.
When feasible and especially for women living with HIV, WHO guidelines recommend additional testing as a triage step after screening (with a molecular test or visual assessment) and before treatment. When direct visual assessment (VIA) is the primary screen, this means additional methods typically requiring referral of the patient or transfer of samples outside PHC facilities: cytology by microscopy (Pap smear), cervical imaging (colposcopy) to determine whether and how to treat, and HPV partial genotyping to identify HPV strains associated with a high-risk of cancer for which more aggressive monitoring and treatment is required.
Challenges
Screening based on visual inspection has poor sensitivity and wide-ranging specificity that depends on the age of the patient and the interpretation of the care provider. This can result in both under- and over-treatment. There is a lack of demand for screening due to lack of awareness about cervical cancer and the benefits of preventive screening and due to sociocultural norms and stigmas more broadly around women’s sexual and reproductive health and cancer. There are commonly shortages of the trained female health workers necessary for screening. When there is access to molecular diagnostic testing, turnaround time for results is long, and women often do not return for their results or, when indicated, treatment thus are lost to follow up.
Diagnosis
A cervical biopsy followed by histopathology can provide a more definitive diagnosis of cervical pre-cancer and cancer, guiding subsequent treatment of the cervical lesion.Challenges
In LMICs, cervical biopsies and histopathology are expensive and not commonly available, and treatment of cervical lesions is guided by the best available screening method, which can be visual inspection (VIA) alone. Even when histopathology is done, it has its own challenges as it can be difficult or impossible to differentiate abnormal cells that are progressing towards cancer from those that will not progress. This can be mitigated by adding more information from other tests (such as HPV genotyping) or increasing the frequency of screening in patients with an indeterminate histopathology result. These solutions, however, are expensive, not commonly available in LMICs, and risk loss to follow-up.
Treatment
Women who test positive for cervical pre-cancer by visual inspection, with or without molecular diagnostics to detect HPV infection, are eligible for treatment. The treatment depends on the nature of the cervical lesions, whether a high-risk HPV strain was detected, and the availability of equipment and personnel for treatment. PHC facilities that offer treatment of pre-cancer, sometimes by same-day test-and-treat, typically have an ablation device. The device uses a probe to treat cervical lesions, either by heating (thermal ablation) or by freezing (cryotherapy), which is less commonly available in LMICs. Cervical imaging by colposcopy can be used to guide treatment but is not commonly available at the PHC level. Similarly, formal diagnosis of cancer and more advanced treatment, including removal of more invasive lesions by surgery, would require patient referral to a higher-level health facility or cancer center. WHO guidelines recommend treatment within six months of diagnosis to reduce the risk of progression to cancer and the loss to follow-up.Challenges
After an HPV diagnosis, many patients do not return for treatment and are lost to follow-up. This is due to concerns and stigma associated with possible outcomes, including the financial impact, and the number of visits required across the cascade of care.
Missed Pre-Cancer Detection is a Critical Gap in Care to Prevent Cervical Cancer
Cervical cancer is preventable and treatable. The slow progression from HPV infection to cancer allows for multiple opportunities to screen women for HPV and cervical pre-cancer lesions and to intervene with appropriate treatment. Missed pre-cancer detection is currently a critical gap to fill. A WHO global strategy outlines “90–70–90” targets (Figure 1) that must be met by 2030 for countries to be on the path towards cervical cancer elimination: 90% of girls fully vaccinated (by age 15), 70% of women screened with a high-performance test (by age 35 and again by 45), and 90% of women with identified cervical disease treated. The best approach for cervical pre-cancer screening depends on the local context (Figure 2).
Toward Cervical Cancer Elimination
Cervical Pre-Cancer Screening Approaches
