Surgery Isn’t Enough: Why Gynecologic Surgeons Must Lead Cervical Cancer Elimination

A Global Call to Action for Cervical Cancer Awareness Month

As we observe Cervical Cancer Awareness Month this January, gynecologic surgeons across all countries must confront an uncomfortable paradox: cervical cancer remains one of the most preventable malignancies, yet it continues to claim hundreds of thousands of lives globally each year. In the United States, approximately 13,490 women will receive this diagnosis in 2026, and 4,200 will die from it. Globally, the burden is catastrophic—662,000 new cases and 348,000 deaths in 2022 alone, with 94% of deaths occurring in low- and middle-income countries. For gynecologic surgeons positioned at the frontline of women’s healthcare worldwide, these numbers represent not just statistics, but a call to renew our commitment to the interventions that can eliminate this disease.

The Sobering Reality: Persistent Disparities

While cervical cancer incidence has declined by more than 50% since the mid-1970s, recent data reveal a troubling plateau in mortality rates. More concerning are the stark racial and ethnic disparities that persist. The death rate for Black women is 55% higher than for White women, while Native American women face an 80% higher mortality rate. These disparities reflect not biological differences but systemic failures in access to prevention, screening, and timely treatment.

Consider this: More than 20% of cervical cancers are diagnosed in women over 65, yet these cases rarely occur in those who maintained regular screening before age 65. This underscores a critical point—cervical cancer is overwhelmingly a disease of inadequate screening. The majority of invasive cervical cancer cases occur in women who were either never screened or inadequately screened. Geographic disparities compound this problem, with rural populations facing both higher incidence and later-stage diagnosis due to barriers in accessing gynecologic care.

Globally, the burden is even more staggering. Cervical cancer ranks as the fourth most common cancer in women worldwide, with 662,000 new cases and 348,000 deaths in 2022. Ninety-four percent of these deaths occurred in low- and middle-income countries, where access to vaccination and screening remains severely limited. The incidence rate in Africa (26.4 per 100,000) is more than four times higher than in North America (6.4 per 100,000), and in Africa, 71 of every 100 women diagnosed will die from the disease compared to only 28 of 100 in North America. These disparities are not merely statistics—they represent systemic failures in global health equity that demand our attention as an international surgical community.

For AAGL members practicing across diverse healthcare systems—from tertiary centers in high-resource countries to district hospitals in low-resource settings—the challenges differ but the imperative remains identical: We must integrate prevention into surgical practice. Whether you have access to the latest HPV assays with extended genotyping or rely on visual inspection with acetic acid (VIA) and same-visit cryotherapy, the principle is universal. Screen every patient. Use the best available tools. Follow through on abnormal results. The World Health Organization’s 90-70-90 elimination targets—90% vaccination coverage by age 15, 70% screening coverage by ages 35 and 45, and 90% treatment of precancer and cancer—are achievable only if every gynecologic surgeon accepts responsibility for their role in this global effort.

Transformative Advances in Screening and Testing

December 2025 brought landmark updates to cervical cancer screening guidelines that fundamentally change how we approach prevention. The American Cancer Society’s updated recommendations, endorsed by ASCCP, introduced two pivotal changes that address longstanding barriers to screening compliance.

Self-Collection for HPV Testing: For the first time, self-collected vaginal specimens are now an acceptable option for primary HPV testing. This represents a paradigm shift in screening accessibility. FDA-approved assays including the BD Onclarity HPV Assay and Abbott Alinity m HR HPV assay demonstrate equivalent sensitivity and specificity to clinician-collected specimens. Self-collection addresses multiple barriers: It eliminates the need for speculum examination, reduces visit burden, accommodates patients with mobility limitations or history of trauma, and extends reach to underserved rural populations. When self-collected specimens test HPV-negative, three-year follow-up is recommended—identical to clinician-collected specimens.

Extended Genotyping: The ASCCP Enduring Guidelines now incorporate extended genotyping into risk-based management algorithms. Rather than simply reporting positive or negative for high-risk HPV, newer assays can identify specific genotypes. This allows for more nuanced risk stratification—patients testing positive for HPV 16 or 18 require immediate colposcopy due to highest cancer risk, while those positive for lower-risk genotypes like HPV 56/59/66 may be managed with one-year surveillance. This precision reduces unnecessary procedures for lower-risk patients while ensuring aggressive management of highest-risk cases.

Screening Exit Criteria: The updated guidelines provide clear exit criteria from screening. Women at average risk can discontinue screening if they have negative primary HPV tests or negative co-testing at ages 60 and 65. This evidence-based approach prevents both underscreening and overscreening, focusing resources where they provide the greatest benefit.

Artificial Intelligence Integration: AI tools for colposcopic image interpretation are emerging, particularly for low-resource settings. These technologies offer near-perfect negative predictive value and could revolutionize triage of HPV-positive women where expert colposcopists are unavailable.

Our Role in Decreasing Cervical Cancer Deaths

As gynecologists, we have unprecedented tools to eliminate cervical cancer. Success requires systematic implementation across multiple domains:

Embrace and Offer Self-Collection: Integrate self-collection into practice workflows immediately. For patients who decline traditional screening, express discomfort with pelvic examination, or face access barriers, self-collection offers a critical alternative. Train staff on patient education and specimen handling. Download the ASCCP Management Guidelines App to access real-time risk-based algorithms for managing self-collected results.

Prioritize HPV Vaccination: Data demonstrate a 90% reduction in cervical cancer among women vaccinated before age 17. Yet only 61% of adolescents are up-to-date with HPV vaccination in the United States. Every clinical encounter is an opportunity—recommend vaccination for all eligible patients ages 9-26, and consider catch-up vaccination through age 45 in select populations. Importantly, recent evidence demonstrates that single-dose HPV vaccination offers robust protection against persistent HPV infection even 15 years post-vaccination, with efficacy approaching that of multi-dose regimens. This breakthrough has profound implications for global vaccine access and coverage, particularly in resource-limited settings where multi-visit schedules present barriers. Several countries have already adopted single-dose schedules, and this should inform our counseling and advocacy efforts. Vaccination prevents not only cervical cancer but also vulvar, vaginal, anal, and oropharyngeal cancers.

Identify and Reach the Unscreened: Most cervical cancer deaths occur in women who were never screened. Implement systems to identify overdue patients through electronic health record queries. Consider mobile health outreach, evening or weekend screening clinics, and partnerships with community organizations serving high-risk populations. Self-collection kits can be mailed to patients unable to attend office visits.

Address Disparities Head-On: Examine your own patient population for screening disparities. Black, Native American, rural, and low-income women require targeted outreach. Partner with Federally Qualified Health Centers, use patient navigators, and advocate for policies expanding Medicaid coverage for screening and treatment in states where gaps exist.

Ensure Follow-Through: Screening is meaningless without appropriate follow-up. Establish robust systems for tracking abnormal results and ensuring patients receive colposcopy, biopsy, and treatment. Studies show that loss to follow-up disproportionately affects underserved populations—the very women at highest risk. Patient navigation programs and reminder systems are essential.

Ensure Colposcopy Access: For our AAGL colleagues practicing globally, colposcopy availability varies dramatically. In high-resource settings, ensure timely referral pathways for abnormal screening results. In low-resource settings where colposcopy may be unavailable or delayed, consider screen-and-treat approaches using visual inspection with acetic acid (VIA) followed by same-visit cryotherapy for eligible lesions, as recommended by WHO. This single-visit approach minimizes loss to follow-up and has proven highly effective where colposcopy infrastructure is limited. For gynecologic surgeons with colposcopy skills, consider dedicating clinical time to this essential service, particularly in underserved areas. Colposcopy competency among gynecologic surgeons strengthens the screening-to-treatment continuum.

Leverage Risk-Based Management: The 2019 ASCCP risk-based guidelines use individualized risk stratification rather than one-size-fits-all algorithms. Familiarize yourself with these guidelines and utilize extended genotyping when available. This approach balances cancer prevention with minimizing unnecessary procedures.

Track Screening as a Quality Metric: Institute screening rate tracking as a standard quality improvement measure in your practice. Query your electronic health record quarterly to identify patients overdue for screening. Calculate your practice’s screening rate and set improvement targets. Consider this a core quality metric alongside surgical outcomes. Publicly report your screening rates within your institution or health system. Quality improvement requires measurement—make cervical cancer screening a priority metric that receives the same attention as surgical complication rates or patient satisfaction scores.

Counsel High-Risk Populations: Women living with HIV face six times higher cervical cancer risk and require screening starting at age 25 with more frequent intervals. Similarly, immunocompromised patients, those with in utero DES exposure, and those with prior high-grade lesions need intensified surveillance. Don’t miss these critical populations.

Beyond Surgery: The Whole Woman

As gynecologic surgeons, we must acknowledge an uncomfortable truth: In our focus on managing endometriosis, chronic pelvic pain, and fibroids, we sometimes neglect routine cervical cancer screening. Every patient who presents for surgical evaluation or preoperative clearance represents an opportunity—perhaps the only opportunity that year—for prevention. When was her last Pap test? Is she due for HPV screening? Has she received the HPV vaccine?

We are more than surgeons; we are guardians of women’s health across the lifespan. The woman consulting us for fibroid management may not have seen a primary care provider in years. The patient with endometriosis may have avoided pelvic examinations due to pain, missing screening entirely. These surgical encounters are prevention opportunities we cannot afford to waste. Build screening assessment into your preoperative workflow. Make it standard practice. Document screening status. Offer testing or refer appropriately. Think about the whole woman, not just the surgical problem at hand.

Recognize Red Flags That Demand Immediate Evaluation: When patients present with post-coital bleeding or irregular vaginal bleeding, cervical pathology must be excluded before attributing symptoms to other conditions. These symptoms—though often benign—can be the only warning signs of invasive cervical cancer. A Pap test or HPV test alone is insufficient for symptomatic patients; direct visualization and cervical cytology are mandatory, and biopsy of any visible lesion is required regardless of cytology results. Don’t assume the bleeding is from fibroids, polyps, or hormonal causes without first examining the cervix. Don’t assume someone else will evaluate it. You are seeing the patient now—this is your responsibility. Symptomatic cervical cancer represents our failure to screen earlier; symptomatic patients require diagnostic evaluation, not screening.

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CLINICAL DECISION GUIDE: When to Screen vs. When to Diagnose

SCREENING (Asymptomatic Patients): • No vaginal bleeding complaints • No visible cervical lesion • Routine preventive care visit • Use: HPV testing (preferred), co-testing, or Pap test • Follow screening intervals (every 3-5 years)

DIAGNOSTIC EVALUATION (Symptomatic Patients): • Post-coital bleeding • Irregular vaginal bleeding • Intermenstrual bleeding • Postmenopausal bleeding (after excluding endometrial pathology) • Visible cervical lesion on examination • Required: Direct visualization, cervical cytology, biopsy of any visible lesion • Biopsy is mandatory even if cytology is normal

Remember: Never attribute bleeding to fibroids, polyps, or hormonal causes without first visualizing and evaluating the cervix. Symptomatic patients need diagnosis, not screening.

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As Tamika Felder, founder of Cervivor, powerfully states: “No one is going to die from cervical cancer on my watch.” This should be our collective commitment as gynecologists—whether in the operating room, the office, or the exam room. Every encounter matters.

Current Screening Guidelines: A Quick Reference

Start screening at age 25 for individuals with a cervix at average risk. This represents a shift from previous guidelines that recommended starting at age 21. The change reflects recognition that cervical cancer is rare before age 25 and that screening younger women leads to more harm than benefit through overtreatment of transient HPV infections and precancerous lesions that would naturally regress.

Preferred screening strategy: Primary HPV testing every 5 years from ages 25-65. If HPV testing unavailable, acceptable alternatives include co-testing (HPV plus Pap) every 5 years, or Pap testing alone every 3 years. For self-collected HPV testing, the interval is every 3 years.

Stop screening at age 65 if adequately screened with normal results. “Adequate” means two consecutive negative HPV tests or negative co-tests at ages 60 and 65, or three consecutive negative Pap tests with the last at age 65. This assumes no history of CIN2+, adenocarcinoma in situ, or cervical cancer. Women with these histories require continued surveillance for 20 years after treatment, even beyond age 65.

Special populations require modified screening: Women living with HIV should begin screening at age 25 and continue more frequently (co-testing or HPV testing every 3 years). Immunocompromised patients, those with DES exposure, and those with prior high-grade lesions need intensified protocols. Never assume these patients are being managed elsewhere—verify their screening status and ensure appropriate follow-up.

Essential Resources for Implementation

ASCCP Management Guidelines and Mobile App:

The ASCCP Risk-Based Management Consensus Guidelines provide real-time, evidence-based recommendations for managing abnormal screening results. Access the comprehensive guidelines at www.asccp.org/guidelines. Download the free ASCCP Management Guidelines mobile app (iOS and Android) to access risk-based algorithms at point-of-care. The app allows you to enter patient-specific data and receive immediate management recommendations. Web-based version available at app.asccp.org.

American Cancer Society Screening Guidelines:

Complete cervical cancer screening guidelines including the December 2025 update on self-collection and screening exit criteria: www.cancer.org/cancer/types/cervical-cancer/detection-diagnosis-staging/cervical-cancer-screening-guidelines.html

WHO Cervical Cancer Elimination Initiative:

Comprehensive global strategy, 90-70-90 targets, implementation tools, and country-specific resources: www.who.int/initiatives/cervical-cancer-elimination-initiative. Access the Knowledge Repository for evidence-based guidelines, screening algorithms for different resource settings, and HPV vaccine information at cceirepository.who.int.

CDC Cervical Cancer Resources:

Screening information, patient education materials, and HPV vaccine resources: www.cdc.gov/cervical-cancer. HPV vaccination schedules and provider resources: www.cdc.gov/hpv.

The Path Forward

The World Health Organization’s global strategy aims to eliminate cervical cancer by achieving 90-70-90 targets: 90% of girls vaccinated by age 15, 70% of women screened by ages 35 and 45, and 90% of those with precancer or cancer receiving appropriate treatment. In the United States, we possess every tool necessary to exceed these targets—effective vaccines, accurate screening tests including self-collection options, and evidence-based treatment protocols.

The question is not whether cervical cancer elimination is achievable, but whether we will marshal the collective will to make it reality. Every preventable cervical cancer death represents a failure of our healthcare system. As gynecologists, we must lead this charge. Update your practice protocols, embrace new screening modalities, systematically identify and reach unscreened populations, and relentlessly pursue equity in access to prevention and treatment.

This Cervical Cancer Awareness Month, let us recommit ourselves to the goal within our reach: A future where no woman dies from a preventable cancer.