Cervical cancer is one of the most important female cancers in the world, it’s number four with respect to the mortality rates. The important point is that it’s almost 100% resolved cancer. So we almost know all the mechanisms involved in developing cervical carcinoma. We know that almost 100% of this cancer is related to HPV and in this respect we have two prevention strategies which are firstly vaccination and then the screening. If all the governments can come together and be hand in hand it is really like a polio disease, polio infectious disease, it’s a cancer that we can totally eradicate through vaccination and screening.

Thanks to the WHO which has started a declaration and called all countries to fight against cervical carcinoma and hopefully there will be a resolution paper which will be published by 2020 in the United Nations Assembly. Then in the next two or three decades there will be zero mortality related to cervical cancer if all countries can come together.

Especially the most important development has occurred in cervical cancer screening. We already know that we have a Pap smear which is in use for more than 50 years which is really a successful tool in many developed European countries. We know that it works and it can decrease the cervical cancer mortality at least 70-80% if you have a high coverage of screening. However, if you look to the realities even if you have such a good screening tool the reality is that only twelve European countries have such a successful Pap smear histology programme. Even in the most developed countries in the majority of the world, despite that this test has been used for more than fifty years in the world, a great majority of the world could not have a successful screening programme. Even in these developed countries where they have a good Pap smear programme, like the UK, Germany, they also want to make a change in the screening programme from Pap smear to other ways.

Why? What is the problem with the Pap smear? If you look, the biggest problem for many parts of the world like my country, Turkey, and like Middle East countries and many Asian countries, is the organisational problem. So Pap smear is really a quite complex system – you need dedicated pathologists and you need a very, very well controlled quality system. You cannot become successful in such programmes because even if you have a dedicated pathologist they don’t do it or they limit the number of the Pap smears that they can evaluate per week. Or once you start the quality assurance many of the pathology experts regret to be involved in continuous evaluation of their quality. Additionally, in the developed countries where you have a very good Pap smear programme they want to change their system because the Pap smear has also some intrinsic scientific problems. For example, it has low sensitivity, just 60%. So you go to evaluation, you can just detect 60 out of 100 cancer cases. On the other hand it has also a poor negative predictive value so even if your Pap smear is negative you cannot reassure the lady for five or ten years. So they have to come at at least three year intervals and the ladies are bored coming to frequent gynaecological examinations. Its reproducibility is low so your Pap smear may be normal in one centre and then abnormal in another and then cancer in another. So really your result depends on the experience of the centre who is evaluating the Pap smear.

What happened in the science is that we have now new HPV DNA tests coming up as a screening test. So this is a DNA test so this is objective so you don’t have inter- and intra-observer variability, it’s the same result almost everywhere with 90% accuracy, it’s very sensitive. Compared to 60% of Pap smear you have at least 95% sensitivity and the false negative rate is four times less. What does it mean? That you can really reassure the lady to come at least once in five years and in vaccinated ladies it can be once in each ten years. So the ladies become more happy. Another advantage for like our country is you don’t need too many manpower, you don’t need too many pathologists, you don’t need too complicated quality assurance and it can be automated, centralised. That’s what I did in Turkey – from the Pap smear we have converted to the HPV DNA test and the cancer screening rate has increased in my country ten times compared to the Pap smear times. Thanks to the WHO that’s probably in the future in many of the world HPV DNA will be the future.

Actually this screening test is not new. We have more than 200,000 ladies randomised in the last ten years and we have the follow-up data of them for at least eight years. So this scientific evidence is not just one year or two years, it’s an accumulation of huge scientific evidence. Now the future is also changing because we know that HPV tests even can be done by self-testing technologies. Even you can check HPV in the future with urine. What does it mean? That the lady will [?? 5:59] herself in her home with a simple test that she can use in her vagina or with a simple urine test like the pregnancy test. So especially in the developing world where their infrastructure or the manpower in pathology is deficient this will be the future to eliminate cervical carcinoma. That is the reason almost all societies, including the United States, European ones, WHO and even ASCO, everybody agrees on the fact that Pap smear is going down and HPV DNA alone can be used for primary cervical cancer screening.

How do you combat any negative view or stigma towards vaccinations from the public?

This is a very complex question, it has many different stakeholders and all these stakeholders should frequently come together. The main problem in HPV vaccination is that it’s an adolescent age vaccination group and anyhow it is related to cancer, anyhow it is related to sexual behaviours, it’s a sexually transmitted disease. So in this age group, adolescent age group, it’s always open in a country that you can certainly have a crisis of some side effects of unproven effects. We even know that this is one of the most closely followed up vaccinations and neither the side effects or the effectiveness scientifically has any question. So it is a safely done vaccination. But what I see is that we have a communication problem. So HPV experts of the country, including the media, including the paediatricians, gynaecologists and the public NGOs, should regularly come together. But what we do, we just come together after a crisis and this crisis becomes a fight against vaccination advocates versus anti-vaccination lobbies. But if you get the control with this group of people and inform the public regularly, periodically, that we are following and this is the amount of side effects, this is the amount of the effectiveness, but this is continuous, not on the crisis, continuously, it will be a very, very nice methodology to be used.

On the other hand we should also have special plans on adolescent training. It’s a difficult age, the most difficult age interval of our lives. We are changing from child ages to adult ages and this age group needs special communication. Social media in this age group is very important. If you look, many vaccination crises start at social media so you have to also check the right information, inform the people from social media regularly. In this way plus a third methodology, I will add that, you should also put some real examples – the people with cervical carcinoma .When you ask them, ‘Do you know that there is a vaccination that you can prevent it?’ and they are all shocked because they never heard about it. So we should use these real examples and show that these are the countries and these are the data after vaccination – reduced papilloma virus, reduced warts, reduced cancer – and these are the countries without any vaccination programme and these are the ladies who are almost dying due to cervical carcinoma. I think these real life experiences can also motivate the ladies to be vaccinated.