Series www.thelancet.com Published online November 1, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31795-0 21 Health, equity, and women’s cancers 2 Interventions to close the divide for women with breast and cervical cancer between low-income and middle-income countries and high-income countries Lynette Denny, Silvia de Sanjose, Miriam Mutebi, Benjamin O Anderson, Jane Kim, Jose Jeronimo, Rolando Herrero, Karen Yeates, Ophira Ginsburg, Rengaswamy Sankaranarayanan Breast and cervical cancers are the commonest cancers diagnosed in women living in low-income and middle-income countries (LMICs), where opportunities for prevention, early detection, or both, are few. Yet several cost-effective interventions could be used to reduce the burden of these two cancers in resource-limited environments. Population- wide vaccination against human papillomavirus (HPV) linked to cervical screening, at least once, for adult women has the potential to reduce the incidence of cervical cancer substantially. Strategies such as visual inspection with acetic acid and testing for oncogenic HPV types could make prevention of cervical cancer programmatically feasible. These two cancers need not be viewed as inevitably fatal, and can be cured, particularly if detected and treated at an early stage. Investing in the health of girls and women is an investment in the development of nations and their futures. Here we explore ways to lessen the divide between LMICs and high-income countries for breast and cervical cancers. Introduction Despite the complexity of diagnosing and treating cancer, there are many cost-effective interventions that do not rely on tertiary care or specialised cancer health care. Just over 14·9 million new cancer cases worldwide were diagnosed in 2013, and 8·2 million deaths were recorded. 1 Of these, 8·0 million new cases and 5·3 million deaths occurred in low-income and middle-income countries (LMICs). Among women worldwide, breast cancer was the commonest cancer, with roughly 1·7 million incident cases and 0·5 million deaths, followed by colorectal, lung, and cervical cancers. Cervical cancer alone accounted for 0·5 million incident cases and 260 000 deaths. 1 More than 85% of new cases and deaths for cervical cancer were in LMICs. In sub-Saharan Africa, despite a slightly lower incidence of cervical cancer than breast cancer (just over 93 000 vs just over 94 000 new cases per year) there were more deaths among women with cervical cancer than among those with breast cancer. 1 The differences in access to care, quality of care, and diagnosis for these two cancers differs strikingly between high-income countries (HICs) and LMICs. The variance in burden is especially evident when Gavi-eligible countries (ie, those with average incomes per person of <US$1 per day, according to World Bank estimates) are compared with HICs (figure). The burden of disease, measured as incidence rate ratios, increases from age 40 years up to age 60 years. Additionally, incidence is Search strategy and selection criteria We searched MEDLINE (OVID), Scopus, and Embase for articles published in English between Jan 1, 2005, and Dec 15, 2015, using the search terms “breast cancer”, “cervical cancer”, “screening”, “prevention”, “low income country”, “middle income country”, and “developing country”. We largely selected publications from the past 5 years, but did not exclude widely referenced and highly regarded publications from 2005 onwards. We also manually searched the reference lists of retrieved articles. Key messages • Cervical cancer incidence and mortality have declined sharply in the past 40 years in many high-income countries due to widespread screening, treatment of precancerous lesions and invasive cancer, and improved socioeconomic status. • Cervical cancer is highly preventable, and universal HPV vaccination of all girls at age 12 years could avert 690 000 cases and 420 000 deaths worldwide over their lifetime. • While cytology-based screening programmes are unsuitable for LMICs, studies of VIA screening and treatment programmes suggest reductions in incidence of high-grade lesions and cervical cancer, but scaling up and sustaining programmes in routine health services is challenging. • HPV testing shows great promise, but is prohibitively expensive for most LMICs. • Breast cancer mortality has decreased in many high-income countries over the past 25 years due to a combination of awareness, early detection, and effective treatments. • Despite controversy, mammography is supported as a way to reduce breast cancer mortality among women aged 50–74 years, but is recommended only in high-resource settings or limited-resource settings where it is proven that health systems can meet the conditions for implementation, including good programmatic quality control. • Screening by clinical breast examination is a promising approach because evidence suggests that it lowers stage distribution at detection, although whether breast cancer mortality is reduced remains unclear. • Management of breast cancer and invasive cervical cancer requires pathology, imaging, and laboratory services, cancer surgery, radiotherapy, chemotherapy, and hormone therapy, provided by adequately trained doctors, nurses, and other support staff; initial high vertical investments to develop facilities and resources would yield long-term benefits for millions of women. HPV=human papillomavirus. LMICs=low-income and middle-income countries. VIA=visual inspection with acetic acid. Published Online November 1, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)31795-0 See Online/Comment http://dx.doi.org/10.1016/ S0140-6736(16)31798-6, http://dx.doi.org/10.1016/ S0140-6736(16)31800-1, and http://dx.doi.org/10.1016/ S0140-6736(16)31799-8