Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries.,The Lancet

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Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries.
The Lancet ( IF 98.4 ) Pub Date : 2020-01-30 , DOI: 10.1016/s0140-6736(20)30157-4
Karen Canfell ₁ , Jane J Kim ₂ , Marc Brisson ₃ , Adam Keane ₄ , Kate T Simms ₄ , Michael Caruana ₄ , Emily A Burger ₅ , Dave Martin ₆ , Diep T N Nguyen ₄ , Élodie Bénard ₆ , Stephen Sy ₂ , Catherine Regan ₂ , Mélanie Drolet ₆ , Guillaume Gingras ₆ , Jean-Francois Laprise ₆ , Julie Torode ₇ , Megan A Smith ₄ , Elena Fidarova ₈ , Dario Trapani ₈ , Freddie Bray ₉ , Andre Ilbawi ₈ , Nathalie Broutet ₁₀ , Raymond Hutubessy ₁₁

Affiliation

Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.
Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, MA, USA.
Centre de recherche du CHU de Québec - Université Laval, Québec, QC, Canada; Département de médecine sociale et préventive, Université Laval, Québec, QC, Canada; MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College, London, UK.
Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Health Management and Health Economics, University of Oslo, Oslo, Norway.
Centre de recherche du CHU de Québec - Université Laval, Québec, QC, Canada.
Union for International Cancer Control, Geneva, Switzerland.
Department for the Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland.
Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France.
Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland.

BACKGROUND WHO is developing a global strategy towards eliminating cervical cancer as a public health problem, which proposes an elimination threshold of four cases per 100 000 women and includes 2030 triple-intervention coverage targets for scale-up of human papillomavirus (HPV) vaccination to 90%, twice-lifetime cervical screening to 70%, and treatment of pre-invasive lesions and invasive cancer to 90%. We assessed the impact of achieving the 90-70-90 triple-intervention targets on cervical cancer mortality and deaths averted over the next century. We also assessed the potential for the elimination initiative to support target 3.4 of the UN Sustainable Development Goals (SDGs)-a one-third reduction in premature mortality from non-communicable diseases by 2030. METHODS The WHO Cervical Cancer Elimination Modelling Consortium (CCEMC) involves three independent, dynamic models of HPV infection, cervical carcinogenesis, screening, and precancer and invasive cancer treatment. Reductions in age-standardised rates of cervical cancer mortality in 78 low-income and lower-middle-income countries (LMICs) were estimated for three core scenarios: girls-only vaccination at age 9 years with catch-up for girls aged 10-14 years; girls-only vaccination plus once-lifetime screening and cancer treatment scale-up; and girls-only vaccination plus twice-lifetime screening and cancer treatment scale-up. Vaccination was assumed to provide 100% lifetime protection against infections with HPV types 16, 18, 31, 33, 45, 52, and 58, and to scale up to 90% coverage in 2020. Cervical screening involved HPV testing at age 35 years, or at ages 35 years and 45 years, with scale-up to 45% coverage by 2023, 70% by 2030, and 90% by 2045, and we assumed that 50% of women with invasive cervical cancer would receive appropriate surgery, radiotherapy, and chemotherapy by 2023, which would increase to 90% by 2030. We summarised results using the median (range) of model predictions. FINDINGS In 2020, the estimated cervical cancer mortality rate across all 78 LMICs was 13·2 (range 12·9-14·1) per 100 000 women. Compared to the status quo, by 2030, vaccination alone would have minimal impact on cervical cancer mortality, leading to a 0·1% (0·1-0·5) reduction, but additionally scaling up twice-lifetime screening and cancer treatment would reduce mortality by 34·2% (23·3-37·8), averting 300 000 (300 000-400 000) deaths by 2030 (with similar results for once-lifetime screening). By 2070, scaling up vaccination alone would reduce mortality by 61·7% (61·4-66·1), averting 4·8 million (4·1-4·8) deaths. By 2070, additionally scaling up screening and cancer treatment would reduce mortality by 88·9% (84·0-89·3), averting 13·3 million (13·1-13·6) deaths (with once-lifetime screening), or by 92·3% (88·4-93·0), averting 14·6 million (14·1-14·6) deaths (with twice-lifetime screening). By 2120, vaccination alone would reduce mortality by 89·5% (86·6-89·9), averting 45·8 million (44·7-46·4) deaths. By 2120, additionally scaling up screening and cancer treatment would reduce mortality by 97·9% (95·0-98·0), averting 60·8 million (60·2-61·2) deaths (with once-lifetime screening), or by 98·6% (96·5-98·6), averting 62·6 million (62·1-62·8) deaths (with twice-lifetime screening). With the WHO triple-intervention strategy, over the next 10 years, about half (48% [45-55]) of deaths averted would be in sub-Saharan Africa and almost a third (32% [29-34]) would be in South Asia; over the next 100 years, almost 90% of deaths averted would be in these regions. For premature deaths (age 30-69 years), the WHO triple-intervention strategy would result in rate reductions of 33·9% (24·4-37·9) by 2030, 96·2% (94·3-96·8) by 2070, and 98·6% (96·9-98·8) by 2120. INTERPRETATION These findings emphasise the importance of acting immediately on three fronts to scale up vaccination, screening, and treatment for pre-invasive and invasive cervical cancer. In the next 10 years, a one-third reduction in the rate of premature mortality from cervical cancer in LMICs is possible, contributing to the realisation of the 2030 UN SDGs. Over the next century, successful implementation of the WHO elimination strategy would reduce cervical cancer mortality by almost 99% and save more than 62 million women's lives. FUNDING WHO, UNDP, UN Population Fund, UNICEF-WHO-World Bank Special Program of Research, Development and Research Training in Human Reproduction, Germany Federal Ministry of Health, National Health and Medical Research Council Australia, Centre for Research Excellence in Cervical Cancer Control, Canadian Institute of Health Research, Compute Canada, and Fonds de recherche du Québec-Santé.

中文翻译：

实现世卫组织消除宫颈癌目标对死亡率的影响：78 个低收入和中低收入国家的比较模型分析。

背景世卫组织正在制定一项旨在消除作为公共卫生问题的宫颈癌的全球战略，该战略提出了每 10 万名妇女中有 4 例病例的消除阈值，并包括 2030 年将人乳头瘤病毒 (HPV) 疫苗接种扩大至 90 人的三重干预覆盖目标%，终生两次宫颈筛查达到 70%，浸润前病变和浸润癌的治疗达到 90%。我们评估了实现 90-70-90 三重干预目标对下个世纪避免的宫颈癌死亡率和死亡的影响。我们还评估了消除倡议支持联合国可持续发展目标 (SDG) 具体目标 3.4 的潜力——到 2030 年将非传染性疾病导致的过早死亡率降低三分之一。方法 WHO 宫颈癌消除模型联合会 (CCEMC) 涉及三个独立的动态模型，即 HPV 感染、宫颈癌发生、筛查以及癌前病变和浸润性癌症治疗。78 个低收入和中低收入国家 (LMIC) 的年龄标准化宫颈癌死亡率下降是在三种核心情景下估算的： 9 岁时仅女孩接种疫苗，10-14 岁女孩补种年; 仅限女孩的疫苗接种加上终身一次的筛查和癌症治疗的扩大；和仅限女孩的疫苗接种以及两次终生筛查和扩大癌症治疗。假设疫苗接种可提供 100% 的终生保护，防止 16、18、31、33、45、52 和 58 型 HPV 感染，并在 2020 年扩大到 90% 的覆盖率。宫颈筛查涉及 35 岁时的 HPV 检测，或 35 岁和 45 岁，覆盖率到 2023 年扩大到 45%，到 2030 年扩大到 70%，到 2045 年扩大到 90%，我们假设 50% 的浸润性宫颈癌女性将接受适当的手术、放疗、到 2023 年和化疗，到 2030 年将增加到 90%。我们使用模型预测的中值（范围）总结了结果。调查结果 2020 年，所有 78 个中低收入国家的宫颈癌死亡率估计为每 10 万名女性 13·2（范围 12·9-14·1）。与现状相比，到 2030 年，仅接种疫苗对宫颈癌死亡率的影响微乎其微，可降低 0·1% (0·1-0·5)，但另外扩大两次终生筛查和癌症治疗将将死亡率降低 34·2% (23·3-37·8)，到 2030 年避免 300 000 (300 000-400 000) 人死亡（终身筛查的结果相似）。到 2070 年，仅扩大疫苗接种就能将死亡率降低 61·7% (61·4-66·1)，避免 4·8 百万 (4·1-4·8) 人死亡。到 2070 年，进一步扩大筛查和癌症治疗将使死亡率降低 88·9% (84·0-89·3)，避免 13·3 百万 (13·1-13·6) 人死亡（终生筛查一次） , 或 92·3% (88·4-93·0)，避免 14·6 百万 (14·1-14·6) 人死亡（通过两次终生筛查）。到 2120 年，仅接种疫苗一项就能将死亡率降低 89·5% (86·6-89·9)，避免 45·8 百万 (44·7-46·4) 人死亡。到 2120 年，进一步扩大筛查和癌症治疗将使死亡率降低 97·9% (95·0-98·0)，避免 60·8 百万 (60·2-61·2) 人死亡（终生筛查一次），或 98·6% (96·5-98·6)，避免 62·6 百万 (62·1-62·8) 人死亡（通过两次终生筛查）。按照世卫组织的三重干预战略，未来 10 年，大约一半 (48% [45-55]) 避免的死亡发生在撒哈拉以南非洲，几乎三分之一 (32% [29-34]) 发生在南亚；在接下来的 100 年里，几乎 90% 的死亡都将发生在这些地区。对于过早死亡（30-69 岁），世卫组织的三重干预策略将导致到 2030 年死亡率降低 33·9% (24·4-37·9)，96·2% (94·3-96· 8) 到 2070 年，98·6% (96·9-98·8) 到 2120。癌症。未来 10 年，中低收入国家宫颈癌过早死亡率有可能降低三分之一，从而有助于实现 2030 年联合国可持续发展目标。在接下来的一个世纪里，成功实施世卫组织消除战略将使宫颈癌死亡率降低近 99%，并挽救超过 6200 万妇女的生命。资助世界卫生组织、联合国开发计划署、联合国人口基金、联合国儿童基金会-世界卫生组织-世界银行人类生殖研究、发展和研究培训特别规划、德国联邦卫生部、澳大利亚国家卫生和医学研究委员会、宫颈癌控制卓越研究中心、加拿大健康研究所、Compute Canada 和 Fonds de recherche du Québec-Santé。

更新日期：2020-02-21

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