Is the beneficial effect of multi‐cohort HPV vaccination on cervical cancer and precancerous lesions seen across all educational levels?

Abstract Human papillomavirus (HPV) vaccination, implemented in multi‐cohort vaccination programs in Denmark since 2008, has led to a decrease in the incidence of cervical cancer and cervical intraepithelial neoplasia grade 3 (CIN3). However, it remains unclear if the beneficial impact of this vaccination approach applies to all educational levels. In the present study, we estimated the incidence of cervical cancer and CIN3 during 2006–2023, overall and stratified by education. Information on all cases of cervical cancer and CIN3 and on education was obtained from high‐quality, nationwide registries. We calculated age‐standardized and age‐specific incidence rates and calculated estimated annual percentage change (EAPC) with corresponding 95% confidence intervals (CI) for the early HPV vaccination period (2006–2012) and the late HPV vaccination period (2013–2023). We observed a decrease in age‐standardized incidence of cervical cancer in the late vaccination period only among women with medium or long education. Impact was particularly found among women aged 20–29 years with medium (EAPC 2013–2023[medium] = −14.2, 95% CI: −15.9; −12.5) or long (EAPC 2013–2023[long] = −13.9, 95% CI: −15.1; −12.7) education. For CIN3, an increase in incidence was seen in the early vaccination period followed by a significant decrease in the late vaccination period, overall and stratified by education. However, in age‐specific analyses, the decrease was only seen for the youngest women. Even in a country with free‐of‐charge multicohort HPV vaccination programs, the beneficial impact was most apparent among women with medium or long education, suggesting that educational inequalities still exist.