KUALA LUMPUR, Sept 4 – While the incidence rate of cervical cancer in Malaysia is lower than the world average (10.2 per 100,000 women compared to 13.3, according to estimates from the Global Cancer Observatory), its burden is considerable, making it one of the leading causes of cancer deaths among women in Malaysia, according to the UNFPA report Enhancing Human Capital through Sexual and Reproductive Health Investments and Family Support Policies in Malaysia.
The Global Cancer Observatory estimates that 1,740 Malaysian women were diagnosed with cervical cancer in 2020, resulting in 991 deaths. Cervical cancer ranks as the fourth leading cause of female cancer in Malaysia (after breast, colorectal and ovarian cancers), and is the second most common cancer among women aged 15 to 44.
The age-specific incidence rate of cervical cancer starts rising after the age of 25 and continues to rise markedly with age. Globally, the average age at diagnosis is 53 years, and the average age of death is 59 years.
About 1.1 per cent of Malaysian women are at risk of developing cervical cancer before age 75. Nearly all cervical cancer cases (99 per cent) are related to infection with high-risk HPV, a sexually transmitted virus; in particular, HPV strains 16 and 18 account for 70 per cent of cases globally, according to the report.
Cervical cancer typically develops 15 to 20 years after human papilloma virus (HPV) exposure in healthy women. It tends also to affect women during their working age, suggesting that the benefits of eliminating cervical cancer go well beyond direct morbidity and mortality impacts.
Treating and managing cases of cervical cancer using several modalities has major cost implications, besides necessitating a woman to be away from work for a considerable period of time.
Two Major Investments In Preventing And Controlling Cervical Cancer
The two major investments in preventing and controlling cervical cancer, and boosting female human capital include HPV vaccination and screening for precancerous lesions (using cytology examinations such as pap smear or detecting the presence of HPV using HPV-DNA tests).
In 1969, Malaysia introduced the pap smear screening programme, which is recommended every three years for all women aged 30 to 65-year-old who are or have been sexually active.
However, uptake of the pap smear screening programme has been relatively low, notes the UNFPA report, which cites the National Health and Morbidity Survey 2019 findings that only 36.6 per cent of women aged 20 and older had a pap smear examination in the past three years.
The Ministry of Health (MOH) and the Ministry of Women, Family, and Community Development (KPWKM) started a pilot programme on the use of an HPV self-sampling test as a screening tool for cervical cancer in 2019, with the target of full adoption by 2023.
Although it is more expensive than the pap smear, the HPV test is considered more effective at identifying women at risk of developing cervical cancer and the recommendation is for women to take the HPV test every five years instead of three. The self-sampling method of the test encourages uptake by increasing patient autonomy and convenience.
While HPV testing is crucial to lowering cervical cancer rates in the short term, vaccination of women before the initiation of sexual activity is key to drive down incidence rates in the long term. Additionally, since available vaccines do not protect against all HPV strains responsible for cervical cancer, vaccinated women still need regular cancer screening.
103,000 Deaths In Malaysia From Cervical Cancer By 2070 Without HPV Vaccination And HPV Screening
The UNFPA report cites a recent study estimating the mortality impacts of scaling up HPV vaccination and HPV screening around the world and found that the global average reduction in cervical cancer mortality due to high HPV vaccination coverage (90 per cent of the targeted population) is only 0.1 per cent by 2030. By 2070, HPV vaccination alone can prevent 61.7 per cent of global deaths.
If HPV screening is added to HPV vaccination (at least once in a lifetime, with 45 per cent HPV screening coverage by 2023, 70 per cent by 2030 and 90 per cent by 2045), cervical cancer mortality reduces on average by 34.2 per cent by 2030, and 88.9 per cent by 2070. These results suggest that the optimal strategy to eliminate cervical cancer should include both HPV vaccination and HPV screening.
The study does not provide results specifically for Malaysia. However, using the global average reductions in cervical cancer mortality from the accessed study, the age-specific cervical cancer mortality rates for Malaysia projected by the Global Cancer Observatory and United Nations (UN) population projections by age and sex, is that by 2070 there would be approximately 103,000 total deaths from cervical cancer if no HPV vaccination and no HPV screening were implemented.
ROI For HPV Vaccination And Screening
Vaccinating 90 per cent of targeted girls would avert about 32,000 deaths by 2070; if rapid scale-up of HPV screening is added to HPV vaccination, about 61,900 deaths could be averted by 2070.
Since the age of death from cervical cancer is around 59 years, and life expectancy in Malaysia for women is about 78 years, women will live on average for 19 additional years if they do not die of cervical cancer.
The value of an additional year of life can be measured using the Value of a Statistical Life Year (VSLY concept), which is generally assumed to be one to three times income per capita.
With a GDP per capita of RM46,450 (as per the Department of Statistics Malaysia, State Socioeconomic Report 2019. 2020) one averted death is valued between RM883,500 and RM2,650,500, showing that the benefits of preventing cervical cancer deaths outweigh the expected costs.
The return of investing in HPV vaccination and HPV screening until at least 2070 is estimated to be 9.6:1, if the VSLY is taken to be equal to GDP per capita, according to the report.