Review: Barriers to Cervical Cancer Prevention in Ukraine
Key findings
- The incidence of cervical cancer is significantly higher in Central and Eastern Europe than in Western Europe: at least one in 50 women is diagnosed with the disease before age 75
- Widespread vaccine hesitancy, limited public understanding of human papillomavirus (HPV) vaccination, and limited healthcare infrastructure have contributed to high rates of cervical cancer in Ukraine
- The COVID-19 pandemic and war with Russia are significant factors underlying the low level of HPV vaccination in Ukraine
- Throughout the world, healthcare providers should make a concerted effort to increase HPV vaccination, cervical cytology, and HPV testing to reduce cervical cancer rates
Cervical cancer is a leading cause of cancer death among women worldwide, but Ukraine has an exceptional burden. War and other disasters have interrupted treatment, allowed new cases to develop, and destroyed tools for screening and diagnosis of pre-invasive disease.
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Annekathryn Goodman, MD, gynecologic oncologist and co-director of Women's Global Health at Massachusetts General Hospital, and colleagues recently reviewed the challenges and barriers to cervical cancer prevention in Ukraine and elsewhere in Eastern Europe. Their paper is published in Health.
Methods
The authors conducted a comprehensive search for case series studies and population data on human papillomavirus (HPV) vaccination policy in Eastern Europe and studies of the incidence of cervical cancer, medical infrastructure, and the impact of disasters in the region. Sixty-five relevant articles were retrieved.
Results
The major findings from the review fall into three categories:
Epidemiology
The team found the incidence of cervical cancer is significantly higher in Central and Eastern Europe than in Western Europe: at least one in 50 women is diagnosed with the disease before age 75, according to a paper in Vaccine. In Ukraine, cervical cancer is the second most common cancer diagnosis and presents at stage III or IV in 17% of women. 40% of women diagnosed with cervical cancer die within a year.
Screening and Vaccination
Ukraine recommends vaccination against HPV for girls ages 9 to 14 years. However, the vaccine is not included in the national immunization program, and all families have to pay out-of-pocket. Furthermore, even before COVID-19 and the Russian attack on Ukraine, the country had been facing shortages of vaccines for many years.
Vaccine hesitancy is a growing problem in Ukraine, particularly among certain segments of the population, including the elderly and people with lower levels of education. A 2019 survey published in The Lancet Infectious Diseases showed only 29% of the population thought any vaccine was safe. Hesitancy is often fueled by misinformation and mistrust of the government and healthcare providers.
In 2022, after the Russian war started, delivery of vaccines became challenging due to disruptions to supply chains, damage to infrastructure, and security risks for healthcare workers.
Disasters
The explosions at the Chernobyl nuclear power plant in 1986 still rank as the worst-ever industrial nuclear disaster. Its influence on HPV-related cancer rates in the region is unclear, but some studies have found slightly higher cervical cancer rates in certain areas.
The COVID-19 pandemic devastated Ukraine's healthcare system because of the loss of life among professionals. Reduced capacity to screen and evaluate women for cervical cancer led to decreased detection of new cancer cases and increased diagnosis at advanced stages.
Those effects have been exacerbated by the Russian war, which has destroyed hospitals and clinics, displaced healthcare workers, and diverted money from healthcare to defense. The war has also displaced almost 20% of the Ukrainian population, according to the United Nations, increasing the risk of SARS-CoV-2 infection due to crowding during transportation and in temporary shelters.
Migrants face barriers to accessing healthcare, including HPV vaccination, because of language barriers, frequent relocation, and hesitancy to register with local governments for fear of deportation.
The Physician's Role in Cervical Cancer Prevention
The authors suggest how Eastern Europe and the international disaster response community can move forward. In addition, they emphasize the need for individual gynecologists and physicians of other specialties, especially dermatologists, urologists and family physicians, to encourage HPV vaccination.
In addressing concerns about vaccinating prepubertal children against sexually transmitted infections, clinicians should steer the conversation to the high lifetime prevalence of HPV infection. Vaccination in childhood may increase the immunogenicity of the vaccine, and administration before sexual contact provides maximum protection.
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