研究分析实现世卫组织消除宫颈癌的目标对死亡率的影响
2020-02-14   阅读:396   来源:柳叶刀

澳大利亚新南威尔士州癌症委员会Karen Canfell研究组在研究中取得进展。他们详细分析了实现世界卫生组织(WHO)消除宫颈癌的目标对死亡率的影响。该项研究成果发表在2020年1月30日出版的《柳叶刀》上。

WHO正在制定一项将宫颈癌作为一个公共卫生问题进行消除的全球战略,提出消除阈值为每10万名女性中仅有4例宫颈癌,并在2030年实现人乳头状瘤病毒(HPV)疫苗接种率90%、两次终生宫颈筛查率70%、浸润前病变和浸润癌治疗率90%的三重干预覆盖目标。

研究组评估了实现90-70-90三重干预目标对下世纪宫颈癌死亡率和避免死亡的影响。还评估了联合国可持续发展目标(SDG)中2030年将非传染性疾病过早死亡率降低三分之一的可能性。

到2020年,所有78个中低收入国家的宫颈癌死亡率预计为每10万名女性中有13.2例。与现在相比,到2030年,仅接种疫苗对宫颈癌死亡率的影响微乎其微,可降低0.1%,而增加两次终生筛查和癌症治疗将使死亡率降低34.2%,到2030年将减少30万人死亡。

到2070年,仅加强疫苗接种便可降低61.7%的死亡率,避免480万人的死亡。2070年还将进一步加大筛查和癌症治疗的力度,一次终生筛查可将死亡率降低88.9%,避免1330万人死亡;两次终生筛查可将死亡率降低92.3%,避免1460万人死亡。

到2120年,仅接种疫苗将使死亡率降低89.5%,避免4580万人死亡。到2120年,进一步加大筛查和癌症治疗的力度,一次终生筛查可使死亡率降低97.9%,避免6080万人死亡;两次终生筛查可将死亡率降低98.6%,避免6260万人死亡。

根据WHO的三重干预战略,在未来10年内,撒哈拉以南非洲和近三分之一的南亚可减少大约一半的死亡病例;在未来100年内,这些地区将减少几乎90%的死亡病例。

对于过早死亡(30-69岁死亡),WHO的三重干预策略将使2030年的死亡率降低33.9%,2070年的死亡率降低96.2%,2120年的死亡率降低98.6%。
该发现强调了立即扩大预防接种、筛查和治疗浸润前病变和浸润性宫颈癌的重要性。

在未来10年,中低收入国家可将宫颈癌的过早死亡率降低三分之一,向实现2030年联合国可持续发展目标迈进。 到下个世纪,成功实施WHO消除宫颈癌的战略将使宫颈癌死亡率降低99%,从而挽救6200多万女性的生命。

附:英文原文

Title: Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries

Author: Karen Canfell, Jane J Kim, Marc Brisson, Adam Keane, Kate T Simms, Michael Caruana, Emily A Burger, Dave Martin, Diep T N Nguyen, élodie Bénard, Stephen Sy, Catherine Regan, Mélanie Drolet, Guillaume Gingras, Jean-Francois Laprise, Julie Torode, Megan A Smith, Elena Fidarova, Dario Trapani, Freddie Bray, Andre Ilbawi, Nathalie Broutet, Raymond Hutubessy

Issue&Volume: January 30, 2020

Abstract: 

Background
WHO is developing a global strategy towards eliminating cervical cancer as a public health problem, which proposes an elimination threshold of four cases per 100?000 women and includes 2030 triple-intervention coverage targets for scale-up of human papillomavirus (HPV) vaccination to 90%, twice-lifetime cervical screening to 70%, and treatment of pre-invasive lesions and invasive cancer to 90%. We assessed the impact of achieving the 90–70–90 triple-intervention targets on cervical cancer mortality and deaths averted over the next century. We also assessed the potential for the elimination initiative to support target 3.4 of the UN Sustainable Development Goals (SDGs)—a one-third reduction in premature mortality from non-communicable diseases by 2030.
Methods
The WHO Cervical Cancer Elimination Modelling Consortium (CCEMC) involves three independent, dynamic models of HPV infection, cervical carcinogenesis, screening, and precancer and invasive cancer treatment. Reductions in age-standardised rates of cervical cancer mortality in 78 low-income and lower-middle-income countries (LMICs) were estimated for three core scenarios: girls-only vaccination at age 9 years with catch-up for girls aged 10–14 years; girls-only vaccination plus once-lifetime screening and cancer treatment scale-up; and girls-only vaccination plus twice-lifetime screening and cancer treatment scale-up. Vaccination was assumed to provide 100% lifetime protection against infections with HPV types 16, 18, 31, 33, 45, 52, and 58, and to scale up to 90% coverage in 2020. Cervical screening involved HPV testing at age 35 years, or at ages 35 years and 45 years, with scale-up to 45% coverage by 2023, 70% by 2030, and 90% by 2045, and we assumed that 50% of women with invasive cervical cancer would receive appropriate surgery, radiotherapy, and chemotherapy by 2023, which would increase to 90% by 2030. We summarised results using the median (range) of model predictions.
Findings
In 2020, the estimated cervical cancer mortality rate across all 78 LMICs was 13·2 (range 12·9–14·1) per 100?000 women. Compared to the status quo, by 2030, vaccination alone would have minimal impact on cervical cancer mortality, leading to a 0·1% (0·1–0·5) reduction, but additionally scaling up twice-lifetime screening and cancer treatment would reduce mortality by 34·2% (23·3–37·8), averting 300?000 (300?000–400?000) deaths by 2030 (with similar results for once-lifetime screening). By 2070, scaling up vaccination alone would reduce mortality by 61·7% (61·4–66·1), averting 4·8 million (4·1–4·8) deaths. By 2070, additionally scaling up screening and cancer treatment would reduce mortality by 88·9% (84·0–89·3), averting 13·3 million (13·1–13·6) deaths (with once-lifetime screening), or by 92·3% (88·4–93·0), averting 14·6 million (14·1–14·6) deaths (with twice-lifetime screening). By 2120, vaccination alone would reduce mortality by 89·5% (86·6–89·9), averting 45·8 million (44·7–46·4) deaths. By 2120, additionally scaling up screening and cancer treatment would reduce mortality by 97·9% (95·0–98·0), averting 60·8 million (60·2–61·2) deaths (with once-lifetime screening), or by 98·6% (96·5–98·6), averting 62·6 million (62·1–62·8) deaths (with twice-lifetime screening). With the WHO triple-intervention strategy, over the next 10 years, about half (48% [45–55]) of deaths averted would be in sub-Saharan Africa and almost a third (32% [29–34]) would be in South Asia; over the next 100 years, almost 90% of deaths averted would be in these regions. For premature deaths (age 30–69 years), the WHO triple-intervention strategy would result in rate reductions of 33·9% (24·4–37·9) by 2030, 96·2% (94·3–96·8) by 2070, and 98·6% (96·9–98·8) by 2120.
Interpretation
These findings emphasise the importance of acting immediately on three fronts to scale up vaccination, screening, and treatment for pre-invasive and invasive cervical cancer. In the next 10 years, a one-third reduction in the rate of premature mortality from cervical cancer in LMICs is possible, contributing to the realisation of the 2030 UN SDGs. Over the next century, successful implementation of the WHO elimination strategy would reduce cervical cancer mortality by almost 99% and save more than 62 million women's lives.

DOI: 10.1016/S0140-6736(20)30157-4

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