Cervical Cancer Elimination Policy and Strategy

Objectives

The strategy seeks to eliminate cervical cancer in the Marshall Islands within two generations through a comprehensive, equitable continuum of prevention, screening, diagnosis, treatment, survivorship and palliative care. It aims to reduce human papillomavirus transmission among girls and boys through vaccination, and to reduce preventable cervical cancer incidence, morbidity and mortality while improving women’s reproductive health, quality of life and productivity.[1]The policy aligns with the National Strategic Plan 2020–2030 and the National Comprehensive Cancer Control Plan, responding to a high cervical cancer burden and supporting the World Health Organization elimination threshold of fewer than four new cases per 100,000 women.[2][3]

• Increase HPV vaccination coverage, building on the school-based programme introduced in 2009 and extending access to girls who are not in school, communities in the outer islands and, where adopted, boys.[2][4][5]
• Expand high-performance HPV testing and cervical screening, particularly for women aged 21–65 years and women over 30 years for HPV DNA testing, while improving follow-up and treatment of positive results.[6][7]
• Ensure timely diagnosis, treatment, rehabilitation, survivorship support and palliative care, including overseas treatment for early-stage cervical cancer where necessary.[6][8]
• Strengthen the health workforce, national and overseas referral pathways, programme governance, cancer information systems, partnerships, advocacy and culturally appropriate public awareness.[6][9][10]

The strategy incorporates successive coverage and service targets. Global elimination pillars cited include full HPV vaccination for 90% of girls by age 15, screening for 70% of women by ages 35 and 45, and treatment or management for 90% of women with pre-cancer or invasive cancer.[2]The national 2030 targets are to vaccinate 85% of girls aged 11–15 years, test 50% of women aged 21–65 years for HPV, provide pelvic examination and treatment or referral for 90% of HPV-positive women, refer 90% of suspected pre-cancers, treat 90% of early-stage cancers and provide palliative management for 90% of late-stage cancers.[6]A separate monitoring framework sets 2028 targets of 80% vaccination among girls and boys, HPV testing for 80% of women aged 21–65 years, treatment for 60% of women testing positive, and recent Pap smears for 50% of women in that age group.[11]

The policy also uses National Comprehensive Cancer Control Plan targets to increase completion of the two-dose HPV series among girls aged 11–15 years from 45% to 80%, increase recent cervical screening among women aged 21–65 years without hysterectomy from 25.3% to 40.0%, improve survivorship quality of life and care planning, and increase palliative care among patients receiving no cancer treatment from 60% to 75%.[3]These objectives reflect the need to address substantial unmet prevention and screening needs, including women who are outside the age group expected to benefit from HPV vaccination.[12]

Implementation

Implementation uses a multisectoral, people-centred and evidence-based model spanning prevention, screening, diagnosis, treatment, survivorship and palliative care. Delivery is led principally by the Ministry of Health and Human Services (MHHS), working with the Cancer Program, immunisation, reproductive health, laboratory, obstetrics and gynaecology services, Outer Islands Health Services, civil society, other government sectors and the National Comprehensive Cancer Control Coalition.[13][8][10]The approach emphasises equity, universal coverage, quality assurance, cost-effectiveness, accountability, stakeholder ownership and appropriate technology.[3]

• Deliver school-based HPV vaccination through school visits that provide information, obtain parental consent and vaccinate eligible girls, while using community outreach and nongovernmental organisation partnerships, including Women United Marshall Islands, to reach children outside school.[5]
• Integrate outer-island vaccination with wider health-service visits and address transport, travel restrictions and uneven coverage across Majuro, Ebeye and remote islands.[4][5]
• Introduce and scale HPV DNA testing, procure test kits, train health workers, strengthen GeneXpert use at the main hospitals, and integrate testing awareness into women’s health programmes.[7][9]
• Extend HPV testing, visual inspection and thermal ablation to outer-island services, supported by refresher training, clinical management training and guidelines for screening, survivorship, pain management and palliative care.[8][9]
• Strengthen communication and referral protocols from outer islands to Majuro and from Majuro to overseas services, while improving access to overseas treatment for early-stage disease and support for patients.[6][9][10]

The service platform comprises two public hospitals in Majuro and Ebeye and approximately 49 outer-island health centres, which are staffed by nurse practitioners and/or health assistants.[14]Basic vaccinations and Pap smears are available to Marshallese citizens at little expense, but screening has largely been opportunistic, mainly provided through the Majuro gynaecology clinic, with ad hoc services elsewhere and some visual inspection with acetic acid.[14][5]Laboratory specimens are processed locally and sent to Hawai'i because the country has no pathologist, contributing to processing delays and a cost of approximately USD 63 per Pap smear or cervical biopsy specimen.[5]

Patient-centred delivery includes addressing cultural, social and geographic barriers, such as reliance on traditional medicine, discomfort with male health workers, loss to follow-up and repeated travel from outer islands.[15]Women with stage-one or stage-two disease may be referred overseas, principally to Hawai'i or the Philippines, for radiotherapy or chemotherapy; referrals include an escort and living allowances for the patient and escort.[15]The survivorship programme within the MHHS Cancer Program is intended to provide navigation or case management, support services, survivorship care plans, clinical guidance and palliative-care training.[15][1]

Governance actions include strengthening the National Comprehensive Cancer Control Coalition through regular meetings, reporting, stakeholder memoranda of understanding, cross-sector partnerships, advocacy and community mobilisation.[7][10]Cervical cancer data are to be maintained through the Cancer Registry, with regular reporting and a monitoring and evaluation framework containing targets and milestones for 2030.[7][10]Annual reporting is identified for HPV vaccination, testing and treatment, Pap smear results and cervical cancer survivorship.[11]The supplied material does not specify a consolidated national budget, detailed financing plan or quantified funding gap, although it calls for increased funding for overseas treatment and identifies financial support as necessary for HPV testing.[1][8]

Monitoring & Evaluation

The monitoring and evaluation approach combines cancer-registry surveillance, service data and annual reporting against vaccination, screening, diagnosis, treatment, survivorship and palliative-care measures. It is intended to support the goal of reducing cervical cancer incidence to below four per 100,000 women and achieving elimination targets by 2030.[2][7]

• Monitor global elimination coverage targets of 90% full human papillomavirus (HPV) vaccination by age 15, 70% high-performance screening at ages 35 and 45, and 90% treatment of pre-cancer and management of invasive cancer.[2]
• Track National Comprehensive Cancer Control Plan targets, including increasing two-dose HPV vaccination among girls aged 11–15 from 45% to 80%, screening among women aged 21–65 without hysterectomy from 25.3% to 40%, survivorship quality-of-life scores from 4.56 to 7.06, and palliative-care coverage among untreated cancer patients from 60% to 75%.[3]
• Report annually on HPV vaccination, HPV testing and treatment, Pap smear results and cervical cancer survivorship.[11]
• Measure the 2028 targets of vaccinating 80% of girls and boys, HPV testing 80% of women aged 21–65, treating 60% of women testing positive, and providing recent Pap smears to 50% of women aged 21–65.[11]
• Maintain cervical cancer data in the Cancer Registry, collect relevant patient data, and produce regular reporting.[7][10]
• Formulate a stakeholder-developed monitoring and evaluation framework with 2030 targets and milestones; endorsement by the National Comprehensive Cancer Control Coalition was planned for June 2023.[10]
• Use the Coalition as an accountability mechanism through regular meetings, action follow-up and reports.[10]

Registry and surveillance data demonstrate a substantial disease burden. The Marshall Islands National Cancer Registry recorded 187 cervical cancer cases between 2005 and 2020, while the Pacific Regional Central Cancer Registry has systematically collected population-based cancer data across participating United States-affiliated Pacific Islands since 2007.[12]Cervical cancer incidence was reported as 70.0 per 100,000 women during 2007–2012, with incidence-based mortality of 34.0 per 100,000 and five-year survival of 58%.[16]From 2017 to 2021, 61 women were diagnosed and 31 died, equivalent to 52% of those diagnosed.[16]

Service data show gaps in prevention and screening coverage. First-dose HPV vaccination coverage among eligible girls averaged 34% over the reported period, ranging from 11% in 2012 to 67% in 2019; vaccination was suspended in 2021 during COVID-19 vaccine roll-out, with recorded coverage of 0% for both doses.[4]In 2020, reported coverage was 28% in Majuro, 63% in Ebeye and 16% in the outer islands.[4]Screening records from Majuro and Ebeye hospitals recorded 294 Pap smears in 2018, 452 in 2019, 334 in 2020, 591 in 2021 and 359 in 2022, with 15, 26, 16, 19 and 22 abnormal results respectively.[17]

Digital laboratory data management has operated since 2018, but reporting remains fragmented because of human-resource and technological constraints.[5]The supplied material does not specify consistent indicator definitions, a comprehensive reporting timetable, independent evaluation methods or detailed accountability responsibilities beyond registry reporting, named implementation roles and Coalition oversight.[7][10]

Costing & Financing

Financing is recognised as necessary for cervical cancer elimination, but the supplied material provides limited quantified costing. The policy seeks sufficient funding, applies a cost-effectiveness principle, and identifies resource mobilisation as a strategic requirement.[13][3]

• Receive project funding from the United Nations Population Fund Pacific for development of the strategy.[13]
• Use external support from the United States National Cancer Institute Health Disparities Program and pursue Centre for Disease Control and Prevention registry co-operative agreements through the regional cancer-control partnership.[12]
• Obtain HPV vaccine supply through the United States Centers for Disease Control and Prevention, without a monetary value specified.[4]
• Allocate an increased budget for overseas treatment of early-stage cervical cancer, although no amount or financing source is provided.[8]
• Cover living allowances for patients referred overseas and their escorts; some patients with financial means fund overseas treatment themselves.[15]
• Provide financial support for introducing HPV testing, which is described as more expensive than visual inspection with acetic acid.[1]
• Pay approximately USD 63 to process each Pap smear or cervical biopsy specimen sent to Hawai'i.[5]

Basic vaccinations and Pap smears are available to Marshallese citizens at little expense.[14]However, the material does not provide a total programme budget, costed workplan, domestic funding allocation, quantified financing gap, expenditure profile, resource-mobilisation target or economic modelling assumption.[13][6][7]