Strategic approaches for global cervical cancer elimination: An update review and call for national action

Abstract

Cervical cancer remains a major health burden, particularly in low‐ and middle‐income countries, despite being one of the most preventable cancers. WHO's 90–70–90 targets aim to eliminate cervical cancer globally by 2030. These targets include 90% of girls fully vaccinated with the HPV vaccine by the age of 15 years, 70% of women screened using a high‐performance test by the age of 35 years and again by 45 years, and 90% of women with cervical disease receiving appropriate treatment. Achieving these goals requires coordinated national efforts to strengthen health systems, ensure equitable access to care, and integrate cervical cancer control into broader health policies. This review outlines key strategic approaches, including the transition from conventional screening methods to HPV‐based screening, the adoption of innovative triage techniques, the implementation of single‐dose HPV vaccination, and the integration of primary treatment with palliative care. The strategy places strong emphasis on addressing health inequities, enhancing monitoring systems, and fostering partnerships between governments, non‐governmental organizations, and the private sector. With concerted global and national action, the elimination of cervical cancer is not only a possibility but an imminent reality.

1. INTRODUCTION

As of 2024, cervical cancer remains a significant global health challenge. WHO reported approximately 660 000 new cases and 350 000 deaths attributed to cervical cancer in 2022. ¹ The burden of this disease is particularly pronounced in low‐ and middle‐income countries (LMICs), where both incidence and mortality rates are significantly higher than the global average: 17.8 new cases per 100 000 women and 11.5 deaths per 100 000 women, compared to global averages of 13.3 cases and 7.3 deaths per 100 000 women, respectively. ¹ , ² , ³ These statistics underscore substantial disparities in cervical cancer prevention and control, both between and within countries. Sub‐Saharan Africa, Central America, and Southeast Asia report the highest incidence and mortality, exacerbated by limited healthcare access, high HIV prevalence, and socioeconomic inequalities. ² , ³ , ⁴

Women living with HIV (WLHIV) are particularly vulnerable to cervical cancer, with evidence showing a sixfold increased risk compared to the general female population. ² In fact, approximately 5% of all cases of cervical cancer are associated with HIV infection. ² In addition, cervical cancer disproportionately affects younger women, with 20% of children experiencing the loss of their mothers to this malignancy. ⁵ Studies demonstrated an increasing trend in the age‐specific average annual percentage changes in the incidence of cervical cancer among women aged 15–49 years globally. ¹ , ³ Addressing these disparities requires targeted interventions, particularly in LMICs where barriers to HPV vaccination, cervical cancer screening, and treatment persist. Enhancing the status of women in these regions is crucial in reducing these disparities in cervical cancer outcomes. ⁴ , ⁵

In response to the global threat of cervical cancer, WHO has launched a comprehensive strategy aimed at eliminating cervical cancer as a public health problem. The goal is to reduce the incidence of cervical cancer to fewer than four cases per 100 000 women‐years of exposure within the next century. This strategy, known as the 90–70–90 targets, sets three ambitious objectives to be achieved by 2030: 90% of girls should be fully vaccinated with the HPV vaccine by the age of 15 years; 70% of women should undergo screening using a high‐performance test by the age of 35 years and again by 45 years; and 90% of women diagnosed with cervical disease should receive appropriate treatment. ⁴ , ⁶ This comprehensive approach emphasizes prevention, early detection, and treatment as key to eliminating cervical cancer globally.

The purpose of this review was to analyze the current global strategic directions aimed at eliminating cervical cancer, as outlined by the WHO's Global Strategy for Cervical Cancer Elimination. This strategy emphasizes three key pillars: vaccination, screening, and treatment. To maximize its effectiveness, the strategy must be tailored to the specific circumstances, challenges, and priorities of each country. Nations are encouraged to review and update their cervical cancer prevention and control policies to align with the global strategy. Given the varying challenges across countries, it is essential for each country to establish context‐specific targets and timelines for cervical cancer elimination, incorporating these objectives into national action plans while considering local capacities and resources.

2. HPV VACCINATION AS A KEY STRATEGIC ACTION

Persistent HPV infection is the primary risk factor for developing cervical cancer. While over 200 HPV genotypes have been identified, certain high‐risk genotype, such as HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59, contribute to the progression of cervical cancer. ⁷ In approximately 10% of cases, persistent HPV infections may progress to preinvasive or invasive cervical cancer over a decade. ⁸ Notably, HPV 16 and 18 alone account for approximately 70% of global cases of cervical cancer, underscoring the critical importance of vaccination against these specific genotypes. ⁷ , ⁸

HPV vaccines are among the most effective tools for the prevention of cervical cancer. ⁸ A key global objective is to ensure that 90% of girls are fully vaccinated with the HPV vaccine by the age of 15 years, which could prevent the majority of cervical cancer cases. As of 2023, 143 countries, covering approximately one‐third of the global target population, had integrated the HPV vaccine into their national immunization programs. ⁸ , ⁹ Despite this progress, disparities in vaccine accessibility persist, posing challenges to achieving comprehensive immunization coverage. ⁷

3. VACCINATION COVERAGE DISPARITIES

In high‐income countries (HICs), significant progress has been made in implementing national HPV vaccination programs. Many now routinely administer the vaccine to adolescent girls and, in some counties, boys to prevent HPV infection before exposure. This has resulted in a significant reduction in the incidence of cervical cancer. ⁸ However, vaccine hesitancy, misinformation about vaccine safety, and periodic vaccine shortages continue to hinder broader coverage. ¹⁰

LMICs face even greater challenges in achieving broad HPV vaccine coverage. Key barriers include limited financial resources for vaccine procurement and distribution, inadequate healthcare infrastructure, and logistical difficulties in conducting large‐scale vaccination campaigns. ¹¹ , ¹² Furthermore, cultural and social barriers contribute to vaccine hesitancy and lower acceptance in certain regions. ¹² The absence of routine vaccination programs in many LMICs has resulted in substantially lower coverage rates compared to HICs. ⁸ , ¹¹

Currently, the estimated global coverage for the first dose of HPV vaccine among girls stands at 27%. Although this remains substantially below the 90% target set for 2030, it represents a notable increase from the 20% coverage reported in 2022. ⁹ International efforts, particularly by Gavi, the Vaccine Alliance, have played a crucial role in expanding HPV vaccination programs in countries with the highest cervical cancer burdens by subsidizing vaccine costs. ¹³ Despite these efforts, global vaccine coverage remains suboptimal, particularly in regions most affected by cervical cancer.

4. EVOLUTION OF HPV VACCINATION REGIMENS

Since the introduction of HPV vaccines in 2006, they were initially licensed as a three‐dose regimen, later revised to a two‐dose regimen for individuals aged under 15 years. Currently, six prophylactic HPV vaccines have been licensed globally (Table 1), all of which are designed to be administered before HPV exposure, ideally before the initiation of sexual activity. ¹⁵ These vaccines contain virus‐like particles that resemble the outer shell of HPV, thereby stimulating an immune response without containing live virus or viral DNA. ¹⁵ The primary targets of all vaccines are HPV types 16 and 18, which are responsible for approximately 70% of cervical cancer cases worldwide. ¹⁶ The nonavalent HPV vaccine offers additional protection by targeting high‐risk HPV types 31, 33, 45, 52, and 58, which together account for an additional 10%–20% of cervical cancer cases. ¹⁵ , ¹⁶ Both the quadrivalent and nonavalent vaccines protect against anogenital warts caused by HPV types 6 and 11.

TABLE 1.

The overview of the licensed HPV vaccines recognized by WHO. ²⁹

Name	Type	Targeted HPV	Manufacturer	Indication	Schedule	Storage a
Cervarix	Bivalent HPV vaccine	HPV 16, 18	GSK	Protects against cervical cancer caused by HPV 16 and 18	Girls and boys aged 9–14 years as a two‐dose schedule (5–13 months apart) If the recipient's age at the time of first dose ≥15 years, three doses should be given (at 0, 1–2.5, and 5–12 months)	HPV vaccines should be maintained at 2–8°C, not frozen and protected from light. Cervarix is stable and can be stored outside the refrigerator for up to 3 days at temperatures of 8–25°C, or for up to 1 day at temperatures of 25–37°C
Cecolin	Bivalent HPV vaccine	HPV 16, 18	Innovax	Protects against cervical cancer caused by HPV 16 and 18	Girls aged 9–14 years as a two‐dose schedule (6 months apart) From age 15 years, a three‐dose schedule is indicated (at 0, 1–2 and 5–8 months)	—
Walrinvax	Bivalent HPV vaccine	HPV 16, 18	Walvax	Protects against cervical cancer caused by HPV 16 and 18	Girls aged 9–14 years as a two‐dose schedule (6 months apart, with a minimum interval of 5 months) From age 15 years, a three‐dose schedule is indicated (at 0, 2–3, and 6–7 months)	—
Gardasil	Quadrivalent HPV vaccine	HPV 6, 11, 16, 18	Merck & Co. (MSD)	Protects against cervical cancer and HPV types 6 and 11 genital warts	Licensed for girls and boys aged 9–13 years as a two‐dose schedule (6 months apart) From age 14, a three‐dose schedule should be given (at 0, 2, and 6 months)	HPV vaccines should be maintained at 2–8°C, not frozen and protected from light. Gardasil is licensed to be stored for 3 days at temperatures of 8–42°C (CTC) or for 4 days at 8–40°C
Cervavac	Quadrivalent HPV vaccine	HPV 6, 11, 16, 18	Serum Institute of India	Protects against cervical cancer and HPV types 6 and 11 genital warts	Girls and boys aged 9–14 years, as a two‐dose schedule (6 months apart). From age 15 years, a three‐dose schedule should be given (at 0, 2, and 6 months)	—
Gardasil9	Nonavalent HPV vaccine	HPV 6, 11, 16, 18, 31, 33,45, 52, 58	Merck & Co. (MSD)	Protection against cervical cancer and genital warts, covering nine HPV types, including high‐risk ones	Licensed for girls and boys aged 9–14 years as a two‐dose schedule (5–13 months apart) From age 15 years, a three‐dose schedule should be given (at 0, 1–2, 4–6 months)	HPV vaccines should be maintained at 2–8°C, not frozen and protected from light. Gardasil‐9 is licensed to be stored for 3 days at temperatures of 8–42°C (CTC) or for 4 days at temperatures of 8–40°C

Note: Adapted from Human papillomavirus vaccines: WHO position paper (2022 update). ¹⁴

Abbreviations: CTC, controlled temperature chain; GSK, GlaxoSmithKline.

^a All HPV vaccines should be maintained at 2–8°C, not frozen, and protected from light. They should be administered as soon as possible after being removed from the refrigerator.

HPV vaccines are recommended for girls aged 9 years and older, with licensing extending up to ages 26 or 45 years, depending on the vaccine. Some HPV vaccines are also licensed for boys, providing protection against HPV‐related genital warts, as well as oropharyngeal and anogenital cancers in men. ¹⁷ This expansion of eligibility reflects the recognition that men play a significant role in HPV transmission and can also benefit from protection against HPV‐related diseases. A gender‐neutral vaccination contributes to wider public health objectives by reducing the global HPV disease burden and enhancing herd immunity. ¹⁸ The introduction of gender‐neutral HPV vaccination programs in schools has resulted in a substantial decline in genital warts. In addition, juvenile‐onset recurrent respiratory papillomatosis, acquired from the mother during birth, has declined in the USA, likely due to the HPV vaccination. ¹⁸ It is anticipated that with higher vaccination coverage, the elimination of targeted HPV types will be further improved. ¹⁸

Extensive clinical trials and post‐licensure studies have demonstrated a robust safety profile for these vaccines. ¹⁵ , ¹⁷ In addition to their safety, these vaccines are highly cost‐effective, particularly when administered to school‐aged children. ¹⁹ , ²⁰ The prevention of HPV‐related diseases, primarily cervical, oropharyngeal, and anogenital cancers, as well as genital warts, significantly reduces healthcare costs. ¹⁶ These savings result from the reduction in long‐term treatments, number of screening procedures, and follow‐up care. The economic benefits are particularly pronounced in LMICs, where access to screening and advanced cancer treatments is limited. ¹⁹

5. EMERGING EVIDENCE SUPPORTING SINGLE‐DOSE HPV VACCINATION

Recent studies indicate that a single dose of the HPV vaccine provides similar protection as multi‐dose regimens in preventing HPV infection and cervical precancerous lesions. ²¹ , ²² This finding has significant implications for expanding access to HPV vaccination. The adoption of a single‐dose approach could enhance global efforts to reduce the burden of cervical cancer by simplifying vaccination programs and increasing coverage rates. ²³

In 2022, WHO endorsed a single‐dose HPV vaccination schedule for girls and women aged 9–20 years. ²² This recommendation is supported by data from two key trials: the Costa Rica HPV Vaccine Trial (CVT) conducted in Latin America ²⁴ and the International Agency for Research on Cancer (IARC) India HPV trial in Asia. ²⁵ The IARC trial, conducted in India, recruited participants between September 2009 and April 2010, with a median follow‐up of 9 years. Among 4348 participants who received three doses, 4980 who received two doses (at 0 and 6 months), and 4949 who received a single dose, the vaccine efficacy against persistent HPV 16 and 18 infections was 95.4% (95% confidence interval [CI] 85.0–99.9) in the single‐dose cohort, 93.1% (95% CI 77.3–99.8) in the two‐dose cohort, and 93.3% (95% CI 77.5–99.7) among three‐dose recipients. ²⁵ These findings suggest that a single dose provides similar protection against HPV types 16 and 18, responsible for nearly 70% of cervical cancer cases. ²⁵ Ongoing trials in Africa are providing further insights into single‐dose HPV vaccination. The Kenya Single‐Dose HPV Vaccine Efficacy (KEN SHE) trial focuses on preventing HPV infection in sexually active young women aged 15–20 years, ²⁶ while the Dose Reduction Immunobridging and Safety Study (DoRIS) trial ²⁷ examines immune response (seroconversion and antibody titers) in girls aged 9–14 years in Tanzania. ²² These studies continue to explore the efficacy and safety of a single‐dose HPV vaccine regimen.

6. IMMUNOBRIDGING STUDIES AND THE FUTURE OF SINGLE‐DOSE VACCINATION

In an immunobridging analysis, antibody responses to HPV 16 and HPV 18 antibodies were compared between participants in the DoRIS trial (single‐dose recipients aged 9–14 years) and the KEN SHE trial (young women aged 15–20 years). ²⁷ After 24 months, immune responses in girls who received a single dose were found to be non‐inferior to those in the older cohort from the KEN SHE trial, where efficacy had been demonstrated up to 36 months after vaccination. ²⁷ This reinforces earlier DoRIS findings, which showed that antibody levels in girls receiving a single dose were comparable to those in historical cohorts of women. ²¹ Broader assessments of HPV types may provide deeper insights into HPV infection dynamics and potential shifts in epidemiology among vaccinated populations. ²²

Evaluating cross‐protection and the possibility of genotype replacement after vaccination is essential for shaping future vaccination strategies and health policies. Concerns have emerged regarding genotype replacement and the protection offered by a single‐dose HPV vaccination. However, genotype competition, a necessary condition for type replacement, has not been observed at the lesion level. ²¹ While multiple HPV infections can occur, lesions are predominantly driven by a single genotype. ²⁸ Furthermore, studies of humoral responses after HPV vaccination suggest a high level of cross‐protection, although transmission models indicate that type replacement cannot yet be entirely ruled out, underscoring the need for surveillance of non‐vaccine HPV types.

In regions with a high prevalence of HIV, particularly in sub‐Saharan Africa, the effectiveness of a single‐dose HPV vaccination schedule raises additional considerations, particularly for individuals who acquire HIV after vaccination. ²⁹ Research shows that the HPV vaccination induces robust antibody seroconversion in people living with HIV, with immune responses lasting at least 4 years, though cross‐reactivity is reduced when compared with the HIV‐negative individual. ²⁹ Despite evidence supporting the immunogenicity of HPV vaccines in HIV‐positive populations, data on efficacy remain inconsistent. Further studies are needed to clarify the impact of HIV infection on the immune response to HPV vaccination. The HPV one and two dose Population Effectiveness (HOPE) study in South Africa, which examines the community‐wide effects of the one‐dose HPV vaccination, is expected to provide valuable insights into this issue. ²⁹

7. UPDATED WHO RECOMMENDATIONS, GLOBAL EFFORTS, AND LESSONS FROM COVID‐19

In light of the emerging evidence, WHO now recommends flexible HPV vaccination schedules: a one‐ or two‐dose schedule for girls aged 9–14 years, a one‐ or two‐dose schedule for girls and women aged 15–20 years, and a two‐dose schedule, with a 6‐month interval, for women aged over 21 years. ¹⁴ The December 2022 WHO position paper highlighted that immunocompromised individuals, including those living with HIV, should receive a minimum of two doses and, where feasible, three doses. The primary target group for HPV vaccination remains girls aged 9–14 years, ideally before sexual debut, while secondary target groups, including boys and older girls, are encouraged to be vaccinated when practical and financially viable. ¹⁴

Several countries, including Australia, Scotland, and the UK, have adopted a single‐dose vaccination strategy. In September 2023, the UK transitioned to a single‐dose schedule for the National Health Service routine adolescent immunization, ²³ targeting schoolchildren aged 12–13 years. Eligible gay, bisexual, and other men who have sex with men under the age of 25 years will likewise receive a one‐dose schedule through sexual health clinics while those aged 25–45 years will continue with a two‐dose schedule. Immunosuppressed individuals, including those living with HIV, will adhere to a three‐dose schedule. In addition, eligible individuals may participate in a catch‐up vaccination until their 25th birthday through their general practitioners. Currently, 37 countries have reported switching or intent to switch to a one‐dose regimen.

The COVID‐19 pandemic significantly disrupted HPV vaccination programs, reduced participation in cervical screening, and limited access to essential treatments. ³⁰ However, it also highlighted opportunities for strengthening public health infrastructure through multisectoral collaboration and increase investments in diagnostic and laboratory capabilities. ³⁰ Furthermore, extensive public health campaigns promoting COVID‐19 vaccination have raised awareness of the importance of immunization, potentially enhancing acceptance of the HPV vaccination as a crucial preventive measure against cervical cancer. Effective collaboration between government and non‐governmental organizations (NGOs) is critical in reinforcing cervical cancer prevention programs. Governments should allocate budgets for HPV vaccination and integrate cervical cancer screening into primary healthcare systems. NGOs can complement these efforts by securing additional funding from international and private sectors, offering technical expertise and conduction of community‐based education programs to enhance large‐scale public health awareness. Furthermore, coordinated efforts can improve data collection and monitoring and evaluation of the programs, ensuring their efficiency and sustainability. ¹² The rapid advancement of digital health platforms and artificial intelligence (AI)‐driven analytics offer further opportunities for the prevention of cervical cancer. AI‐powered tools enable real‐time surveillance, track screening coverage, and monitor treatment adherence. ³¹ , ³² Furthermore, AI‐predictive models can help identify high‐risk populations and optimize resource allocation. ³²

8. TRANSITION OF CERVICAL CANCER SCREENING

Recent updates in cervical cancer screening underscore the critical importance of early detection and the incorporation of advanced testing methods. WHO now recommends that women undergo screening using high‐performance tests by the age of 35 years and again by the age of 45 years, with the goal of ensuring that at least 70% of women are screened within these age groups. ⁶ , ¹⁶

The integration of primary HPV testing has become a cornerstone of cervical cancer prevention strategies. HPV testing can identify up to 14 high‐risk carcinogenic HPV genotypes, offering a high negative predictive value for detecting high‐grade cervical intraepithelial neoplasia (CIN). ¹⁶ WHO strongly advocates for the use of HPV testing as the primary screening method in all settings. Countries currently employing cytology‐based screening should maintain quality‐assured cytology screening while planning a transition to HPV‐based screening. ³³ In countries where visual inspection with acetic acid (VIA) is the primary method, WHO strongly recommends a rapid shift to HPV‐based screening due to the poor reproducibility and accuracy of VIA. ³³

Key steps in this transition include stakeholder engagement, capacity assessments, comprehensive policy development, and the design of effective service delivery models. ³⁴ It is essential that these tests are appropriate for screening, clinically validated, and prequalified by WHO to enhance the accurate detection of high‐risk HPV types associated with cancer.

In recognition of the heightened risk of cervical cancer among WLHIV, more frequent cervical screening is recommended every 3–5 years, beginning at the age of 25 years. ³⁵ The integration of cervical screening services within HIV management clinics is crucial for enhancing cervical cancer control in this vulnerable group. Early initiation of, and adherence to, antiretroviral therapy is essential to preventing the progression of HPV infections to precancerous or invasive stages. ³⁵ While screening twice in a lifetime provides certain benefits, WHO guidelines recommend initiating cervical cancer screening at age 30 years for HIV‐negative women and at age 25 years for WLHIV, continuing until the age of 50 years. WHO further advises screening intervals of 5–10 years for the general population and 3–5 years for WLHIV. ³³

9. SELF‐SAMPLING HPV TEST

Self‐sampling HPV tests empower women to collect their own cervical samples for HPV testing, enhancing the accessibility and convenience of cervical cancer screening. ³⁶ , ³⁷ This approach is particularly beneficial for those who face barriers to attending healthcare facilities, such as geographical constraints, cultural stigma, or personal discomfort. ³⁸ The procedure involves using a swab or brush to collect a sample from the vaginal area, which is then sent to a laboratory for analysis. Studies have demonstrated that self‐sampling is as effective as clinician‐collected samples in detecting high‐risk HPV infections. ³⁸ WHO endorses self‐sampling within HPV‐based screening programs, particularly in low‐resource settings, to enhance screening coverage and reach underserved populations. However, it is crucial that self‐sampling is integrated into broader cervical cancer screening initiatives, with effective management guidelines for high‐risk HPV‐positive women. ³³

Alternative self‐sampling delivery models have gained attention for their impact on screening uptake. Traditional methods often rely on mailed reminders for clinician‐obtained samples, whereas digital platforms and social media have improved access. Two primary delivery models exist: the “opt‐in” method, where individuals request a self‐sampling kit, and the “send‐to‐all” or “opt‐out” method, which involves automatic kit distribution. While the opt‐out approach generally increases participation, it is also more resource‐intensive. ³⁷ , ³⁸

WHO advocates integrating the HPV vaccination with broader health services to enhance accessibility and efficiency. ³⁹ Four typologies have been proposed to improve HPV vaccination and cervical cancer screening coverage. ³⁹ The first approach involves using HPV vaccination in girls aged 10–13 years as an opportunity to distribute a self‐sampling cervical screening kit to female caregivers. The second typology co‐locates vaccination and screening services, enabling women and girls to access both at the same facility, such as schools or mobile clinics. The third typology recruits women and girls together but offers vaccination and screening at different times and locations. The fourth typology integrates educational sessions or leaflets into HPV vaccination programs to increase awareness of cervical cancer prevention and encourage screening participation.

An effective example of self‐sampling HPV test is Malaysia's “ROSE” (Removing Obstacles to cervical Screening) program, ⁴⁰ which successfully integrated HPV screening with digital platforms to invite participation and utilized digital registries to connect women to care. Other innovative delivery models include offering a self‐sampling kit in the primary care setting, local pharmacies, and through community outreach programs.

Since no universal patterns for self‐sampling delivery exist, pilot studies should be conducted to customize strategies for specific populations, assessing the feasibility and suitability of vaginal self‐sampling before broader implementation and should be based on the available resources. ³³

10. TREATMENT OF CERVICAL DISEASE

It is crucial to ensure that 90% of women diagnosed with cervical disease receive appropriate treatment. This includes treatment for both preinvasive and invasive cervical cancer treatment, as well as palliative care when necessary. Preinvasive cervical lesions are classified using terminology including CIN and squamous intraepithelial lesion (SIL). High‐grade lesions, such as CIN2–3 and high‐grade squamous intraepithelial lesions (HSILs), indicate significant precancerous changes and require treatment to prevent progression to invasive cancer. ⁴¹ CIN1 and low‐grade SIL often regress spontaneously but require monitoring. ⁴¹ Treatment modalities for HSIL include excisional procedures or ablative methods.

WHO recommends fully integrating primary cervical screening with precancer treatment and, where feasible, providing same‐day services to maximize impact and minimize loss to follow‐up. ³³ Two primary strategies are recommended: screen‐and‐treat approach and screen‐triage‐and‐ treat approach.

10.1. Screen‐and‐treat approach

In the screen‐and‐treat model, treatment is initiated based solely on a positive HPV DNA test result, without secondary screening or histopathological confirmation. ⁴² When a woman tests positive and is eligible for ablative treatment, the treatment should ideally be provided immediately after informed consent during the same visit. Before treatment, ablative methods can be employed after VIA of the cervix to confirm the appropriateness of the procedure and to rule out the presence of invasive cancer. In cases where a woman is not eligible for ablative treatment, excisional treatment such as large loop excision of the transformation zone (LLETZ) is recommended and should be provided on the same day at the same facility. ⁴²

10.2. Screen‐triage‐and‐treat approach

In the screen‐triage‐and‐treat model, the decision to treat is based on a positive primary screening test followed by a positive triage test. This triage process may or may not involve histological diagnosis. WHO recommends using partial HPV genotyping, colposcopy, VIA, or cytology as the triage test, depending on the established programs within each country. ⁴² Furthermore, this approach is recommended for WLHIV due to their higher prevalence of HPV infection and increased risk of developing preinvasive and invasive cervical cancer. ⁴²

In HICs, standard practice includes obtaining a histological diagnosis before treatment to minimize obstetric complications arising from excisional procedures. ⁴³ LLETZ is the most common treatment method and can be performed in clinics under local anesthesia. After the procedure, tissue specimens should be promptly sent to pathology laboratories for analysis, ensuring that the results are returned in a timely manner. Training in LLETZ should be a standard part of the curriculum for obstetricians and gynecologists. In addition, some health systems may consider training nurse practitioners or nurse‐midwives to perform these procedures.

11. P16/KI‐67 DUAL‐STAINING: A NEW TRIAGE METHOD TO REDUCE COLPOSCOPY REFERRALS

The outcome of HPV infection varies widely, making follow‐up of HPV‐positive women both complex and time‐consuming. Traditionally, cytology is used to triage women negative for HPV16 or 18, but new biomarkers such as p16/Ki‐67 dual‐staining offer a more effective approach. Co‐expression of these proteins signals cell cycle deregulation caused by HR‐HPV infection and is associated with high‐grade cervical lesions. ⁴⁴ Studies show that p16/Ki‐67 dual‐staining has a higher sensitivity (74.9%) for identifying CIN2+ compared to cervical smear cytology (51.9%), with similar specificity. This helps prioritize colposcopy for women at higher risk while reducing unnecessary procedures for those at lower risk. ⁴³ , ⁴⁵ Among HPV‐positive women with normal cytology, dual‐staining detects 91.9% of CIN2+ cases, outperforming HPV16/18 genotyping. This method also lowers the 5‐year cumulative incidence risk of CIN3+ to 3.3% for women testing negative for p16/Ki‐6746. ⁴⁶

Overall, p16/Ki‐67 dual‐staining is a highly effective triage tool for managing HPV‐positive women with normal cytology and identifying those at high risk for cervical cancer.

12. TREATMENT OF INVASIVE CERVICAL CANCER

The treatment of invasive cervical cancer remains consistent; however, ensuring that 90% of women diagnosed with cervical disease receive appropriate treatment poses significant challenges within the three pillars of cervical cancer elimination strategies. Effective evaluation involves proper biopsy, accurate pathological diagnosis, disease staging, and tailored treatment. However, diagnostic capacity varies across regions, underscoring the need for accessible biopsy services, laboratory support, and efficient communication systems for disseminating results. Histological diagnosis is critical for appropriate treatment and is best supported by integrated laboratory networks, while telepathology can be beneficial in resource‐limited settings. ³³

Cervical cancer staging follows the 2018 FIGO system, utilizing imaging when available. In settings without imaging, clinical evaluation is essential for assessing tumor size and invasion. ⁴⁷ Imaging modalities, such as chest X‐rays and computed tomography scans, assist in staging, although access can vary significantly. Teleradiology may be recommended in regions lacking sufficient radiological expertise. Multidisciplinary tumor boards are vital for optimizing patient management and treatment planning. ⁴⁸

Treatment strategies depend on the cancer stage and may involve surgery, radiation, chemotherapy, and palliative care. Early‐stage cancers are typically managed with surgery, while advanced stages often require chemoradiation. Chemotherapy is also utilized for recurrent or metastatic disease, although responses are usually short‐lived, necessitating careful consideration of cost and toxicity. ⁴⁷ Palliative care is essential not only for end‐of‐life situations but also for alleviating suffering throughout the disease continuum. ⁴⁹ It enhances patients' quality of life, provides financial protection, and reduces overall healthcare costs. Integrating palliative care with primary care is crucial, with community health workers playing a vital role in monitoring and supporting patients. National policies should incorporate palliative care within prevention, screening, and treatment frameworks to ensure comprehensive patient care.

13. CONCLUSION

The elimination of cervical cancer is within reach, but achieving this ambitious goal will require concerted global efforts and national action. WHO has laid out a strategic roadmap focused on prevention, early detection, and treatment to significantly reduce the burden of cervical cancer worldwide. These strategies are crucial, particularly in LMICs, where the majority of cases occur. The transition to HPV‐based screening, along with the widespread adoption of HPV vaccination, represents the most effective path toward prevention and early detection.

To align with WHO recommendations, national governments must implement comprehensive cervical cancer control programs that integrate vaccination, screening, and treatment. Strengthening healthcare infrastructure, increasing public awareness, and ensuring access to affordable screening and treatment are essential components of these efforts. In addition, the sustainable expansion of population‐based cancer registries worldwide is crucial for monitoring progress toward the 90–70–90 target integral to the national elimination strategy.

The urgency of this call to action cannot be overstated. By aligning national policies with WHO guidelines, countries have the opportunity to save countless lives and make cervical cancer a preventable and treatable disease. The fight against cervical cancer is a global one, and with strategic national action, elimination is not just a possibility but an imminent reality. Now is the time to commit to these strategies and work toward a future where cervical cancer no longer claims lives.

AUTHOR CONTRIBUTIONS

All authors contributed to the concept, research, manuscript writing, review, and revision of the manuscript. All authors approved the final version of the manuscript.

FUNDING INFORMATION

None.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest.

Wilailak S, Kengsakul M, Kehoe S. Strategic approaches for global cervical cancer elimination: An update review and call for national action. Int J Gynecol Obstet. 2025;171(Suppl. 1):120‐128. doi: 10.1002/ijgo.70276

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.