Successful cervical cancer prevention in Vietnam: A cautionary tale in global health

Background/Methods

After documenting in 1996 that the Vietnam War had contributed to the problem of cervical cancer in Vietnam, we participated in a volunteer grassroots effort to establish a nationwide Papanicolaou cytology-based cervical cancer prevention program in Vietnam and performed root cause analyses of real-world obstacles to successful cervical cancer prevention.

Findings

Cytologic screening is feasible anywhere cervical screening is appropriate. Developing countries should allocate their limited resources toward screening, rather than HPV vaccination, until the possibility has been excluded that HPV vaccines may be ineffective for cervical cancer prevention. Cytology is the only primary screening test appropriate for women of all ages and will be a required confirmatory testing component for non-cytologic primary screening tests. Critical real-world obstacles to successful cervical cancer prevention involve people far more than technology and present themselves as puzzles with the structure of the 'prisoner's dilemma' in game theory. The introduction of cytologic screening to southern Vietnam was associated with reductions in cervical cancer incidence from 29.2/100,000 in 1998 to 16.5/100,000 in 2004.

Conclusions

We propose a global consensus policy: Cytologic screening services (with or without non-cytologic screening services) should be provided without further delay in any setting where cervical screening is appropriate but unavailable, with consideration given to HPV vaccination after, rather than before, full coverage of target demographic groups by screening services has been achieved. Successful cervical cancer prevention for medically underserved women requires careful yet complete avoidance of certain policies espoused by the Bill and Melinda Gates Foundation.