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The European response to the WHO call to eliminate cervical cancer as a public health problem

Abstract The age‐standardised incidence of cervical cancer in Europe varies widely by country (between 3 and 25/100000 women‐years) in 2018. Human papillomavirus (HPV) vaccine coverage is low in countries with the highest incidence and screening performance is heterogeneous among European countries. A broad group of delegates of scientific professional societies and cancer organisations endorse the principles of the WHO call to eliminate cervical cancer as a public health problem, also in Europe. All European nations should, by 2030, reach at least 90% HPV vaccine coverage among girls by the age of 15 years and also boys, if cost‐effective; they should introduce organised population‐based HPV‐based screening and achieve 70% of screening coverage in the target age group, providing also HPV testing on self‐samples for nonscreened or underscreened women; and to manage 90% of screen‐positive women. To guide member states, a group of scientific professional societies and cancer organisations engage to assist in the rollout of a series of concerted evidence‐based actions. European health authorities are requested to mandate a group of experts to develop the third edition of European Guidelines for Quality Assurance of Cervical Cancer prevention based on integrated HPV vaccination and screening and to monitor the progress towards the elimination goal. The occurrence of the COVID‐19 pandemic, having interrupted prevention activities temporarily, should not deviate stakeholders from this ambition. In the immediate postepidemic phase, health professionals should focus on high‐risk women and adhere to cost‐effective policies including self‐sampling.

coverage in the target age group, providing also HPV testing on self-samples for nonscreened or underscreened women; and to manage 90% of screen-positive women.
To guide member states, a group of scientific professional societies and cancer organisations engage to assist in the rollout of a series of concerted evidence-based actions. European health authorities are requested to mandate a group of experts to develop the third edition of European Guidelines for Quality Assurance of Cervical Cancer prevention based on integrated HPV vaccination and screening and to monitor the progress towards the elimination goal. The occurrence of the COVID-19 pandemic, having interrupted prevention activities temporarily, should not deviate stakeholders from this ambition. In the immediate postepidemic phase, health professionals should focus on high-risk women and adhere to cost-effective policies including self-sampling.  1 These estimates concern the European region as defined by the United Nations. The incidence rates vary widely within Europe, with agestandardised incidence rates (ASIR) ranging from less than 5/100000 in Malta (3.5), Switzerland (3.8) and Finland (4.7) to ASIRs over 20/100000 in Latvia (25.0), Bosnia Herzegovina (23.9), Estonia (22.5), Moldova (21.4), Serbia (20.3) and Bulgaria (20.3) (see Figure 1; Table 1).
There is a clear Western to Eastern Europe trend with ASIRs lower than 10/100000 and age-standardised mortality rates (ASMR) lower than 3/100000 in Northern, Southern and Western Europe, compared with ASIR of 16/100000 and ASMR of 6/100000 in Central-Eastern Europe. In the 28 member states of the European Union (EU) (as defined in 2018, still including the United Kingdom), the average age-standardised incidence and mortality rates are 10.0 and 3.1 per 100 000 women-years, respectively. For a more detailed assessment of the burden of cervical cancer in Europe vs other continents and on the methodology of estimation, we refer to a recent publication in Lancet Global Health 1 and the description of the sources and methods used in developing the GLOBOCAN estimates. 2,3

| PREVENTION OF CERVICAL CANCER
Historically, screening by detection and treatment of cervical precancer lesions identified through cytological examination of Pap smears has resulted in a significant reduction in cervical cancer incidence and mortality. [4][5][6] The implementation of the European Guidelines for Quality Assurance of Cervical Cancer Screening has played a pivotal role in achieving this result. 7 However, recent trend analyses indicate that even in countries with well-organised cytology-based screening programmes, cervical cancer incidence rates have stopped decreasing or are even increasing. 1,[8][9][10] This phenomenon might be explained by an increased exposure to oncogenic types of the human papillomavirus (HPV), lower screening coverage rates, particularly among young women, and the limitations of cytology-based screening. 1 Therefore, new effective preventive tools, which have become available in the last decade, should be implemented without delay.
Strong evidence has accumulated, indicating that primary prevention by vaccination against the main carcinogenic HPV types is safe and protects well against future HPV infection and associated anogenital precancer in young females and males. 11 Table 2). The European Centre for Disease Control and Prevention in its recently released guidance on HPV vaccination in EU countries stated that a gender neutral vaccination becomes increasingly cost-effective in the presence of persistently suboptimal coverage of females with reducing vaccine price. 16 However, in countries with HPV vaccination coverage of 80% or higher among girls, boys are already well protected by herd-immunity, which renders gender-neutral vaccination less cost-effective. Interventions to increase vaccination coverage among girls where it is low might be more cost-effective than adding vaccination of boys. 17 Intervention research aiming to identify effective strategies to increase HPV vaccination uptake and implementation of such strategies should be promoted.
Regarding secondary prevention, randomised population-based trials have demonstrated that HPV-based screening is more performant in protecting against incident cervical precancer and cancer than cytology. 18,19 In addition, screening with validated polymerase chain reaction-based HPV assays offers the advantage that it can be performed on a specimen collected by the woman herself. The offer of self-sampling devices has been shown to be performant in reaching underscreened populations. 20,21 Neither the World Health Organisation (WHO) nor EU guidelines recommend screening by cotesting with HPV and cytology. 22,23 HPV infection is mainly sexually transmitted and this fact entails sensitive and tailored communications, including appropriate health education, to the general public as well as to individual women needing counselling in order to reduce stigma, shame and worry, by taking into account the particular social and cultural background. 24

| WHO CALL FOR THE ELIMINATION OF CERVICAL CANCER
Recognising that cervical cancer affects many women at an age when they have important economic and familial responsibilities, and acknowledging its high level of preventability, has motivated the WHO Director General to launch an appeal to all countries of the world to eliminate this disease as a public health problem. 26 It is estimated that by vaccinating 90% of girls before they reach the age

BOX 4 Actions on treatment
• Across all European countries, 90% of women with Grade III cervical intraepithelial neoplasia should be treated within 3 months. All women with diagnosed cervical cancer should have access to appropriate oncological services including palliative care for incurable cases.
• All European country cancer plans should include actions towards achieving these treatment goals.
• Guidelines on HPV vaccination and cervical cancer screening should also review the relevance of ablation (cryotherapy, thermal ablation) as a simple, safe and efficacious technique to treat cervical precancers, especially in younger women in Europe.
SARS-CoV-2 have interrupted the implementation of current preventive programmes and delayed new activities planned in Europe and elsewhere. 28 Concerns related to cervical cancer control amidst the COVID-19 pandemic and the period thereafter are addressed in Box 6.

Monitoring of EU Member State Cancer Plans
As part of the coordination role that the EU should play in assisting member states to combat cancer, a public monitoring and reporting system should be established with respect to EU member state cancer plan items, similar to Although waiting for an official mandate from the EU Commission, a large group of professional societies and cancer organisations are engaged and willing to assist the WHO and European health authorities to achieve the laudable goal of eliminating cervical cancer.