HPV and cervical cancer Prevention in Brazil: who should we save? The daughters or the mothers?

Prevention of cervical cancer as a preventable cause of death is subject to an increase interest as shown by its inclusion last year at the United Nations high-level meeting on Noncommunicable disease Prevention and control(1). For more than half a century, cervical cancer screening for precursor lesions and appropriate management and treatment was the mainstay of hPV prevention. In 1988 a large campaign was launched in Brazil to reach women who had never been screened. Brazil has a large cervical cancer screening programme that was initiated in 1996 through its National cancer Institute. Now there are efforts to incorporate screening programme into the primary care family health programmes. But still with all the components of cervical cancer programme in place, it is very sad to see that the incidence rate of cervical cancer is still 22.2 per 100,000 in all women. It kills 9.4 per 100,000 Brazilian women. It ranks second to breast cancer in terms of incidence but it kills more women 15-44 year of age than breast cancer(2). For many of cervical cancer statistics, Brazil is in the most affected quartile of the world. And it does not look that there will be a significant downward trend for a while. meanwhile Brazil has excellent vaccine programme indicators. For example: at least 95% of targeted infants did complete dPT 3 dose as recommended(3). But Brazil still does not have recommendations for hPV prophylactic vaccine. While at least one of the two prophylactic vaccines is available in at least 124 countries around the world, recommendations and adoption of one of the two vaccines is reality in at least 39 countries: 22 are classified as “high income” by the World Bank, 15 are middle income, and two are low income (Bhutan and Rwanda). Two more low income countries, lesotho and Nepal, are making active plans for national introduction in 2012(4). hPV burden is not only about cervical cancer. It is also about many other anogenital cancers and genital warts for which the quadrivalent vaccine has shown great efficacy(5). As I am looking at the closing ceremonies of the london Olympics, I see that Brazil will be the host of world competitions very soon; the mundial for football in 2014 and the summer Olympics in 2016. These world class events will engulf billions of dollars. World class events but still such high rates of cervical cancer and no hPV vaccine program... Some will propose investing for better screening program while other will propose investing in adolescent prophylactic vaccine program... I do not think that we have to save daughters over their mothers or vice versa. We can save them both! cervical cancer is now considered so preventable and of great economic value with the availability of very safe and effective prophylactic vaccines for adolescent girls combined with better screening in older women. With so many Brazilian internationally renowned researchers in the field of HPV prevention, Brazil should be a world class leader in preventing cervical cancer. Sadly hPV kills so many Brazilian. Not taking a stance forward against cervical cancer is perpetuating sexual health inequities for Brazilian women, their family and the Brazilian society as a whole.