@article {661249,
	title = {The role and contribution of treatment and imaging modalities in global cervical cancer management: survival estimates from a simulation-based analysis},
	journal = {Lancet Oncol},
	volume = {21},
	number = {8},
	year = {2020},
	month = {2020 Aug},
	pages = {1089-1098},
	abstract = {BACKGROUND: Cervical cancer is the fourth most common cancer among women worldwide, causing more than 300 000 deaths globally each year. In addition to screening and prevention, effective cancer treatment is needed to reduce cervical cancer mortality. We discuss the role of imaging in cervical cancer management and estimate the potential survival effect of scaling up imaging in several different contexts.

METHODS: Using a previously developed microsimulation model of global cancer survival, we estimated stage-specific cervical cancer 5-year net survival in 200 countries and territories. We evaluated the potential survival effect of scaling up treatment (chemotherapy, surgery, radiotherapy, and targeted therapy), and imaging modalities (ultrasound, x-ray, CT, MRI, PET, and single photon emission CT [SPECT]) to the mean level of high-income countries, both individually and in combination.

FINDINGS: We estimate global cervical cancer 5-year net survival as 42{\textperiodcentered}1\% (95\% uncertainty interval [UI] 33{\textperiodcentered}8-48{\textperiodcentered}5). Among individual imaging modalities, expanding MRI would yield the largest 5-year survival gains globally (data are absolute percentage point increase in survival 0{\textperiodcentered}6, 95\% UI 0{\textperiodcentered}1-2{\textperiodcentered}1), scaling up ultrasound would yield the largest gains in low-income countries (0{\textperiodcentered}5, 0{\textperiodcentered}0-3{\textperiodcentered}7), expanding CT and x-ray would have the greatest effect in Latin America (0{\textperiodcentered}8, 0{\textperiodcentered}0-3{\textperiodcentered}4) and Oceania (0{\textperiodcentered}4, 0{\textperiodcentered}0-3{\textperiodcentered}2), and expanding PET would yield the largest gains in high-income countries (0{\textperiodcentered}2, 0{\textperiodcentered}0-0{\textperiodcentered}8). Scaling up SPECT did not show major changes in any region. Among individual treatment modalities, scaling up radiotherapy would yield the largest absolute percentage point gains in low-income countries (5{\textperiodcentered}2, 0{\textperiodcentered}3-13{\textperiodcentered}5), and expanding surgery would have the largest effect in lower-middle-income countries (7{\textperiodcentered}4, 0{\textperiodcentered}3-21{\textperiodcentered}1) and upper-middle-income countries (0{\textperiodcentered}8, 0{\textperiodcentered}0-2{\textperiodcentered}9). Estimated survival gains in high-income countries were very modest. However, the gains from expanding any single treatment or imaging modality individually were small across all income levels and geographical settings. Scaling up all treatment modalities could improve global 5-year net survival to 52{\textperiodcentered}4\% (95\% UI 44{\textperiodcentered}6-62{\textperiodcentered}0). In addition to expanding treatment, improving quality of care could raise survival to 57{\textperiodcentered}5\% (51{\textperiodcentered}2-63{\textperiodcentered}5), and the cumulative effect of scaling up all imaging modalities together with expanded treatment and quality of care could improve 5-year net survival for cervical cancer to 62{\textperiodcentered}5\% (57{\textperiodcentered}7-67{\textperiodcentered}8).

INTERPRETATION: Comprehensive scale-up of treatment, imaging, and quality of care could substantially improve global cervical cancer 5-year net survival, with quality of care and imaging improvements each contributing about 25\% of the total potential gains. These findings suggest that a narrow focus on the availability of treatment modalities could forgo substantial survival gains. Investments in imaging equipment, personnel, and quality of care efforts will also be needed to successfully scale up cervical cancer treatment worldwide.

FUNDING: Harvard T H Chan School of Public Health and National Cancer Institute.},
	issn = {1474-5488},
	doi = {10.1016/S1470-2045(20)30316-8},
	author = {Ward, Zachary J and Surbhi Grover and Scott, Andrew M and Woo, Sungmin and Salama, Dina H and Jones, Elizabeth C and El-Diasty, Tarek and Pieters, Bradley R and Trimble, Edward L and Vargas, H Alberto and Hricak, Hedvig and Rifat Atun}
}
