Background

Cervical cancer is a leading cause of mortality among women. In 2020, an estimated 604 000 women were diagnosed with cervical cancer worldwide and about 342 000 women died from the disease. Cervical cancer is the most commonly diagnosed cancer in 23 countries and is the leading cause of cancer death in 36 countries. The vast majority of these countries are in sub-Saharan Africa, Melanesia, South America, and South-Eastern Asia.

In May 2018, Dr Tedros Adhanom Ghebreyesus, World Health Organization (WHO) Director-General, issued a call to action for the elimination of cervical cancer. In November 2020, the Director-General launched the Global strategy to accelerate the elimination of cervical cancer, including the following targets for each of the three pillars for 2030: 90% human papillomavirus (HPV) vaccination coverage of eligible girls, 70% screening coverage with a high-performance test and 90% of women with a positive screening test or a cervical lesion managed appropriately. Following the launch of the global strategy, a large panel of experts met to define the key areas of focus to increase access to screening and treatment to reach the 2030 targets. One of the agreed areas of focus was to update the existing WHO recommendations for screening and treatment to prevent cervical cancer, and to simplify the algorithms.

Methods

This updated guideline for screening and treatment to prevent cervical cancer was developed in three steps:

1. Review the current guidelines and identify recommendations to update or to develop de novo.
2. Develop questions based on population (P), intervention (I), comparator (C) and outcomes (O) (PICO questions) for the recommendations and conduct new systematic reviews or update those conducted for the previous guideline, and model outcomes when primary research was not available.
3. Apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to assess the certainty of evidence and to develop recommendations using evidence-to-decision (EtD) tables.

The Guideline Development Group (GDG) for this guideline was formed in early 2019, and the GDG, WHO Secretariat, methodologists and technical groups (see Annex 1) met several times to establish the PICO questions, methodology and timeline. The WHO Secretariat led and coordinated the whole process to ensure recommendations were developed in line with the WHO handbook for guideline development, second edition (2014). The methods for evidence synthesis and mathematical modelling were used as applied in the previous edition of the guideline, WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. Based on clinical expertise, research and knowledge of tests in development, the Guideline Development Group (GDG) initially identified the screening tests and clinical algorithms for screening and treatment that could be evaluated. The GDG prioritized seven algorithms for evaluation, and these informed the systematic reviews. In 2020, the systematic review teams performed the systematic reviews for each of the PICO questions and, in parallel, the systematic reviews that had been prepared for the International Agency for Research on Cancer’s IARC handbooks of cancer prevention: cervical cancer screening, Vol. 18 (2021) were integrated for the development of these recommendations.

When relevant evidence was not available in primary research, a mathematical model was used to estimate the risk of important outcomes (e.g. recurrence of high-grade cervical intraepithelial neoplasia [CIN], cervical cancer) associated with the use of different screening and treatment strategies. In addition, a modelling group was created to evaluate the impact and cost–effectiveness of the different screening and treatment algorithms. Furthermore, we searched the published literature for studies providing information on acceptability, feasibility and costing aspects of these algorithms, and conducted a survey on feasibility and values and preferences of people using these services. GDG meetings took place on a weekly basis between August 2020 and November 2020 to review and assess the evidence and agree on the final new and updated recommendations and good practice statements presented in this guideline.

Summary of screening and treatment recommendations to prevent cervical cancer

In this present publication, there is a total of 23 recommendations and 7 good practice statements.

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Among the 23 recommendations, 6 are identical for both the general population of women and for women living with HIV and 12 are different and specific for each population.

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Among the 7 good practice statements, 3 are identical for both the general population of women and for women living with HIV and 2 are different and specific for each population.

In Table 1 below we have grouped the recommendations and good practice statements in two columns for the general population of women (left column, nos. 1–14) and for women living with HIV (right column, nos. 21–34), while in Table 2, the populations are not separated (nos. 41 and 42).¹

There are currently 11 recommendations and 3 good practice statements for each population in Table 1, and an additional recommendation and good practice statement for both populations in Table 2.

Table 1

Screening and treatment recommendations and good practice statements for the general population of women and women living with HIV.

Table 2

Recommendation and good practice statement for treatment not covered in previous guidelines.

Footnotes

1

There are gaps in these numbers because WHO intends to issue additional recommendations soon on screening tests and implementation, which will be numbered as needed (expected to be 15–20 for the general population of women and 35–40 for women living with HIV).