A systematic analysis points in the wrong direction for cervical cancer elimination – Author’s reply

In their Correspondence, Ashley Jackson raises concern about the inclusion of unsafe sex as a behavioural, potentially modifiable risk factor for cervical cancer in the Global Burden of Disease (GBD) 2019 Study

and the potential negative implications this framing could have on misdirecting policy makers towards ineffective strategies to reduce cervical cancer burden. We appreciate this feedback and the opportunity to clarify our intentions in the published analysis.

Cervical cancer is an important contributor to the global burden of cancer,

and, as noted by Jackson, is linked to persistent infection with high-risk human papillomaviruses (HPVs) that are transmitted through sexual contact. In the GBD study, the risk factor of unsafe sex is used to quantify the risk of having sex with someone that might have an infection that can be sexually transmitted if protection is not used, and is a risk factor associated with HIV, sexually transmitted infections, and cervical cancer as outcomes.

As this exposure can be challenging to estimate, 100% of cervical cancer burden is estimated to be attributable to this risk factor.

The terms modifiable and potentially modifiable were used to refer to the risk factors included in this analysis in general and were meant to indicate that the risk-attributable burden of the cancers analysed could theoretically be mitigated through changes to the various risk exposures included. For cervical cancer, these mitigation efforts would include reduction in future persistent high-risk HPV infections through comprehensive prevention strategies encompassing vaccination as well as potentially safer sexual practices.

We agree that vaccination against HPV should be emphasised as a crucial cervical cancer prevention strategy and, in alignment with the WHO cervical cancer elimination initiative,

that evidence-based strategies towards the elimination of cervical cancer should also include screening and treatment of precancer and invasive cancer. The burden of cervical cancer weighs disproportionately in low Socio-demographic Index settings, and is most likely multifactorial in aetiology and includes disparities in access to high-quality screening and treatment.