Insufficient resources for cervical cancer in Pakistan: a significant burden on public health

Cervical cancer ranks fourth globally among women’s cancer causes ^[1^], while in Pakistan, it ranks as the third most common cancer among women and the second most common in the age range of 15–44 years^[2^]. The mortality rate according to a World Health Organization (WHO) report published in 2024 is 350 000 deaths in 2022 worldwide^[1^]. Every year, approximately 5008 women in Pakistan receive cervical cancer diagnosis, with a reported mortality rate of 3197^[2^]. This high number necessitates early detection and treatment to control. Persistent and untreated human papilloma virus (HPV) infection causes 95% of cervical cancers^[1^], while HPV subtypes 16 and 18 contribute about 88.1% of invasive cancers^[2^].

According to the American College of Obstetricians and Gynecologists (ACOG) guidelines published in April 2023, there are several screening methods available for early detection and, in turn, treatment to decrease the mortality rate. Globally, screening begins at age 21 years, with a recommendation for cytology every 3 years until age 30 years. From 30–65 years of age, there are three screening tests available (Table 1):

• Every 5 years, primary high-risk human papilloma-virus (HRHPV) testing.

• Cervical cytology every 3 years.

• Co-testing involves both primary HRHPV testing and cervical cytology^[3^].

Table 1.

Screening methods for cervical cancer (based on ACOG guidelines)

Age group	Recommended screening method	Frequency
21–30 years	Cytology (Pap smear)	Every 3 years
30–65 years	Primary hrHPV testing	Every 5 years
	Cervical cytology (Pap smear)	Every 3 years
	Co-testing (hrHPV + cytology)	Every 5 years

hrHPV, high-risk human papillomavirus. Data based on ACOG April 2023 Guidelines.

Despite global recommendations for these tests, the uptake of these tests is significantly low in Pakistan, a lower-middle-income country where discussions around sexual health remain taboo, resulting in a high mortality rate (Table 2). The increasing incidence is further burdened by the lack of awareness about cervical cancer and other health issues. Numerous barriers, some at the level of health professionals and others at the patient’s level, contribute to this lack of screening awareness. Physicians mostly cited obstacles and enablers at the policy and individual levels, whereas women believed that the primary issues (organizational level) were poor quality and restricted access to health care services (Table 3). Women still encounter obstacles that prevent them from fully adhering to routine screening, even in the case of an effective cervical cancer screening program that provides free screening. These obstacles include not having enough time to see a doctor, not having family support, and physically being far from health facilities. At a personal level, women are unaware of the future risks, are feared, and feel a sense of embarrassment because of a lack of education^[4^]. At the societal level, lower- and middle-class families often stigmatize screening, believing that the screening itself may cause the disease^[4^] or that it is merely a means for physicians to enhance their earnings. Another factor implicated in this is the lack of privacy and equipment in tertiary care centers, where the majority of patients report these issues as having a traumatizing impact on the female population.

Table 2.

Incidence and mortality of cervical cancer in Pakistan and globally (mortality data from WHO 2024; Pakistan-specific data from HPV Information Centre)

Region	Incidence (annual)	Mortality (annual)	Most affected age group	Rank among cancers
Global	N/A	350 000 deaths (2022)	N/A	4th
Pakistan	5008 cases	3197 deaths	15–44 years	3rd

Table 3.

Barriers to cervical cancer screening in Pakistan

Barrier level	Specific barriers
Individual level	Lack of awareness, fear, embarrassment, misconceptions about screening causing disease.
Societal level	Stigma around sexual health discussions, financial constraints, lack of family support.
Organizational level	Poor healthcare access, inadequate facilities, lack of privacy, insufficient training for health care providers.

HPV vaccination is recommended to prevent one of the leading causes of HPV or cervical cancer. According to WHO, till 2023, there were six vaccines available worldwide recommended for all girls aged 9–14 years or before they become active sexually (Table 4) ^[1^]. All these vaccines protect against HPV 16 and 18, the two major subtypes of invasive cervical cancer^[1^]. The availability of these vaccines is extremely limited in Pakistan, and their high cost significantly hinders their uptake, as the majority of people cannot afford them^[5^].

Table 4.

WHO-approved HPV vaccines for girls aged 9–14 years

Vaccine name	Manufacturer	HPV types covered	Recommended age	Dosage schedule	Availability in Pakistan
Cervarix	GlaxoSmithKline	HPV 16, 18	9–14 years	2 doses (0, 6 months)	Limited
Gardasil	Merck	HPV 6, 11, 16, 18	9–14 years	2 doses (0, 6 months)	Limited
Gardasil 9	Merck	HPV 6, 11, 16, 18, 31, 33, 45, 52, 58	9–14 years	2 doses (0, 6 months)	Not available
Cecolin	Innovax/China	HPV 16, 18	9–14 years	2 doses (0, 6 months)	Not available
Cervavax	Serum Institute of India	HPV 16, 18	9–14 years	2 doses (0, 6 months)	Not available
Walrinvax	Walvax/China	HPV 16, 18	9–14 years	2 doses (0, 6 months)	Not available

The estimated incidence burden of cervical cancer in Pakistan surpasses the WHO’s target due to a lack of acceptance and availability of screening methods. The combined data analysis from 1995 to 2022 in Pakistan produced both unadjusted and adjusted age-standardized incidence rates for cervical cancer, surpassing the WHO’s eradication objective of 4 per 100 000 women^[6^]. Pakistan now ranks among the top 10 countries with the highest cervical cancer mortality rate^[7^]. A recent study from 2022 revealed that inadequate knowledge about HPV vaccination, cervical cancer risk factors, and misunderstandings about cervical screening significantly hindered the effective reduction of cancer incidence and early detection. This issue was not exclusive to individuals from lower socioeconomic classes, as even those with higher socioeconomic status lacked knowledge about cancer prevention and early detection^[7^]. The incidence of new cases reported from the three registeries in Pakistan, according to a recent research paper on the basis of age-standardized incidence rates, is 3376/year^[6^]. The Pakistan cervical cancer profile from 2021 reports a crude cervical cancer rate of 4.7/100 000 women, and an age-specific rate of 6.1/100 000 women^[8^].

The government should establish programs that enable women to undergo screening at work, utilize portable point-of-care devices for HPV detection, and establish mobile medical units in remote areas. We should prioritize self-administered tests over samples taken by a medical professional, as this could potentially alleviate the fear of pain. The government should establish programs that enable women to undergo screening at work, utilize portable point-of-care devices for HPV detection, and establish mobile medical units in remote areas. Furthermore, doctors who communicate clearly and empathetically with one another may reduce women’s apprehension and even overcome their existing aversion to receiving medical care from men. This calls for sufficient training in doctor–patient communication and has the potential to raise public confidence in health care systems generally. Health care practitioners recognize that establishing a thorough cervical screening program demands resources often lacking in low- and middle-income nations. Nonetheless, fostering strategic partnerships at the community level, leveraging both public and private resources and initiatives, can strengthen cervical cancer prevention efforts.

Ethical approval

Not applicable.

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Sources of funding

None.

Author’s contributions

J.Q., M.M. was involved in study concept and design, data collection and writing and J.G. participated in writing, editing, and publication of study.

Conflicts of interest disclosure

None.

Guarantor

Jaazba Qamar.

Research registration unique identifying number (UIN)

Not applicable.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

Not applicable.