The Decibel - Cervical cancer is on the rise in Canada

Episode Date: December 11, 2023

A recent report from the Canadian Cancer Society underlines a troubling trend: cervical cancer is on the rise and seeing its most significant increase in nearly 40 years. Despite having a vaccine against HPV – the predominant cause of the cancer – hundreds of Canadian women are dying every year.The Globe’s national health reporter Carly Weeks joins the podcast to explain what experts think should do to help prevent the rise of cervical cancer cases in Canada.Questions? Comments? Ideas? E-mail us at [e-mail]

Canada has an ambitious goal of eliminating cervical cancer by 2040. But a recent report from the Canadian Cancer Society shows that incidents of the disease are actually on the rise, and it's the most significant increase in nearly 40 years. Carly Weeks is the Globe's health reporter. She'll tell us what we know and don't know about these rising numbers and what experts think needs to be done to bring them down. I'm Maina Karaman-Wilms and this is The Decibel from The Globe and Mail.

Carly, thank you so much for being here. Well, thank you for having me. I think before we get into the cervical cancer rates in Canada, let's just define what we're talking about here. So what exactly is cervical cancer and how do you get it? So cervical cancer is caused by, in most cases, by a human papillomavirus. So that's a sexually transmitted infection that is very common. Essentially, everyone will get it at some point in their lives. Virtually all cases of cervical cancer are caused by HPV. There are some rare cases that aren't. But I think for the vast majority of listeners, you know, HPV is really the primary concern. It can lead to abnormal changes in the cervix, which is part of the female reproductive system. So essentially,

what happens is that these abnormal cells can grow, can develop into cancer. And this is why there's been such emphasis on early detection and treatment. And you use the word eventually there. So this is actually a slow growing cancer, isn't it? Yeah, this is the kind of cancer that does take many years to grow and become a problem. That's why we've seen in recent years more jurisdictions moving to sort of less frequent screening. So once upon a time, the idea was you needed to go for like an annual pap smear. Now, the recommendations are every two to three years, depending on your risk profile. So cervical cancer is now one of the

fastest increasing cancers in Canada. Can you just explain, though, what does that mean? Yeah, fastest increasing for women. So what has been happening is that since 2015, the incidence rate of cervical cancer has been going up at a rate of 3.7% every year, so nearly 4% a year. This is the largest increase in cervical cancer in about 40 years. Nearly 1600 people will be diagnosed with cervical cancer this year. And of those, 400 will die as a result. And given, you know, all of the things and the tools in the toolbox to prevent and treat cervical cancer, you know, it's very concerning to see this trend happening and signals that more needs to be

done. Yeah, and we're certainly going to talk about these measures to prevent cancer. But first, I take it this is a pretty surprising increase, Carly, like to see these numbers go up so drastically? It is, yeah. And I think that, you know, it's worth noting Canada is not alone here. There's other peer countries that have seen the same kinds of increases. It's not entirely clear what's going on. I mean, on the one hand, you'd want to say, well, falling vaccination rates are to blame, but it likely is even too early to see those kinds of trends manifest. You know, it's going to take time for people who are unvaccinated to go and become adults and then be at risk of developing cervical cancer. So there's likely a combination of things going on. You know, for instance, everything from people who have not been screened, or, you know, there's

lots of issues and barriers when it comes to getting screened for cervical cancer. At the same time, you know, we may have a lot of people who've, you know, are living in Canada, who've never had access to screening, say, in their home country. So there's likely a whole bunch of different little things that are all combining here. But regardless, the message that this sends is that this is something that we do need to focus more on because the rates are clearly going up and this is quite alarming.

Yeah. So let's talk more then about these tools of prevention that we do have. We talked about how cervical cancer is caused by HPV, but there is a vaccine here to help. So can we talk a little bit about that vaccine? Yeah, when we talk about a cervical cancer, there's really prevention and early detection are the keys. So a couple of decades ago, there was this, you know, landmark discovery that HPV is the cause of cervical cancer and other types of cancer, you know, anal cancer, penile cancer. And so there was a vaccine that was developed and brought online to basically prevent the strains of HPV that are linked to those types of cancer. So really huge. One of

the biggest developments in recent medical history, really important. So the first HPV vaccine was actually approved in Canada in 2006. So it was like in the next couple of years where provinces and territories began developing their own programs for, you know, getting girls vaccinated. And then within the next several years after that, provinces and territories slowly started adding boys onto that. So we're essentially at a place now where these vaccines are, for the most part, universally available to those younger cohorts. So now what we have is a vaccine that's given typically in two doses, sometimes in three, starting at around, you know, the youngest ages, I think in Canada, grade four, but often around

grade six or seven is when these vaccines are given out in schools, sort of before the onset of sexual activity to kind of give that maximum level of protection. And so what has been the situation with vaccination rates in Canada then, Carly? We've been talking about vaccines in general for a few years now, especially because of the pandemic. This is a specific kind of shot. What do we know about the rates of kids getting this shot? So there has been historic problems with HPV vaccination rates. Part of that is tied to the fact that when the vaccine first came out, there was a lot of concern over the fact that it's designed to protect against a sexually transmitted infection. And I think some people took that as sort of a moral, they had a moral objection to this,

essentially saying, you know, why are you giving a child something that protects against a sexually transmitted infection? There were some examples of churches coming out against it. I think a lot of that has now fallen by the wayside, but there's still this lingering effect. I mean, we see that, you know, rates of measles, mumps, rubella vaccination are, you know, typically around the 80s to 90s percent. And when it comes to HPV, it has always been stubbornly around that like 60 to 80 percent in a lot of jurisdictions. So it sounds like there's a bit of a stigma there because it's an STI. Yeah, it's been a bit stigmatized. And I think partly is just the idea of there was a lot of just fear and concern over exposing adolescents to this.

But really the idea, I think, that we need to get out there more or that, you know, we may have not done a great job on is communicating, this is really about protecting against cancer later in life. That sort of maybe was one step that was missing. Now, of course, since the pandemic, all vaccine uptake has really been thrown up in the air, because a lot of vaccine programs were simply shut down. Now, one of the challenges we have in Canada is that there is no national vaccine registry. So we really rely on provinces and territories to release their most up-to-date information on who is getting vaccinated and where they live. That information is often not readily available. And even when it is,

it can be out of date. So, you know, some of the most recent information we have from Ontario, for instance, is from, I think, the end of the 2022 school year. So it's not quite as up to date as it could be. But what we do know is from the most recent Ontario data that I was mentioning, that vaccination rates in that cohort of kids that were affected by the pandemic. So say if you're in that grade six range during the pandemic, the vaccination rates plummeted to, you know, very low levels. There have been catch-up programs since then to try and capture, you know, those groups of kids that have not been vaccinated,

but even still they're struggling. I think, you know, less than one in three kids in those years are vaccinated against HPV. So, I mean, when you look at those numbers, we really need to be around 90% if we want to be on the pathway to eliminating cervical cancer. So it's clear that there is a huge amount of work to be done and maybe even a new approach to get those rates up. Yeah, I think it's like it's 23% of all 12-year- olds who missed their HPV shot during the pandemic are caught up. So these are these numbers are quite low. What if you didn't get the shot in school, though, Carly? Like if you're around 30 or maybe a little bit older, you wouldn't have gotten it in school. It wasn't a

program then. So should you still be getting vaccinated? Yeah. The conventional wisdom was, you know, this is this is for kids. This is for adolescents before the onset of sexual activity. Thinking has really evolved since then. So the consensus is now very much in favor of getting vaccinated as an adult. I mean, even if you've been exposed to HPV, that doesn't mean, you know, you shouldn't go and try and protect yourself in this way. The barrier here is that if you're an adult, chances are you're going to have to pay out of pocket several hundred dollars to get vaccinated. So, you know, someone who has a higher income and higher education level, that might be a lot easier to accomplish than someone who, say, you know, is working several jobs and may not have even been screened for cervical cancer in years because they don't have a family doctor and they can't afford the vaccination. Yeah. And some insurance programs do do cover it, of course,

but it really depends on what kind of access you have, really. So I guess in some cases, uptake on vaccinations is falling short. Okay. So that's the first part of prevention. We also mentioned screening, Carly. So what do we have for that? Yeah, this is actually really exciting. So, you know, when I talk about PAPs, I don't know why I'm talking about exciting, but stay with me for a second. So for decades, PAP tests have been the basically only way to, you know, do that screening for cervical cancer to see, you know, do you have abnormal

cells? So essentially what happens is, you know, a person goes into a doctor's office, it's an uncomfortable procedure, your legs are in stirrups. They insert sort of like a little device into the vagina. They push something up there. They scrape out some cells. It's about as fun as it sounds. What then happens is though that sort of swab of cells gets examined by a technician to look for the presence of abnormal cells. If they're there, then the person would then go for different sort of follow cells. If they're there, then the person would then go for different sort of follow-up tests. What's happened since then? So, you know, there's lots of issues with the PAB test. It's uncomfortable. A lot of people may have cultural

or religious objections to it. If you don't have a family provider, how are you going to get one done? So lots of different barriers on the road to getting that PAB test done. But what's now coming online slowly, but surely is a DNA based HPV test. So this test has been actually around for a while. And other countries have been using this with great success. Essentially, what happens is with this kind of an HPV test, you could receive in the mail a swab. So it's essentially what I've been told is like a long Q-tip. You insert it yourself, mail it back, and then it's tested not for the presence of abnormal cells, but for the presence of DNA of an HPV infection that's linked to cancer. So it's much more accurate. You're no longer sort of relying on the presence of cells and are they abnormal? You're actually looking for the DNA, sort of like the tiniest, you know, molecule that could

indicate a link to cervical cancer. The challenge is that it's really not widely available across Canada yet. And it's coming. But I guess I've been told that there's a lot of logistical issues to work out in the meantime. So that's one of the reasons we don't have it yet. But it is coming. And coming in like the next few years, like this is something that we can expect to roll out pretty broadly relatively soon? Yes. I mean, PEI, I think this year was the first province to go full on with HPV testing. Other provinces have committed to doing it, but it's the timelines are really up in the air, which I think is probably the most, or one of the more unfortunate things. I mean, you can understand that there's,

you know, logistical challenges and issues to get in place. But this is really sort of a, you know, a golden opportunity to bring screening rates up. And so the emphasis, I know a lot of experts really want to see that rolled out sooner rather than later. We'll be right back. So let's come back to kind of the bigger overarching goals here to reduce the rates of cervical cancer. So Canada has a plan to eliminate cervical cancer by 2040. Where did this goal come from? And I guess also, what do we mean when we say eliminate?

This is a goal that the World Health Organization first sort of emerged with in 2020, essentially saying, if you look around, we have the tools to prevent cervical cancer. We have the tools to do early detection and treatments before it even becomes cancerous. The World Health Organization is essentially challenging countries to meet a couple of different targets. You know, here's we want to see every country getting to a really high vaccination coverage rate for teenagers. We want to see every country bringing up a really high vaccination coverage rate for teenagers. We want to see every country bringing up their screening rates. Canada has taken this challenge on and is going even further by attaching a year to it by saying we're going to not just get on the path to eliminating cervical cancer, we're actually going to eliminate it by 2040. Now, of course, you will never fully get rid of cervical

cancer. There will always be these breakthrough cases and things like that. And, you know, the rare case that's not caused by an HPV infection. But the idea is that you bring the case number so low that it essentially is, you know, no longer a public health or major public health concern. Okay. So the thing is, though, of course, we're seeing this increase in cervical cancer right now. That's where we started talking about this. So it seems like we're not on track to meet that 2040 goal. How is Canada doing with this target? I mean, it's a real mixed bag right now. You know, on the one hand, I mean, I've spoken to experts who point to the fact that our healthcare infrastructure, you know, despite its challenges is still very good. You know, we have access to

vaccines, we have access to pap tests, and slowly, eight more HPV tests. So we have everything that we need. And so we really don't need to worry. And I've spoken to others who say, you know, if you actually look at what's going on on the ground, you know, we have cause to be very concerned about missing this target overall, because we know that there's historic challenges with screening, especially with some more at-risk groups that we're not doing enough to address. And same goes with vaccination. We've seen a huge drop in vaccination rates, and that is going to come back to really bite us when you see more people who are not protected being diagnosed with cervical cancer in the coming years. And of course, health care across Canada is done by province.

I guess, are there any parts of the country that are maybe doing better on this front? When you look at overall vaccination coverage, for instance, Newfoundland and Labrador seems to be doing better than the rest. Now, again, this is relying on some older, outdated data. Not every province and territory is actually disclosing how well they're doing. to be doing better than the rest. Now, again, this is relying on some older, outdated data. Not every province and territory is actually disclosing how well they're doing. So it can be a bit difficult to really get that overall sense. So I'd say of all the provinces, they're the only one that actually is probably at the 90% vaccination threshold where we need to be. Others, you know, the vaccination rates, even before the pandemic would really range from, you know, anywhere from like 50 something percent to 80 some percent.

So it is a bit of a mixed bag. And then those vaccination coverage rates don't really tell you sort of in certain communities where vaccination rates are very low and in others where it's very high. So, you know, if you start to recall how things unfolded with COVID, you would see that in, you know, higher income areas, the vaccination coverage would be very high. And in lower income areas, the vaccination coverage would be very low. And there's a couple of very good reasons for that. So, you know, we don't, you know, like many things in health in Canada, we don't have a great sense of really, I think, how we're doing in that real time level. And so when I've talked to people who are concerned about us missing that timeline, I think that, you know, they're looking at some of the communities who might be, you know, underserved and saying, this is where we need to be focusing more,

because we're clearly going to miss the targets if you look at what's going on there. Yeah. So those are some of the big challenges then that we face in Canada here. I want to talk about some other countries too, because according to the WHO, there are some countries that are doing better than us when it comes to cervical cancer elimination. Australia is on target to eliminate this cancer in the next 10 years. Norway reported finding no cases of cervical cancer caused by HPV in 25-year-olds. So this would be like the first cohort of people who were offered the vaccine as kids through their national vaccination program. So Carly, I guess, what can we learn? What can Canada learn from these other countries? So when you look at countries like Australia, you know, they have been using HPV testing

for about six and a half years. In 2017, they brought it fully online. So they're, you know, sort of ahead of the curve in bringing these groundbreaking tests to the public. This is the test you're talking about, they can do at home and mail it in, the more accurate test. Yeah, the more accurate, accessible test. So they've seen their screening rates increase. There's been, I think, real attention paid to cervical cancer in a bigger, more comprehensive way than maybe we have in Canada. You know, I think that those countries that are seeing great success have really made it a huge priority. I think what the World Health Organization's goal or this campaign is designed to do is to remind other countries, like, this is

where we need to get as well. Like, this is something that, you know, we can't just be complacent about because we have vaccines and because we can prevent it and detect it early. We need to actually focus on making sure that gets done. So yeah, so one of the big solutions that we've talked about is the uptake of this HPV test, the new way to do this testing and screening. Let's talk about vaccines. What can we do to improve vaccine uptake? There's actually a lot of proven strategies to increase vaccine uptake. And yes, it does require a lot of work. And it's a lot more than what we tend to see from, say, governments where there's like billboard campaigns or social media campaigns. It goes even further than that.

So really what evidence shows is that you need to really increase confidence in vaccines, so public trust, and you need to have accessibility of vaccines. So there can't be like a cost associated with it. It has to be available in your neighborhood or community. And you have to be able to trust in it. So what we saw during COVID and what research has been bearing out for many years, even pre-COVID, is that having a trusted source of information can make all the difference. Yeah. So I guess just lastly here, Carly, I mean, despite the rates of cervical cancer in Canada been increasing in the past few years, is it still possible for us to eliminate the disease by 2040

to hit that goal? I think that what it will really come down to is what happens in the next, say, five or so years. You know, if we can start to turn things around with vaccinations, bring those rates up to where they need to be through a variety of different methods in schools and outside of schools, increase access to HPV testing and educate communities who've never heard of this or don't understand the importance of getting screened, why they need this test. I think that there's a good chance of getting there.

It will just take a lot of focus and effort. But, you know, the goal is so worthwhile. So hopefully we do put in the effort necessary. Carly, thank you so much for being here today and walking us through all of this. Of course. Anytime. Thanks for having me. That's it for today. I'm Mainika Raman-Wellms. Our producers are Madeline White, Cheryl Sutherland, and Rachel Levy-McLaughlin. David Crosby edits the show. Adrienne Chung is our senior producer, and Angela Pachenza is our executive editor. Thanks so much for listening, and I'll talk to you tomorrow.