What’s needed for Canada’s cervical cancer endgame?
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* Jennifer Blake

I read with interest Dr. Popadiuk’s commentary1 on cervical cancer screening starting at 25 years of age. I am familiar with the powerful OncoSim tool, but I continue to have nagging concerns that, by doing right for the majority, we may inadvertently leave behind the most disadvantaged.

Although some of my concerns may be emotional, likely because of the effect of having seen young women with cervical cancer, I also know that it has been challenging to show the benefit of widespread screening for these aggressive cancers in young women, and thus I set emotions aside. I fully accept that provinces have to make resource allocations, yet 3 things continue to concern me:

1.  The young women who are unvaccinated with human papillomavirus vaccine, especially those who may also have other risk factors for cervical cancer (e.g., smoking, poor nutrition, involvement in the sex trade or victims of early abuse). Is 25 early enough to be able to detect preinvasive or micro-invasive disease?

2.  The missed opportunity to find a lesion when a relatively small loop excision or a fertility-preserving procedure could remove it, compared with a more potentially damaging excision or radical procedure later. When this was examined in England and Wales, comparing onset of screening at age 20 to age 25, 58% of the admittedly low number of cancers detected would have been at a micro-invasive stage.2 To what extent is society prepared to go to enable young women to receive a treatment that could improve survival and preserve fertility?

3.  I cannot accept the argument that screening should not be done because of the potential damage done by needless intervention. The latter is a professional problem that needs to be addressed; we should educate by introducing clear and unambiguous guidelines, and intervene only when necessary. Choosing Wisely3 is a widely applauded program that is dedicated to the issue of needless intervention.

A global commitment to the prevention of cervical cancer has been made;4 now, what would it take for Canada to become the first, or second, country to eliminate cervical cancer? The next step is important. At this point, the worst thing would be to create a segment of the hardest to reach in our population, who are at risk of cervical cancer and who might fall through the cracks. We would miss an opportunity to screen and treat this group, and instead expose them to the consequences of more invasive treatments for a preinvasive disease.

Any proposed change to screening should address specific provisions for the unvaccinated and the most vulnerable; include steps to ensure that screening rates remain high, despite vaccination programs; and redirect resources that are freed up from policy changes to accelerate elimination of the disease.

The Canadian Partnership Against Cancer found that currently only 67% of Canadian women aged 21–65 years reported a pap smear within the past 3 years,5 against a target of 80%. In 2012, 6 provinces reported meeting the 80% target — now none do.6 Cancer Care Ontario reported a decline in pap screening and retention in the screening program: “The timing of the decrease in participation and retention coincides with the update of the cervical screening guidelines in 2011.”7 We must remain vigilant.

Canada is in a very good position to begin contemplating these next steps and fortunate indeed to have data and tools to help make good decisions; however, the effect for those women who will not be screened could be life changing.

## Footnotes

*   **Competing interests:** None declared.

## References

1.  Popadiuk C, Decker K, Gauvreau C. Starting cervical cancer screening at 25 years of age: the time has come. CMAJ 2019;191:E1–2.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo4OiIxOTEvMS9FMSI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xOTEvMTcvRTQ4MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  Landy R, Birke H, Castanon A, et al. Benefits and harms of cervical screening from age 20 years compared with screening from age 25 years. Br J Cancer 2014;110:1841–6.
    
    

3.  Choosing Wisely Canada [homepage]. Available: [https://choosingwiselycanada.org/](https://choosingwiselycanada.org/) (accessed 2019 Jan. 17).
    
    

4.  WHO Director-General calls for all countries to take action to help end the suffering caused by cervical cancer. Geneva: World Health Organization; 2018. Available: [www.who.int/reproductivehealth/call-to-action-elimination-cervical-cancer/en/](http://www.who.int/reproductivehealth/call-to-action-elimination-cervical-cancer/en/) (accessed 2019 Jan. 17).
    
    

5.  Women aged 21–69 reporting at least one Pap test in 42-month period (%), by jurisdiction —2010–13 screening years [figure]. Toronto: Canadian Partnership Against Cancer. Available: [www.systemperformance.ca/cancer-control-domain/screening/cervical-cancer-screening/](http://www.systemperformance.ca/cancer-control-domain/screening/cervical-cancer-screening/) (accessed 2019 Jan. 17).
    
    

6.  Cancer screening in Canada: an overview of screening participation for breast, cervical and colorectal cancer. Toronto: Canadian Partnership Against Cancer; 2015. Available: [www.getcheckedmanitoba.ca/files/g-rep-overview-15.pdf](http://www.getcheckedmanitoba.ca/files/g-rep-overview-15.pdf) (accessed 2019 Jan. 17).
    
    

7.  Cancer Care Ontario. Ontario cancer screening performance report 2016. Toronto: Cancer Care Ontario; 2016. Available: [www.cancercareontario.ca/en/screening-performance-report-2016](http://www.cancercareontario.ca/en/screening-performance-report-2016) (accessed 2019 Mar. 18).