HPV vaccines allow nations, states to set deadline for eliminating cervical cancer

20 Years of HPV Vaccine Success

This is part 3 in a three-part series marking the 20th anniversary of the approval of the HPV vaccine. Part 1 was published June 8 and Part 2 yesterday. All three are available here .

When Jennifer Simpson was diagnosed with cervical cancer, she hadn’t been screened for the disease in 25 years.

“I always thought, ‘there are 50 other things I could be doing right now,’” said Simpson, who lives in Birmingham, Alabama.

She didn’t have a primary care provider, and relied on urgent care clinics when she was sick. Simpson didn’t see the point in annual checkups, believing, “if there was something wrong with me, I would know it.”

Six years ago, a doctor finally persuaded her to be screened for cervical cancer.

“I'll be honest, I didn't know what a Pap smear was for,” Simpson said. “I'm a college-educated woman and I consider myself fairly intelligent, but it had never occurred to me there was a reason that you're supposed to get those.”

One exam turned into another. When her healthcare provider told her that a biopsy had found “high-grade lesions” on her cervix, Simpson went into denial. She delayed returning to the clinic for four months.

“I was pretty sure that meant I had cancer, but he didn't specifically say, ‘You have cancer and we need to fix this,’” Simpson said. “So I was able to, to go, ‘OK, well, if I don't think about it, it's not there.’”

Simpson was eventually diagnosed as having early cervical cancer. She had her uterus, ovaries, and fallopian tubes surgically removed, and has no evidence of disease today. But she wonders if she could have avoided cancer if she had seen a doctor sooner.

“I did everything as a patient that you should not do,” Simpson said.

A worldwide effort

Simpson, 54, now teaches other women about the importance of cervical cancer prevention.

She volunteers with a coalition of public health groups working to eliminate cervical cancer as a public health problem in Alabama, the first state in the country to create a formal plan to end the disease.

The effort to eliminate cervical cancer was made possible by vaccines that protect against the human papillomavirus (HPV), which were approved 20 years ago this week. HPV causes more than 99% of cervical cancers , as well as five other types of cancer.

Studies have shown that HPV vaccines have reduced the risk of cervical cancer by 80% in women vaccinated by age 16 and by 66% in those vaccinated after 16. Vaccinating children earlier is even more effective. A study in Scotland found no cases of cervical cancer among women vaccinated before age 14.

“This is definitely achievable with vaccination, screening, and treatment,” said Rebecca Perkins, MD, an obstetrician and gynecologist and investigator at the Woman, Mother and Baby Research Institute at Tufts Medical Center.

The World Health Organization (WHO) launched a global strategy to eliminate the disease in 2020. As of January, 164 countries have introduced HPV immunization nationally or regionally, up from 117 countries just five years ago.

Australian health officials say their country is on track to eliminate cervical cancer by 2035. The country has already eliminated cervical cancers in people under 25.

Australia’s “success shows what is possible when a country commits to vaccination, screening, follow-up care, and public health infrastructure,” said Tamika Felder, a cervical cancer survivor and founder of the advocacy group Cervivor.

A recent analysis in The Lancet projects that high-income countries could eliminate cervical cancer by 2048. Low- and middle-income countries, which lack the resources for mass screenings and vaccination, are likely to suffer from cervical cancer much longer. Public health leaders fear that the loss of funding for the US Agency for International Development, a federal agency dismantled last year, will stall efforts to vaccinate women in developing countries, endangering the lives of thousands of women.

Alabama leading the way

Women in Alabama are more likely to die from cervical cancer than residents of any other state.

A study published in January in JNCI Cancer Spectrum found that Alabama’s death rate from cervical cancer—6.8 per 100,000 women, more than twice the national average— is the highest in the country.

“That's just not OK,” said Nancy Wright, MPH, director of cancer prevention and control at the Alabama Department of Public Health. “We have to do something about that.”

Alabama health officials launched Operation Wipe Out in 2021 in Chambers County, which had an exceptionally high burden of cervical cancer. Thanks to efforts by Wright and others, Alabama in 2023 adopted the program state-wide, becoming the first state to launch a strategic plan to eliminate cervical cancer.

The state aims to eliminate the disease by 2033.

A unique opportunity

The world has never eliminated a type of cancer.

But several unique features of cervical cancer—which afflicts 660,000 women worldwide a year, killing nearly 350,000—make its elimination possible, Perkins said.

First, scientists understand the disease extraordinarily well. They know that HPV causes almost all cases of cervical cancer, and that cervical lesions have a long precancerous stage before becoming malignant, allowing them to be caught and treated, Perkins said.

Second, healthcare providers have ways to prevent the disease and find it early.

Infographic: Natalie Vestin / CIDRAP

Routine screenings, including HPV tests and Pap tests, can detect cervical precancers early enough to be for them to be cured with a small office procedure, sparing women from harsh cancer treatments that threaten their fertility, Perkins said. Screening can detect cervical cancers early.

Lastly, safe and effective vaccines can prevent infection with HPV.

Countries don’t need to reduce cervical cancer cases to zero to claim they have eliminated the disease as a public health problem. Instead, the WHO calls for nations to reach and maintain a cervical cancer rate below 4 per 100,000 women.

Nations can meet that goal by doing three things by 2030, according to the WHO:

Vaccinating 90% of girls against HPV shot by 15;

Screening 70% of women with a high-performance test by the age of 35, and again by the age of 45;

Treating 90% of women with pre-cancer or invasive cancer.

The US as an outlier

Although nearly 200 nations have committed to eliminating cervical cancer—including Scotland , New Zealand , and Rwanda —the United States has not.

The United States would have to lower its cervical cancer rate by more than half to quality for elimination. In 2019, the United States’ incidence rate was just under 9 per 100,000 women. As of 2021, the state closest to eliminating cervical cancer was Massachusetts, with an incidence rate of 4.3 per 100,000 women. Mississippi, with a cervical cancer rate of nearly 15 per 100,000, has even further to go.

US progress against cervical cancer has been uneven.

Although screenings cut the number of cervical cancer diagnoses in half over the past 50 years, those declines have leveled off in recent years, according to the American Cancer Society.

And while cervical cancer incidence dropped by 65% from 2012 to 2019 among women aged 20 to 24—an age-group that was eligible for HPV vaccination—rates rose among women ages 30 to 44, who were born too late to receive the vaccine.

The United States also appears to be far from reaching the WHO’s vaccination goal. Data from the 2024 National Immunization Survey show only 78% of US teens aged 13 to 17 had received one or more doses of the HPV vaccine.

Although the path to eliminating cervical cancer in the United States is complicated, Felder said she remains hopeful.

Infographic: Natalie Vestin / CIDRAP

“We have the tools to eliminate cervical cancer; we know what works,” Felder said. “The question is whether we have the collective commitment to implement those tools equitably and consistently across the country.”

Felder said the United States “needs a coordinated national strategy,” beyond state and regional efforts.

“Developing these plans does more than set goals; it brings together the partners needed to turn prevention into action,” Felder said. “Cervical cancer elimination isn't just a public health objective. It's a moral imperative. No one should be diagnosed with or die from a cancer we have the ability to prevent."

Protecting women of the future

Treatments for cervical cancer can be painful, cost women their fertility, and push them into early menopause. Many cervical cancer survivors live with long-term sexual dysfunction, Perkins said.

Although researchers are searching for more effective, less toxic therapies, “30% of women diagnosed with cervical cancer die from it , and that hasn’t changed in 30 years.”

Given such limitations, prevention is essential, Perkins said.

States with lower rates of screening and vaccination tend to have more diagnoses and deaths from cervical cancer, research shows.

Alabama’s elimination campaign initiative aims to attack cervical cancer on several fronts—through increased education, vaccination, screening, and appropriate follow-up care, Wright said.

Cervical cancer elimination isn't just a public health objective. It's a moral imperative. No one should be diagnosed with or die from a cancer we have the ability to prevent.

Technology could help.

Earlier this year, the Department of Health and Human Services issued cervical cancer screening guidance that allows women to avoid uncomfortable pelvic exams. Instead, women can now collect their own sample to test for HPV, much the same way that people test themselves for COVID-19. Women can self collect at a clinic or at home, and mail their sample to a lab.

Studies in the United States and Australia have found that self collection boosted HPV screening rates.

“There are so many women in Alabama in rural areas, where you don’t have access to care,” Wright said. “There are also women who have had trauma, and who have an intense fear, and aren’t going to come in for a cervical cancer screening. Self collection opens the door for them.”

Although a federal program provides cervical cancer screenings to women with low incomes, those screenings are just the first step in the process of checking someone for cancer, Wright said.

Closing a gap in follow-up exams

More than 40% of women fail to return for critical follow-up exams, called colposcopies, according to a study from UAB. Follow-up rates are even lower for Black and Hispanic women.

Colposcopies are crucial, because they allow healthcare providers to take a closer look at suspicious lesions and, if needed, collect tissue samples, which can reveal whether the growth is malignant, benign, or precancerous.

To address that gap, the state health department bought handheld medical devices that allow nurse practitioners to perform follow-up exams anywhere in the state. Last year, six nurse practitioners performed 1,000 colposcopies, boosting the percentage of women receiving follow-ups to 70%, Wright said.

About one in four women examined had high-grade cervical lesions, putting them at elevated risk for cancer, Wright said.

“We're reaching the population that needs to get a colposcopy,” Wright said. “If we keep doing this, it's going to directly impact our mortality rate.”

Eliminating cervical cancer could be particularly difficult in a mostly rural state with high rates of poverty, where many residents lack health insurance . Alabama is one of 10 states that opted not to expand Medicaid, the federal insurance program for people with low incomes or disabilities. And Alabama is ranked 47th in the country for health by the United Health Foundation.

Yet other states aim to follow Alabama’s example on cervical cancer. Earlier this year, Louisiana launched its own elimination program.

Wright also has advised public health leaders in Florida, Kentucky, Mississippi, North Carolina, Oregon , South Carolina, Texas, and Wisconsin. “We offer our materials to everyone,” Wright said.

Spreading the word

Simpson’s most recent volunteer visit was to a residential treatment center for women with substance use disorders.

“I was so unbelievably blessed” to have survived, Simpson said, “that I just feel like I need to pay it forward. I try to participate in every educational opportunity that comes by.”

Simpson also works full-time as a patient navigator, helping people with cancer access the care they need.

“I felt really bad that, as a patient, I just buried my head in the sand,” Simpson said. “But after working with patients, I found that that's a very common reaction.”

When Simpson talks to women, she emphasizes the importance of regular checkups and vaccination.

“I tell everybody, ‘This can happen to you,’” Simpson said. “‘But it is preventable. It is detectable. It is treatable. You do not have to die from this.”