Abstract
PURPOSE
The vast majority of cervical cancer is preventable through human papillomavirus vaccination and screening with cytology or DNA testing. After decades of progress, recent cervical cancer trends in Western populations show a plateau or modest increase in incidence rates. Further investigation is required to understand the drivers of these emerging trends. In this study, we examined age-specific cervical cancer incidence rates in Canada from 1992 to 2022.
METHODS
Data were obtained from the Canadian Cancer Registry maintained by Statistics Canada, which included cancer cases, population counts, and incidence rates of cervical cancer by age and province for the period 1992 to 2022. Joinpoint regression analysis was used to estimate temporal incidence trends across age groups.
RESULTS
Cervical cancer incidence rates in Canada decreased among women age 25-34 years and those 65 years and older since 1992. Incidence rates among women age 35-44 years and 45-54 years have increased by 1.1% (95% CI, 0.5 to 2.5) and 1.6% (95% CI, –0.1 to 8.6) per year since 2001 and 2012, respectively. In 2022, the highest incidence rate of cervical cancer was among women age 35-44 years (18.1 per 100,000 women), which is comparable with rates in 1992.
CONCLUSION
Cervical cancer incidence rates have been increasing in recent years among women age 35-54 years. This cohort may be falling into a cancer prevention gap. Targeted public health interventions are warranted to address the rising incidence of cervical cancer among this cohort of Canadian women.
INTRODUCTION
Cervical cancer incidence and mortality have significantly declined since the 1950s, largely because of human papillomavirus (HPV) vaccination and cytology-based screening (ie, the Papanicolaou test) and, more recently, HPV DNA testing.1-4 Despite this progress, cervical cancer remains the fourth most common cancer among women globally.5 Persistent infection with an oncogenic genotype of HPV is a primary cause of cervical cancer.6 In Canada, between 2007 and 2010, all provinces and territories implemented publicly funded, school-based vaccination programs for girls.8 In addition, most provinces have established organized cervical cancer screening programs since the early 2000s, whereas others rely on opportunistic screening through primary care.7
In 2020, the WHO9,10 launched a unifying goal of cervical cancer elimination, defined as fewer than 4 cases per 100,000 women-years. To align with the WHO, Canada has committed to cervical cancer elimination by 2040.11 In Canada, in 2024, there were an estimated 1,600 new patients with cervical cancer and 400 deaths, and the projected incidence rate of cervical cancer was 8 per 100,000 women-years, double the elimination target.12 Concerningly, after a 30-year decline in cervical cancer incidence, the rates have been increasing by 3.7% per year since 2015,13 with diagnoses being made both in younger age groups and at later stages of disease.14-17 Cervical cancer is now the fastest-increasing cancer among Canadian women.13 This study aimed to examine the detailed trends in cervical cancer incidence over the past 30 years across age groups to understand what factors may be driving the reported increases in overall cervical cancer rates in Canada.
METHODS
Registered cases of cervical cancer aggregated over 5-year age groups, with corresponding population counts, were obtained from 1992 to 2022 by province from the Canadian Cancer Registry (CCR) via the Statistics Canada Web Data Services API. The CCR is a population-based registry comprising provincial and territorial cancer registry data submitted to Statistics Canada,18 where the data are collected and maintained. Nova Scotia and Quebec were excluded from the analysis because of incomplete reporting to 2022. Cervical cancers were defined by the International Classification for Disease (10th edition) code C53 cancers.
At both the national and provincial level, we described age-specific cervical cancer incidence trends and estimated age-specific annual percent changes (APC) and average annual percent changes with corresponding 95% CIs. We used age categories relevant to cervical cancer screening in Canada (25-34, 35-44, 45-54, 55-64, 65-74, ≥75 years) and truncated age groups younger than 25 years. For provincial analysis, because of small number of patients, we grouped the Atlantic provinces (New Brunswick, Prince Edward Island, and Newfoundland) and grouped age as 25-54 and ≥55 years. Statistical analysis was conducted using Joinpoint Regression Program, version 5.0, developed by the National Cancer Institute, which identifies inflection points in temporal trends and fits linear segments to the log-transformed incidence rates.
RESULTS
National Age-Specific Cervical Cancer Trends
Among younger women age 25-34 years, incidence rates decreased from 10.6 to 9.2 per 100,000 between 1992 and 2022 (APC –0.4% [95% CI, –0.8 to –0.1]; Fig 1 and Table 1). For those age 35-44 years, incidence rate declined until 2001, followed by an increase from 12.7 to 18.1 per 100,000 (APC 1.1% [95% CI, 0.5 to 2.5]). This age group also had the highest rate of cervical cancer in 2022 at 18.1 per 100,000, which was comparable with the rate in 1992 (Data Supplement, Table S1). Among women age 45-54 years, the rate decreased from 1992 to 2012, followed by an increase from 10.9 to 15.1 per 100,000 (APC 1.6% [95% CI, –0.1 to 8.6]). In the 55-64 age group, incidence rates decreased from 1992 to 2015 by –1.8% (95% CI, –5.7 to 3.8) annually, followed by a slight increase of 0.7% (95% CI, –1.7 to 8.2). Among women age 65-74 years, the rate decreased by –4.2% (95% CI, –11.4 to –2.5) annually until 2005, followed by a smaller decline of –1.1% (95% CI, –2.3 to 5.6). The ≥75 age group experienced the most sustained decline throughout the study period (APC, –3.1% [95% CI, –3.6 to –2.7]).
FIG 1.
Trends in age-specific cervical cancer incidence rates in Canada. We present APC in age-specific cervical cancer incidence rates with 95% CIs (shaded regions) among women in Canada (excluding Quebec and Nova Scotia), separately by age group from 1992 to 2022. Lines show the estimated trends in incidence rates on the basis of Joinpoint regression. Points show the actual age-specific incidence rates by age group. Dashed black line represents WHO cervical elimination target of 4 cases per 100,000 persons. APC, annual percent change.
TABLE 1.
Age-Specific Trends in Cervical Cancer Incidence Rates (per 100,000 women), Canada (excluding Quebec and Nova Scotia), 1992-2022
| Age Category, Years | Period | Rates (per 100,000) | APC (95% CI) | AAPC (95% CI) | |
|---|---|---|---|---|---|
| Starting | Ending | ||||
| 25-34 | 1992-2022 | 10.6 | 9.2 | –0.4 (–0.8 to –0.1) | –0.4 (–0.8 to –0.1) |
| 35-44 | 1992-2001 | 17.9 | 12.7 | –2.8 (–8.8 to –0.7) | –0.1 (–0.6 to 0.4) |
| 2001-2022 | 12.7 | 18.1 | 1.1 (0.5 to 2.5) | ||
| 45-54 | 1992-2012 | 16.3 | 10.9 | –1.4 (–3.5 to –0.7) | –0.4 (–0.9 to 0.1) |
| 2012-2022 | 10.9 | 15.1 | 1.6 (–0.1 to 8.6) | ||
| 55-64 | 1992-2015 | 15.7 | 10.1 | –1.8 (–5.7 to 3.8) | –1.2 (–1.8 to –0.6) |
| 2015-2022 | 10.1 | 10.9 | 0.7 (–1.7 to 8.2) | ||
| 65-74 | 1992-2005 | 18.2 | 8.9 | –4.2 (–11.4 to –2.5) | –2.4 (–3.1 to –1.7) |
| 2005-2022 | 8.9 | 9.8 | –1.1 (–2.3 to 5.6) | ||
| ≥75 | 1992-2022 | 17.5 | 7.5 | –3.1 (–3.6 to –2.7) | –3.1 (–3.6 to –2.7) |
NOTE. Bold indicates statistical significance.
Abbreviations: AAPC, average annual percentage change; APC, annual percentage change.
Birth cohort analysis showed that women born after 1993 had lower incidence rates compared with those born between 1953 and 1957, consistent with early impacts of HPV vaccination (Data Supplement, Fig A1). By contrast, women born between 1965 and 1992 had rates comparable with those born between 1946 and 1964, whereas individuals born before 1946 had progressively higher rates.
Provincial Age-Specific Cervical Cancer Trends
Across most regions, incidence rates decreased among women age ≥55 years, with the largest declines in Manitoba (APC, –2.7% [95% CI, –4.8 to –0.7]) and the Atlantic region (APC, –2.7% [95% CI, –4.1 to –1.1]; Table 2 and Data Supplement, Fig A2). Among women age 25-54 years, rates increased over the entire study period in Saskatchewan and the Atlantic region (APCs, 1.4% [95% CI, 0.4 to 2.6] and 0.6% [95% CI, –1.0 to 2.3], respectively), whereas in British Columbia and Ontario rates declined initially then reversed in 2003 (APC, 1.2% [95% CI, 0.3 to 4.9]) and in 2001 (APC, 0.2% [95% CI, –0.3 to 2.5]), respectively.
TABLE 2.
Age-Specific Trends in Cervical Cancer Incidence Rates (per 100,000 women), by Region (excluding Quebec and Nova Scotia), 1992-2022
| Region | Age Group, Years | Period | Rates (per 100,000) | APC (95% CI) | AAPC (95% CI) | |
|---|---|---|---|---|---|---|
| Starting | Ending | |||||
| Alberta | 25-54 | 1992-2022 | 17.0 | 13.7 | –0.7 (–1.3 to –0.2) | –0.7 (–1.3 to –0.2) |
| ≥55 | 1992-2022 | 23.8 | 11.2 | –2.2 (–3.0 to –1.2) | –2.2 (–3.0 to –1.2) | |
| Atlantic provinces | 25-54 | 1992-2022 | 14.2 | 16.2 | 0.6 (–1.0 to 2.3) | 0.6 (–1.0 to 2.3) |
| ≥55 | 1992-2022 | 19.9 | 8.2 | –2.7 (–4.1 to –1.1) | –2.7 (–4.1 to –1.1) | |
| British Columbia | 25-54 | 1992-2003 | 12.9 | 10.2 | –2.4 (–9.2 to –0.4) | –0.2 (–0.8 to 0.5) |
| 2003-2022 | 10.2 | 14.4 | 1.2 (0.3 to 4.9) | |||
| ≥55 | 1992-2013 | 13.8 | 6.9 | –2.8 (–14.7 to 15.8) | –1.4 (–2.9 to 0.2) | |
| 2013-2022 | 6.9 | 10.8 | 2.0 (–7.6 to 21.4) | |||
| Manitoba | 25-54 | 1992-2022 | 13.0 | 18.6 | –0.5 (–1.5 to 0.5) | –0.5 (–1.5 to 0.5) |
| ≥55 | 1992-2022 | 22.6 | 11.6 | –2.7 (–4.8 to –0.7) | –2.7 (–4.8 to –0.7) | |
| Ontario | 25-54 | 1992-2001 | 14.5 | 10.7 | –2.3 (–8.5 to –0.6) | –0.6 (–1.0 to –0.1) |
| 2001-2022 | 10.7 | 12.9 | 0.2 (–0.3 to 2.5) | |||
| ≥55 | 1992-2003 | 16.4 | 11.0 | –3.8 (–11.9 to –1.7) | –2.3 (–3.0 to –1.5) | |
| 2003-2022 | 11.0 | 9.2 | –1.4 (–6.6 to 5.3) | |||
| Saskatchewan | 25-54 | 1992-2022 | 15.3 | 24.7 | 1.4 (0.4 to 2.6) | 1.4 (0.4 to 2.6) |
| ≥55 | 1992-2022 | 12.2 | 5.5 | –1.6 (–3.4 to 0.2) | –1.6 (–3.4 to 0.2) | |
NOTE. Bold indicates statistical significance.
Abbreviations: AAPC, average annual percentage change; APC, annual percentage change.
DISCUSSION
This 30-year national analysis revealed shifting cervical cancer incidence trends by age group. Although rates decreased among older age groups, women age 35-54 experienced trend reversals, with rates rising since the early 2000s. By 2022, women age 35-44 years had the highest incidence rate nationally, and similar patterns were observed in most regions.
These findings should be considered in the context of WHO's global strategy and the Canadian Partnership Against Cancer's (CPAC) national framework for cervical cancer elimination.10,11 Although Canada has made progress, current incidence rates across all ages remain above the elimination threshold. Implementation of HPV DNA primary testing, including self-testing, could help address these gaps, particularly in underserved populations. The COVID-19 pandemic also disrupted screening services, with reductions in the number of Pap tests and colposcopies reported across Canada.19-22 The downstream impact of these reductions may not yet be fully reflected in rates reported up to 2022.
Our birth cohort analyses suggested that while cohorts born after 1993 are starting to see some benefit of vaccination, the 35-54 age group, born between 1971 and 1990, has not had notable improvements compared to those born between 1946 and 1964. This group may have missed the benefits of school-based vaccination programs introduced in 2007 and may not have received catch-up doses because of a lack of awareness and/or cost.
Another critical factor is access to screening. In Canada, younger adults experience higher levels of geographic mobility, often relocating for education or work. This mobility, coupled with a shortage of primary care physicians (PCPs), has likely exacerbated gaps in access to preventative health care. It is estimated that nearly half (48%) of Canadian women age 18-49 years lack a regular PCP, which contributes to disruptions in cervical cancer screening.23 A national report from 2016 highlighted this issue, finding that up to 30% of screen-eligible women younger than 50 years did not undergo cervical cancer screening between 2010 and 2013.24 This underscores a critical gap in cancer prevention efforts with potentially severe consequences for women who are underscreened, as evidenced by the rising incidence rates in younger women observed in our study. Similar trends have also been observed in other studies, with diagnoses being made both in younger age groups and at later stages of disease.14-17
Our study had several limitations. Owing to data limitations, we were unable to explore vaccination and screening patterns, cancer staging, sociodemographic factors, and other factors known to influence screening rates and cervical cancer incidence. Although individual-level screening data were not available for this analysis, population-level participation remains an important factor in understanding cervical cancer incidence trends. According to recent reports from the CPAC, cervical cancer screening participation rates in most provinces and territories fall below the national target of 90%, with many jurisdictions reporting rates between 60% and 70%.24 These suboptimal screening rates may contribute to the continued incident cases. Another limitation is that we did not have information on hysterectomy status. As a result, we were unable to adjust the population denominators for hysterectomy status, which may have led to an underestimation of cervical cancer incidence rates, particularly for older age groups.
When interpreting long-term cervical cancer incidence trends, it is important to consider the broader public health and health policy context, as well as changes in technologies and diagnostic classification systems. The implementation of school-based HPV vaccination programs in Canada was often accompanied by public education campaigns in schools and communities raising awareness about HPV and cervical cancer prevention.25,26 These initiatives, together with national awareness efforts led by organizations such as CPAC, may have led to increased public awareness, improved screening uptake, and earlier detection in subsequent years.25,26 However, the extent of the public awareness campaigns varied across jurisdictions, which may have contributed to the regional variations we observed in incidence trends.
In conclusion, we observed increasing cervical cancer incidence rates among women age 35-54 years, particularly in the 35-44 age group, who had the highest incidence rate in 2022. By contrast, incidence rates decreased among older age groups, although at a slower pace in recent years. These trends point to a potential prevention gap for women who missed early vaccination programs and may face barriers to screening access. Targeted public health strategies, including implementing HPV DNA primary screening with access to self-testing, catch-up vaccination programs, and outreach to underserved populations, are needed to support Canada's elimination goals. Without these focused initiatives, cervical cancer rates could continue to increase, reversing decades of progress.
Corinne Doll
Employment: Alberta Health Services, Arthur Child Comprehensive Cancer Center
No other potential conflicts of interest were reported.
SUPPORT
Supported by the Canadian Institute of Health Research Fellowship (No. 530744; I.A.N.) and the Armstrong Investigatorship in Molecular Cancer Epidemiology (D.R.B.).
AUTHOR CONTRIBUTIONS
Conception and design: Ioana A. Nicolau, Matthew T. Warkentin, Corinne Doll, Heather Bryant, Darren R. Brenner
Collection and assembly of data: Ioana A. Nicolau, Matthew T. Warkentin, Kirk Graff, Darren R. Brenner
Data analysis and interpretation: All authors
Manuscript writing: All authors
Final approval of manuscript: All authors
Accountable for all aspects of the work: All authors
AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to https://ascopubs.org/authors.
Corinne Doll
Employment: Alberta Health Services, Arthur Child Comprehensive Cancer Center
No other potential conflicts of interest were reported.
REFERENCES
- 1. Shahmoradi Z, Damgacioglu H, Clarke MA, et al. Cervical cancer incidence among US women, 2001-2019. JAMA. 2022;328:2267–2269. doi: 10.1001/jama.2022.17806. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Warkentin MT, Ruan Y, Ellison LF, et al. Progress in site-specific cancer mortality in Canada over the last 70 years. Sci Rep. 2024;14:5688. doi: 10.1038/s41598-024-56150-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Shaw PA. The history of cervical screening I: The Pap. Test. J SOGC. 2000;22:110–114. [Google Scholar]
- 4. Pataky RE, Izadi-Najafabadi S, Smith LW, et al. Strategies to accelerate the elimination of cervical cancer in British Columbia, Canada: A modelling study. Can Med Assoc J. 2024;196:E716–E723. doi: 10.1503/cmaj.231682. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74:229–263. doi: 10.3322/caac.21834. [DOI] [PubMed] [Google Scholar]
- 6. De Martel C, Plummer M, Vignat J, et al. Worldwide burden of cancer attributable to HPV by site, country and HPV type. Int J Cancer. 2017;141:664–670. doi: 10.1002/ijc.30716. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Canadian Partnership Against Cancer Cervical cancer screening in Canada: 2021/2022. https://www.partnershipagainstcancer.ca/topics/cervical-cancer-screening-in-canada-2021-2022/programs/
- 8. Dubé E, Gagnon D, Clément P, et al. Challenges and opportunities of school-based HPV vaccination in Canada. Hum Vaccin Immunother. 2019;15:1650–1655. doi: 10.1080/21645515.2018.1564440. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.World Health Organization . Cervical Cancer Fact Sheet. Geneva Switzerland, WHO, 2024. https://www.who.int/news-room/fact-sheets/detail/cervical-cancer [Google Scholar]
- 10.World Health Organization Global strategy to accelerate the elimination of cervical cancer as a public health problem. Geneva, Switzerland, WHO; 2020. https://iris.who.int/bitstream/handle/10665/336583/9789240014107-eng.pdf?sequence=1 [Google Scholar]
- 11.Canadian Partnership Against Cancer . Action Plan for the Elimination of cervical cancer in Canada, 2020–2030 (Action Plan) 2024. https://s22457.pcdn.co/wp-content/uploads/2020/11/Elimination-cervical-cancer-action-plan-EN.pdf [Google Scholar]
- 12. Brenner DR, Gillis J, Demers AA, et al. Projected estimates of cancer in Canada in 2024. CMAJ. 2024;196:E615–E623. doi: 10.1503/cmaj.240095. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Canadian Cancer Statistics 2023. 2023. https://cancer.ca/Canadian-Cancer-Statistics-2023-EN [Google Scholar]
- 14. Beachler DC, Tota JE, Silver MI, et al. Trends in cervical cancer incidence in younger US women from 2000 to 2013. Gynecol Oncol. 2017;144:391–395. doi: 10.1016/j.ygyno.2016.11.031. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Francoeur AA, Liao C-I, Caesar MA, et al. The increasing incidence of stage IV cervical cancer in the USA: What factors are related? Int J Gynecol Cancer. 2022;32:1115–1122. doi: 10.1136/ijgc-2022-003728. [DOI] [PubMed] [Google Scholar]
- 16. Raveinthiranathan N, Simkin J, Donken R, et al. Age-specific trends of invasive cervical cancer incidence in British Columbia, Canada, 1971–2017. Curr Oncol. 2023;30:7692–7705. doi: 10.3390/curroncol30080557. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Shack L, Lau HY, Huang L, et al. Trends in the incidence of human papillomavirus-related noncervical and cervical cancers in Alberta, Canada: A population-based study. CMAJ Open. 2014;2:E127–E132. doi: 10.9778/cmajo.20140005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Statistics Canada . Canadian Cancer Registry Documentation. https://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=3207 [Google Scholar]
- 19.Canadian Partnership Against Cancer Response to COVID-19. https://www.partnershipagainstcancer.ca/topics/cervical-cancer-screening-in-canada-2021-2022/key-highlights/response-covid-19/
- 20. Decker KM, Feely A, Bucher O, et al. Evaluating the impact of the COVID-19 pandemic on cancer screening in a central Canadian province. Prev Med. 2022;155:106961. doi: 10.1016/j.ypmed.2022.106961. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. El-Zein M, Ali R, Farah E, et al. Pan-Canadian survey on the impact of the COVID-19 pandemic on cervical cancer screening and management: Cross-sectional survey of healthcare professionals. Elife. 2023;12:e83764. doi: 10.7554/eLife.83764. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Meggetto O, Jembere N, Gao J, et al. The impact of the COVID-19 pandemic on the Ontario Cervical Screening Program, colposcopy and treatment services in Ontario, Canada: A population-based study. Bjog. 2021;128:1503–1510. doi: 10.1111/1471-0528.16741. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Statistics Canada Primary health care providers, 2019. 2020. Health Fact Sheets. https://www150.statcan.gc.ca/n1/pub/82-625-x/2020001/article/00004-eng.htm
- 24.Canadian Partnership Against Cancer . Cervical cancer screening in Canada, monitoring and evaluation of quality indicators—Results report 2011 to 2013 (2016) Toronto, Ontario, Canada: https://www.partnershipagainstcancer.ca/topics/cervical-cancer-screening-quality-indicators [Google Scholar]
- 25.Canadian Partnership Against Cancer . Cross-cutting recommendations: Awareness and education. https://www.partnershipagainstcancer.ca/topics/hpv-screening-pathway/cross-cutting-recommendations/awareness-education/ [Google Scholar]
- 26. Perez S. Progress and challenges in Canada's path toward the elimination of cervical cancer. Curr Oncol. 2024;31:5850–5861. doi: 10.3390/curroncol31100435. [DOI] [PMC free article] [PubMed] [Google Scholar]