Cervical cancer screening in vaccinated populations: challenges and implications for low- and middle-income countries

Cervical cancer remains a public health problem, with the highest burden in low- and middle-income countries (LMICs). As vaccinated cohorts reach screening age, most modeling and policy discussions about the relationship between screening and vaccination have focused on high-income countries, early adopters of human papillomavirus (HPV) vaccination with robust, well-established cervical cancer screening programs. Challenges and solutions proposed for these settings are not necessarily applicable to LMICs, which have historically lagged in cancer prevention and operate within more constrained health systems. We analyze HPV vaccination patterns by country-level income and highlight inequities across program rollout and coverage. Using 6 LMICs expected to screen vaccinated cohorts before 2030, we outline financial, health-system, and information-system challenges. We examine how mathematical models may guide screening policies and illustrate, through Costa Rica's experience, how research can support implementation of cervical cancer elimination interventions. LMICs will need cost-effective risk-stratified screening approaches tailored to local resources as cervical cancer risk declines over coming years. However, because many women more than 30 years old have not been vaccinated and remain at risk of developing cervical cancer, global efforts to ensure good-quality screening are crucial.