Gynaecological Oncology, Westmead Hospital, Westmead, New South Wales
The story of cervical cancer control is a drama of epic proportions. It has chapters on basic science, viral infection and carcinogenesis, epidemiology and the successful integration of multimodality cancer therapy. It is the story of the most successful cancer screening project in human history, having reduced the most common cancer in women to a rare event in many populations. Australia now has the lowest mortality from cervical cancer in the world. And finally, with universal vaccination programs we have the prospect of completely eradicating a whole range of human papillomavirus (HPV) related disease.
This edition of Cancer Forum celebrates and reviews the achievements and remaining challenges of cervical cancer control in Australia. Cathryn Wharton and colleagues summarise the current status of cervical cancer in Australia. Despite the successes of the screening program, there are still challenges and Penny Blomfield and Marion Saville address the problem of glandular lesions – a type of cervical cancer that has had little impact from screening in any jurisdiction.
Women still develop the disease and there are treatment challenges for clinicians working in the area. Jim Nicklin summarises the current state of the art in relation to treatment. Kim Hobbs acknowledges and addresses the unique psychosocial dimensions of this cancer – due to the demographics of the population who develop the disease and to its largely preventable nature, women who are diagnosed with cervical cancer will often face uniquely distressing circumstances. Encouragingly, the small cohort of young women who develop cervical cancer will gain hope from the prospects of fertility preserving surgery discussed by Alison Brand.
Finally, Margaret Davy reviews some of the history of the cervical screening program, which is a case study in successful collaboration across various stakeholder groups that has extended over decades.
The viral aetiology of this cancer has opened the prospect of a new population based approach to cancer control. The Australian National HPV Vaccination program means that Australian women will be among the first cohort of young women in the world to be vaccinated against a whole range of HPV diseases. Into the future, there is the prospect of vaccines to treat these diseases: these prospects are discussed by Merja Ruutu and colleagues from the University of Queensland, all of whom have been instrumental in the development of the prophylactic vaccines.
Cervical cancer prevention has traditionally been based on cervical cytologic surveillance detecting a wide range of cellular abnormalities. Cervical cytology has been successful despite its poor sensitivity and specificity. It has recently been supplemented by the HPV vaccination program, which will eventually dramatically worsen the sensitivity of cytology.
The time is now right for a completely new approach to cervical cancer prevention in Australia. Having these twin pillars of cervical cancer prevention in place, along with the immense infrastructure and expertise that has developed in the area, Australia has a unique opportunity to now seek the best way to prevent cervical cancer in its population into the future. We have an opportunity to build on the twin pillars, incorporate new technology and algorithms and develop a highly sophisticated and comprehensive re-engineered program.
However, this will not be simple, as cervical cancer prevention is characterised by diverse and often-conflicting interests. Previous attempts to introduce change have been resisted fiercely. The current screening program is not sustainable for a whole range of reasons. Cytologic techniques are too valuable a resource to be wasted on screening and there are more efficient techniques available, such as molecular testing for HPV, that need to be efficiently and safely incorporated into our prevention paradigm.
The challenge for the cancer control community is to bravely move into the future, embrace new technologies, build on the scientific evidence base and provide a comprehensive cervical cancer prevention program.