Progress against cervical cancer in Canada: Report

Executive summary

• The primary cause of cervical cancer is persistent infection with a high-risk type of human papillomavirus (HPV).
• Over time, cervical screening and advances in cancer treatment have substantially reduced the age-standardized rate of new cervical cancer cases and deaths.
  • The age-standardized rate of new cervical cancer cases in females declined by 66.0% between 1969 and 2019. However, it has begun a recent significant upward trend that started prior to the pandemic, and inequities exist. Rates of cervical cancer are higher among females residing in rural areas and lower income neighbourhoods.
  • The age-standardized rate of cervical cancer deaths in females decreased by 86.6% between 1951 and 2022 and continues on a significant downward trend.
• Between 2011 and 2017, 64.9% of new cervical cancer cases were diagnosed at an early stage (stage 0/I, or II). Diagnosing cancer at an early stage improves treatment success and survival rates.
• The age-standardized percentage of females aged 25 to 69 years who self-reported having a Pap test within the past 3 years declined from 82.2% in 1998 to 78.6% in 2017. Significant declines were noted in the youngest age groups and, as of 2017, screening inequities continued to exist.
  • Sexual orientation, marital status, educational attainment, place of residence, ethnicity, country of birth, and immigrant status were all related to having a Pap test within the past 3 years.
• All provinces and territories have publicly funded school-based, gender-neutral HPV vaccination programs, generally offered between grades 4 and 7. According to the childhood National Immunization Coverage Survey (cNICS), 84.0% of 14-year-olds (86.4% of females and 81.5% of males) had received at least one dose of HPV vaccine as of 2021.
• Significant progress has been made in reducing the burden of cervical cancer over the past 7 decades, but the burden could be further reduced. HPV vaccination, HPV-based screening, and timely treatment are well-established approaches that can lower the risk of cervical cancer.

Introduction

This report provides a concise summary of the epidemiology of cervical cancer in Canada, and discusses progress towards eliminating cervical cancer as a public health problem. According to Brisson et al.^{footNote 1}, this is defined as an age-standardized rate of 4 or fewer new cases per 100,000 females (using the age structure of the 2015 global female population as the standard).This report summarizes rates of cervical cancer incidence, mortality, and screening over time. It also discusses human papillomavirus (HPV) vaccination rates over time and the potential impact of the COVID-19 pandemic.

This information can be used to inform policies, programs, resource allocation, and research to address gaps. It helps ensure progress continues to be made against cervical cancer in Canada.

About cervical cancer

Cervical cancer is the fourth most diagnosed cancer and fourth leading cause of cancer death among females worldwide^{footNote 2}. Cervical cancer has greatly decreased over time in high-income countries like Canada. This is due to the availability of cervical screening and advances in treatment.

Nonetheless, a projected 1600 females in Canada were diagnosed with cervical cancer in 2024, and 400 died from the disease^{footNote 3}. In addition, survival for females diagnosed with cervical cancer in Canada is moderate: 5-year survival is 74% and 10-year survival is 68%^{footNote 4}.

In addition to the initial diagnosis and treatment of cervical cancer, a substantial percentage of survivors have reduced quality of life from:

• post-treatment complications
• longer-term symptoms (like lymphedema, bowel, bladder and sexual dysfunction, menopausal symptoms)
• cervical cancer recurrences
• development of other treatment-related cancers^{footNote 5footNote 6footNote 7footNote 8footNote 9}

Action plan

HPV vaccinations and HPV-based screening and treatment programs are proven effective. They make cervical cancer almost entirely preventable and curable if detected early and adequately treated. This creates opportunity for the burden of cervical cancer in Canada to be further reduced.

The World Health Organization launched a call to action in 2018^{Footnote 10Footnote 11}. In response, the Canadian Partnership Against Cancer released the “Action Plan for the Elimination of Cervical Cancer in Canada, 2020-2030”. The Action Plan commits to eliminating cervical cancer as a public health problem by 2040. The plan sets ambitious goals for HPV vaccination, HPV primary screening, and improved follow-up of screening results^{Footnote 12Footnote 13}.

The plan also includes Peoples-specific priorities and actions for First Nations, Inuit and Métis such as:

• culturally appropriate care closer to home
• Indigenous-governed research and data systems to identify inequities that need action and monitor progress

Risk factors for cervical cancer

Persistent infection with a high-risk HPV type is the primary cause of precancerous lesions developing on the cervix. If not detected and treated, these lesions can progress to cervical cancer. The International Agency for Research on Cancer has identified:

• 12 HPV types as carcinogenic to humans (HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59)
• 1 HPV type as probably carcinogenic (HPV 68)

HPV infection is spread through contact with infected genital skin, mucous membranes or bodily fluids. It can be transmitted through sexual intercourse and oral sex. The number of sexual partners is the main determinant of anogenital HPV infection in both males and females. Most sexually active people will acquire at least 1 HPV infection during their lifetime. Before HPV vaccinations became available, this was greater than 80% of sexually active people. Most infections are asymptomatic (70% to 90%) and resolve spontaneously within 1 to 2 years. The time between acquiring an HPV infection and developing cervical cancer is usually 15 to 20 years or longer^{Footnote 14Footnote 15Footnote 16Footnote 17}.

The most important risk factor for cervical cancer is persistent infection with a high-risk HPV type. However, other factors can act with HPV or independently to increase the risk of cervical cancer including:

• infection with human immunodeficiency virus or other sexually transmitted diseases
• becoming sexually active at a young age
• long-term use of oral contraceptives
• giving birth multiple times
• young age at first pregnancy
• smoking tobacco or breathing in second-hand smoke
• a compromised immune system
• obesity which can negatively impact the detection of precancers during cervical screening

Being exposed to diethylstilbestrol in the womb is an independent risk factor for a specific type of cervical cancer called clear cell adenocarcinoma^{Footnote 17Footnote 18Footnote 19Footnote 20}.

Rates of new cervical cancer cases

Unlike most cancers, the rate of new cervical cancer cases does not consistently increase with age. Cervical cancer rates peak at age 40 to 44 years. More than 50% of cases are diagnosed before the age of 50 years (Figure 1).

Figure 1: of new cervical cancer cases for females in Canada, 2014-2018

Figure 1: Notes

• Estimates are for Canada excluding Quebec.
• Source: Statistics Canada's Canadian Cancer Registry and annual demographic estimates.

Figure 1: Text description

Rates over time

In Canada (excluding Quebec, for which complete data were not available), the age-standardized rate of new cervical cancer cases in females has decreased. It went from 25.6 per 100,000 (95% CI: 24.3, 27.1) in 1969 to 8.7 per 100,000 (95% CI: 8.2, 9.2) in 2019. This is a decrease of 66.0% (Figure 2).

Figure 2: Age-standardized rates of new cervical cancer cases and cervical cancer deaths over time for females in Canada

Figure 2: Notes

• Age-standardized rates for new cervical cancer cases are presented by year of diagnosis for 1969 to 2019 and exclude Quebec.
• Age-standardized rates for cervical cancer deaths are presented by year of death for 1950 to 2022.
• Rates are age-standardized to the 2011 Canadian standard population.
• Source: Statistics Canada's National Cancer Incidence Reporting System (1969 to 1991), Canadian Cancer Registry (1992 to 2019) via Table 13-10-0747-01 (available at: https://doi.org/10.25318/1310074701-eng), Canadian Vital Statistics Death Database, and annual demographic estimates.

Figure 2: Text description

We used the most recent available combined 5 years of data prior to the COVID-19 pandemic to compare rates across Canada. Age-standardized rates of new cervical cancer cases ranged from a low of 7.1 per 100,000 (95% CI: 6.2, 8.1) in Manitoba to a high of 10.6 per 100,000 (95% CI: 9.4, 11.9) in Saskatchewan (Figure 3).

Figure 3: Age-standardized rates of new cervical cancer cases and cervical cancer deaths for females in Canada by province and the combined territories

Figure 3: Notes

• Age-standardized rates for new cervical cancer cases are for the combined years 2015 to 2019, except for Quebec where the rate is for the combined years 2013 to 2017, and the overall rate for Canada excludes Quebec.
• Age-standardized rates for cervical cancer deaths are for the combined years 2018 to 2022.
• Rates are age-standardized to the 2011 Canadian standard population.
• Source: Statistics Canada's Canadian Cancer Registry, Canadian Vital Statistics Death Database, and annual demographic estimates.

Figure 3: Text description

Similarly, age-specific rates of new cervical cancer cases have substantially declined over time. The decreases range from 40.6% among females in their 20s to greater than 70.0% among females aged 50 years and older (Figure 4).

Figure 4: Rates of new cervical cancer cases in females by age group and selected time periods, Canada, 1969 to 2018

Figure 4: Notes

• Estimates are for Canada excluding Quebec.
• Source: Statistics Canada's Canadian Cancer Registry and annual demographic estimates.

Figure 4: Text description

However, when we analyze age-specific trends by single calendar year, 3 age groups no longer show significant downward trends:

• 30-to-39-year-olds have had a stable rate since 1974 (1974 to 2001, annual percent change (APC) = -1.4%, 95% CI: -2.4%, +2.4%; 2001 to 2018, APC = +0.2%, 95% CI: -1.1%, +4.8%)
• 40-to-49-year-olds had a stable rate between 2005 and 2018 (APC = +0.8%, 95% CI: -0.2%, +2.9%)
• 60-to-69-year-olds had a stable rate between 2005 and 2018 (APC = -0.9%, 95% CI: -2.3%, +3.2%)

In addition, after declining for more than 4 decades, the age-standardized rate of new cervical cancer cases increased 3.7% (95% CI: 1.4%, 6.4%) per year between 2015 and 2019^{footNote 4}. This is the greatest annual percent increase in recent years compared to other cancers.

Increases have also been noted in other developed countries including Sweden, Norway, Netherlands, and the United Kingdom, particularly among young females^{Footnote 21Footnote 22}. Amboree et al.^{Footnote 23} also found recent increases in non-Hispanic white females living in lower-income counties in the United States. These increases were observed for the age-standardized rates of new cervical cancer cases, late-stage cervical cancers, and cervical cancer mortality.

Factors that may be contributing to increases in Canada and elsewhere include:

• suboptimal or decreased screening participation
• changing sexual practices
• utilization of highly sensitive HPV testing
• an increase in the proportion of females unable to complete diagnostic follow-up and treatment of precancerous lesions

Stage at diagnosis

About 65% of all cervical cancer cases are diagnosed at an early stage (stage 0 ,I, or II) (Figure 5). This percentage decreases with age from a high of 81.3% among females in their 20s to a low of 41.2% among 80-plus-year-olds (Figure 6). This partly reflects the impact of population-based screening which is currently recommended for females aged 25 to 69 years^{Footnote 24}.

Figure 5: Stage at diagnosis distribution for new cervical cancer cases among females in Canada, 2011-2017

Figure 5: Notes

• Estimates are for Canada excluding Quebec and New Brunswick.
• Source: Statistics Canada's Canadian Cancer Registry.

Figure 5: Text description

Figure 6: Stage at diagnosis distribution for new cervical cancer cases among females in Canada by age group, 2011-2017

Figure 6: Notes

• Estimates are for Canada excluding Quebec and New Brunswick.
• Some labels cannot be clearly displayed. To view all the data see Figure 6 - Text description.
• Source: Statistics Canada's Canadian Cancer Registry.

Figure 6: Text description

Rates by urban or rural residence and income

The age-standardized rate of new cervical cancer cases varies with urban or rural residence and neighbourhood household income.

Compared to females residing in urban areas, females in rural areas have:

• higher age-standardized rates of new cervical cancer cases (9.1 vs. 7.6 per 100,000)
• higher age-standardized rates of stage-specific new cervical cancer cases, except for cancers diagnosed at stage II (Figure 7)

Figure 7: Age-standardized rates of new cervical cancer cases for females in Canada by urban/rural residence and stage at diagnosis, 2011 to 2017

Figure 7: Notes

• Estimates are for Canada excluding Quebec and New Brunswick.
• Rates are age-standardized to the 2011 Canadian standard population.
• Source: Statistics Canada's Canadian Cancer Registry and annual demographic estimates by census metropolitan areas and census agglomerations.

Figure 7: Text description

The age-standardized rate of new cervical cancer cases decreases as neighbourhood household income increases. This inequity has decreased over time (Figure 8). Compared to the highest income neighbourhoods, the age-standardized rate for new cervical cancer cases was:

• 1.6 (95% CI: 1.3, 1.9) times greater in the lowest income neighbourhoods in 1996
• but only 1.2 (95% CI: 1.0, 1.5) times greater in 2016

Figure 8: Age-standardized rates of new cervical cancer cases for females in Canada by area-based neighbourhood household income quintile and census year, 1996 to 2016

Figure 8: Notes

• Estimates are for Canada excluding Quebec.
• The long form Census questionnaire, which captures income, was not conducted in 2011.
• Rates are age-standardized to the 2011 Canadian standard population.
• Source: Statistics Canada's Canadian Cancer Registry and custom population estimates by area-based neighbourhood household income quintiles.

Figure 8: Text description

Rates by Indigenous status, race, and ethnicity

We used the Canadian Cancer Registry to estimate the rates of new cervical cancer cases reported above. The registry does not collect the identifiers needed to examine rates by Indigenous status, race, or ethnicity.

However, other research indicates that Indigenous and racialized females experience higher rates of cervical cancer than non-Indigenous and non-racialized females. During time periods spanning from 1988 to 2010, province-specific and national studies have found rates of new cervical cancer cases in First Nation and Inuit females to be 1.6 to 2.5 times greater than rates in other females or the general female population^{Footnote 25Footnote 26Footnote 27Footnote 28Footnote 29}.

Elevated rates for Indigenous peoples and other races and ethnicities, such as Black and Hispanic females, have also been noted in other developed countries like Australia, New Zealand, and the United States^{Footnote 30Footnote 31}.

Cervical cancer mortality rates

Unlike the rate of new cervical cancer cases, the death rate for cervical cancer continually increases with age (Figure 9). Nonetheless, between 2018 and 2022, more than a quarter of deaths due to cervical cancer occurred in females younger than 50 years of age. About 70% occurred in females of screening age (25 to 69 years of age).

Figure 9: cervical cancer deaths for females in Canada, 2018 to 2022

Figure 9: Notes

• Source: Statistics Canada's Canadian Vital Statistics Death Database and annual demographic estimates.

Figure 9: Text description

Mortality rates over time

The age-standardized mortality rate for cervical cancer among females in Canada peaked at 14.2 per 100,000 (95% CI: 13.0, 15.5) in 1951. It decreased by 86.6% to 1.9 per 100,000 (95% CI: 1.8, 2.1) in 2022. It continues on a significant downward trend (2004 to 2022, APC = -0.9%, 95% CI: -1.4% to -0.3%) (Figure 2).

For the combined years 2018 to 2022, the age-standardized mortality rate for cervical cancer ranged from:

• a low of 1.7 per 100,000 (95% CI: 1.3, 2.3) in Manitoba
• to a high of 2.9 per 100,000 (95% CI: 1.5, 5.2) in Prince Edward Island (Figure 3)

Across all age groups, cervical cancer mortality rates have declined by more than 75% over time (Figure 10).

Figure 10: Rates of cervical cancer deaths in females by age at death and selected time periods, Canada, 1950 to 2022

Figure 10: Notes

• Source: Statistics Canada's Canadian Vital Statistics Death Database and annual demographic estimates.

Figure 10: Text description

However, when we analyzed age-specific trends by single calendar year, we found that 2 age groups are no longer demonstrating significant downward trends:

• 60- to 69-year-olds had a stable rate between 2003 and 2022 (APC=-0.7%, 95% CI: -1.5%, +0.4%)
• 70- to 79-year-olds had a stable rate between 2005 and 2022 (APC=-1.8%, 95% CI: -3.1%, +2.8%).

Mortality rates by Indigenous status, race, and ethnicity

We used the Canadian Vital Statistics Death Database to estimate the cervical cancer mortality rates reported above. It does not collect the identifiers needed to examine rates by Indigenous status, race, or ethnicity.

Other research indicates that Indigenous and racialized females experience higher rates of cervical cancer mortality than non-Indigenous and non-racialized females. During time periods spanning from 1988 to 2010, province-specific studies found that cervical cancer mortality rates in First Nation and Inuit females were 2.9 to 3.9 times greater than in other females or the general female population^{Footnote 26Footnote 27}.

Elevated rates for Indigenous peoples and other races and ethnicities, such as Black and Hispanic females, were also noted in the United States^{Footnote 31}.

Cervical cancer screening

There is no virus-specific treatment for HPV infection. However, screening and treatment of cervical precancerous lesions is highly successful in preventing cervical cancer. This is demonstrated by the declines in the age-standardized rate of new cervical cancer cases (Figure 2). Over time, national guidelines for the age to start and discontinue routine screening and frequency of screening have changed. They have evolved to minimize the harms and optimize the benefits of cervical screening^{Footnote 32Footnote 33Footnote 34Footnote 35Footnote 36}.

The most recent national guidelines, released in 2013, recommend a routine Pap test every 3 years for asymptomatic women aged 25 to 69 years who have been sexually active. For women aged 70 and older with 3 successive negative Pap tests in the last 10 years, routine screening may cease. According to the Task Force who created the guidelines, there was no evidence to recommend:

• a specific interval between first sexual activity and first Pap test
• more frequent screening for women at increased risk owing to multiple sexual partners^{Footnote 24}

An update to these national guidelines is expected in the near future^{Footnote 37}.

Currently, 9 provinces in Canada have organized cervical screening programs that are fully implemented. Opportunistic screening is available in Quebec and the territories. However, Quebec and the Northwest Territories are planning to implement organized programs. Provincial and territorial programs generally recommend that screening:

• begin at age 21 or 25 years
• continue until age 65 to 70 years
• occur every 2 to 3 years^{Footnote 38}

Pap test use over time

The age-standardized percentage of females aged 25 to 69 years who self-reported having a Pap test in the past 3 years in Canada (excluding the territories):

• peaked at 82.2% (95% CI: 80.7%, 83.8%) in 1998
• decreased to 78.6% (95% CI: 77.6%, 79.6%) in 2017 (Figure 11) and varied by jurisdiction

Figure 11: Age-standardized percentage of females aged 25 to 69 years reporting a Pap test in the past 3 years, Canada, 1996 to 2017

Figure 11: Notes

• Estimates are for Canada excluding the territories.
• Rates are corrected for hysterectomies (see technical notes). For surveys conducted over two years, estimates are plotted in the year contributing the greatest number of respondents.
• Rates are age-standardized to the 2011 Canadian standard population.
• Source: Statistics Canada's National Population Health Survey 1996-1997 and 1998-1999, and Canadian Community Health Survey 2000-2001, 2003, 2005, 2008, 2012, and 2017.

Figure 11: Text description

Relative to the national estimate in 2017, the age-standardized percentage of females screened in the past 3 years was:

• significantly higher in Newfoundland and Labrador, Manitoba, Saskatchewan, and Alberta
• significantly lower in Quebec and Nunavut (Figure 12)

Figure 12: Age-standardized percentage of females aged 25 to 69 years reporting a Pap test in the past 3 years by province or territory, Canada, 2017

Figure 12: Notes

• Estimates are corrected for hysterectomies (see technical notes).
• Percentages are age-standardized to the 2011 Canadian standard population.
• Source: Statistics Canada's Canadian Community Health Survey 2017 for provincial data, and Canadian Community Health Survey 2017 and 2018 combined for territorial data.

Figure 12: Text description

Age-specific trends for Canada (excluding the territories) show the youngest age groups had lower rates in 2017 compared to 1996 (Figure 13):

• the percentage of 25-to-29-year-olds screened in the past 3 years decreased from 86.1% (95% CI: 83.0%, 88.9%) in 1996 to 76.1% (95% CI: 72.3%, 79.6%) in 2017
• the percentage of 30-to-34-year-olds screened in the past 3 years decreased from 87.7% (95% CI: 85.4%, 89.7%) in 1996 to 82.9% (95% CI: 80.2%, 85.3%) in 2017

Figure 13: Percentage of females aged 25 to 34 years reporting a Pap test in the past three years, Canada, 1996 to 2017

Figure 13: Notes

• Estimates are for Canada excluding the territories.
• Rates are corrected for hysterectomies (see technical notes).
• For surveys conducted over two years, estimates are plotted in the year contributing the greatest number of respondents aged 25 to 69 years.
• Source: Statistics Canada's National Population Health Survey 1996-1997 and 1998-1999, and Canadian Community Health Survey 2000-2001, 2003, 2005, 2008, 2012, and 2017.

Figure 13: Text description

Demographic and socioeconomic factors associated with cervical screening

In 2017, the percentage of females aged 25 to 69 years reporting a Pap test within the past 3 years was 78.4% (95% CI: 77.4%, 79.4%). The rate varied from a low of 63.9% (95% CI: 60.5%, 67.1%) for 65-to-69-year-olds to a high of 82.9% (95% CI: 80.2%, 85.3%) for 30-to-34-year-olds (Figure 14).

Figure 14: Percentage of females aged 25 to 69 years reporting a Pap test in the past three years by age group, Canada, 2017

Figure 14: Notes

• Rates are corrected for hysterectomies (see technical notes).
• Since the percent for 25-to-69-year-olds is not age-standardized, it differs slightly from the age-standardized percent for this age group displayed in other figures.
• Source: Statistics Canada's Canadian Community Health Survey 2017 for provincial data, and Canadian Community Health Survey 2017 and 2018 combined for territorial data.

Figure 14: Text description

The most common reasons for not having a Pap test in the past 3 years included females or their doctors thinking it was unnecessary or doctors not bringing it up (Figure 15).

Figure 15: Reasons for not getting a Pap test in the past 3 years for females aged 25 to 69 years in Canada, 2017

Figure 15: Notes

• Estimates are corrected for hysterectomies (see technical notes).
• Respondents could report more than one reason.
• Source: Statistics Canada's Canadian Community Health Survey 2017 for provincial data, and Canadian Community Health Survey 2017 and 2018 combined for territorial data.

Figure 15: Text description

Socioeconomic and geographic characteristics associated with lower screening rates included:

• being non-heterosexual
• never marrying
• lower educational attainment
• residing in a lower income neighbourhood or rural area
• having an East or Southeast Asian, South Asian, West Asian or Arab, or Inuit ethnic background
• being born in Africa or Asia
• having immigrated 10 or fewer years ago (Figures 16 and 17)

Figure 16: Age-standardized percentage of females aged 25 to 69 years reporting a Pap test in the past 3 years by , Canada, 2017

Figure 16: Notes

• Estimates are corrected for hysterectomies (see technical notes).
• Post-secondary education includes certificate, diploma, or degree.
• Income quintiles are based on the national distribution of household income.
• Percentages are age-standardized to the 2011 Canadian standard population.
• Source: Statistics Canada's Canadian Community Health Survey 2017 for provincial data, and Canadian Community Health Survey 2017 and 2018 combined for territorial data.

Figure 16: Text description

Figure 17: Age-standardized percentage of females aged 25 to 69 years reporting a Pap test in the past 3 years by , Canada, 2017

Figure 17: Notes

• Estimates are corrected for hysterectomies (see technical notes).
• Other indigenous status includes multiple Indigenous statuses or unknown detailed indigenous status
• Other North America includes Greenland, Saint Pierre and Miquelon, and United States.
• Oceania includes Christmas Island, Cocos (Keeling) Islands, and United States Minor Outlying Islands.
• South America includes South Georgia and the South Sandwich Islands.
• Percentages are age-standardized to the 2011 Canadian standard population.
• Source: Statistics Canada's Canadian Community Health Survey 2017 for provincial data, and Canadian Community Health Survey 2017 and 2018 combined for territorial data.

Figure 17: Text description

These findings are consistent with previous research based on the Canadian Community Health Survey^{Footnote 39}. Population-based survey data in the United States also found that:

• the percentage of eligible females reporting a Pap test within the past 3 years has significantly decreased over time, particularly among 21-to-29-year-olds
• Asian ethnicity, recent immigration, lower educational attainment, and lower income were related to lower screening rates^{Footnote 40}.

Immigration status

Lower cervical screening rates among immigrant females is an important issue for Canada. This is particularly true for those born in Africa or Asia. In 2021, more than 8.3 million people, or almost one-quarter (23.0%) of the Canadian population, were or had ever been a landed immigrant or permanent resident. Recent immigrants were defined as persons obtaining landed immigrant or permanent resident status since January 1, 2016. The top 2 regions of birth for recent immigrants were Asia (62.0%) and Africa (15.6%). The majority were of working age — 67.8% were aged 25 to 64 years^{Footnote 41}.

Barriers to screening for immigrant females in Canada include:

• being single
• lower educational attainment
• lower income
• lack of knowledge about risk factors for cervical cancer, the importance of screening for early detection, and how to access screening
• language barriers
• lack of well-translated and culturally appropriate education materials
• social stigma and beliefs
• failure to respect or accommodate cultural and social customs and practices
• embarrassment
• not having a family doctor
• not having a female health care provider
• having a health care provider from the same region as the immigrant female
• lack of physician knowledge or recommendation of the screening test^{Footnote 42}

HPV primary screening

Infection with a high-risk strain of HPV is the cause of most cervical cancers. HPV testing to detect cervical cancer is substantially more sensitive than the Pap test. It is anticipated that a test for high-risk strains of HPV will replace the Pap test for routine cervical screening in Canada^{Footnote 43}. HPV primary screening is when testing for HPV is initially used to identify individuals at risk of cervical cancer. It is already implemented in a few jurisdictions. Almost all of the remaining jurisdictions are planning to implement it.

HPV self-screening provides a less invasive and more private method for people to collect a vaginal sample from themselves. It can be done in an environment of their choosing, including their own home. One jurisdiction is already providing HPV self-screening and several others are planning to implement it.

In May 2023, Prince Edward Island became the first province in Canada to implement HPV primary screening through cervical screening clinics and primary care providers. Work is underway to start implementing HPV self-screening in 2024^{footnote 13}.

In January 2024, British Columbia launched an HPV primary screening program. People can request a self-screening kit online or by phone. The kit can be used at home or with the aid of a health care provider^{footnote 13}.

The remaining 8 provinces and 2 territories plan to implement HPV primary screening, and 6 provinces and 1 territory plan to implement HPV self-screening^{Footnote 38}.

HPV vaccination

In February of 2007, the National Advisory Committee on Immunizations (NACI) released the first national guidelines on HPV vaccination in Canada. They recommended vaccination for females aged 9 to 26 years of age. When NACI released the initial guidelines, there was insufficient research to make recommendations for females older than 26 years of age and males.

In January 2012, NACI expanded vaccine recommendations to females over the age of 26 years, males aged 9 to 26 years, and males older than 26 years who have sex with males. In February 2015, the HPV vaccine recommendations were expanded to include all males over the age of 9 years.

In July 2024, the number of HPV vaccine doses recommended by NACI decreased from 2 or 3 to 1 for individuals aged 9 to 20 years. They decreased from 3 to 2 for those aged 21 years and older. For those considered immunocompromised or living with human immunodeficiency virus, NACI continues to recommend a 3-dose schedule^{Footnote 44}. The recent changes in the number of doses are in line with World Health Organization recommendations^{Footnote 17}.

In Canada, implementation of publicly funded school-based HPV vaccination programs started as early as school years 2007/2008 for girls and 2013/2014 for boys. As of the 2017/2018 school year, all provinces and territories have publicly funded school-based, gender-neutral HPV vaccination programs. They are generally offered between grades 4 and 7^{Footnote 45}. The Government of Canada’s current vaccination coverage goal for HPV is 90% to be achieved by 2025. This goal was established prior to recent changes in the number of doses recommended by NACI, and is based on receipt of 2 or more doses of HPV vaccine by 17-year-olds^{Footnote 46}.

HPV vaccination coverage

In Canada, national vaccination coverage is measured through the childhood National Immunization Coverage Survey (cNICS). The survey provides estimates of the percentage of children who have received routine vaccinations recommended by NACI by the ages of 2, 7, 14, or 17 years^{Footnote 47}.

According to the cNICS, the percentage of 14-year-olds who received at least 1 dose of HPV vaccine was 84.0% (95% CI: 80.9%, 86.6%) in 2021 and has increased over time^{Footnote 48Footnote 49}.

The percentage of 14-year-old females with at least 1 dose of HPV vaccine:

• was 74.6% (95% CI: 70.2%, 78.5%) in 2015
• increased to 87.1% (95% CI: 83.5%, 90.0%) in 2019
• remained stable at 86.4% (95% CI: 82.2%, 89.7%) in 2021

The percentage of 14-year-old males receiving at least 1 dose of HPV vaccine increased from 73.0% (95% CI: 69.2%, 76.5%) in 2019 to 81.5% (95% CI: 76.8%, 85.4%) in 2021.

Doses captured in the 2021 cNICS may have been administered in the earlier part of the 2019/2020 school year. This was prior to the onset of the pandemic, so the full impact of the pandemic on HPV vaccination rates may not be reflected in these estimates.

More recent data for 6 provinces and territories combined (Alberta, Saskatchewan, Manitoba, New Brunswick, Nova Scotia and Yukon Territory) indicates that the percentage of 14-year-olds with at least 1 dose of HPV vaccine has decreased. The percentage peaked at 80.7% as of December 31, 2021 and dropped to 76.1% as of December 31, 2023^{Footnote 50}.

Effectiveness of HPV vaccination

The health benefits of high HPV vaccination coverage are established. Research has shown that HPV vaccination programs result in substantial reductions in HPV infections that vaccines target, precancerous cervical disease, and cervical cancer among vaccinated females. Those vaccinated at a younger age experience the greatest benefits^{Footnote 51Footnote 52Footnote 53Footnote 54}.

Steben et al.^{Footnote 54} assessed the real-world impact of 10 years of publicly funded HPV vaccination programs in Canada. They found an 86% reduction in both the prevalence of vaccine-targeted HPV types and incidence of cervical precancerous lesions. In England, the incidence of cervical cancer decreased an estimated 87% among young females offered the vaccine at age 12 to 13 years. This is in comparison to unvaccinated cohorts^{Footnote 53}. HPV vaccination also protects against other HPV-associated cancers (such as vaginal, vulvar, penile, anal, oropharyngeal) and genital warts^{Footnote 55}.

Vaccine hesitancy

In Canada, the rate of refusal of every vaccine offered is low. In 2021, cNICS indicated that less than 1% of 14-year-olds had not received any vaccine in their lifetime. However, some parents or guardians of 14-year-olds who had received at least 1 vaccine reported being initially hesitant about vaccinating their child with a vaccine other than influenza. The percentage who reported this initial hesitancy but ended up vaccinating their child increased from 14.5% in 2019 to 19.7% in 2021.

The most commonly reported reasons for hesitancy among parents or guardians of 2-and-14-year-olds in 2021 were:

• concern about side effects (66.7%)
• believing that vaccines were not necessary (24.4%)
• not being confident in vaccine effectiveness (18.5%)^{Footnote 49}

Plans to increase HPV vaccination

The “Action Plan for the Elimination of Cervical Cancer in Canada, 2020-2030” includes strategies to increase HPV vaccination rates such as:

• increasing awareness and acceptability of the HPV vaccine using high-quality evidence
• collaborating with leaders from local communities to co-develop and implement education and program delivery approaches that address vaccine hesitancy and barriers to participating in school-based programs
• offering the HPV vaccine in secondary school to individuals who missed receiving it earlier
• collecting and reporting data from school-based HPV-vaccination programs that can identify inequities, inform interventions, and evaluate change^{Footnote 12}

Impact of the COVID-19 pandemic

Data from selected provinces indicated that the COVID-19 pandemic negatively impacted cervical screening and HPV vaccination.

COVID-19, cervical screening and cancer incidence

Several Canadian jurisdictions have examined the impact of the COVID-19 pandemic on cervical cancer screening, diagnoses, and outcomes. No impacts on cervical cancer diagnoses, stage at diagnosis, or 1-year survival after diagnosis were noted in Alberta. This includes cases diagnosed up to the end of December 2020^{Footnote 56}.

In Ontario, March to August 2019 were compared to the same months in 2020. Monthly averages decreased for:

• Pap tests by 63.8% (range: 41.0% to 92.3%)
• colposcopies by 39.7% (range: 14.3% to 75.1%)
• treatments by 31.1% (range: 23.6% to 43.5%)^{Footnote 57}

The number of screens in December of 2020 were still 20.4% lower than in December 2019^{Footnote 58}.

In 2020 in Manitoba, the number of Pap tests decreased by an estimated 83% in April and 49% in May. By January 2021, no significant decline was noted. Overall, an estimated 22,086 fewer Pap tests were performed because of the pandemic^{Footnote 59}.

We analyzed data for Canada excluding Quebec and Nova Scotia, for which complete data were not available. The age-standardized rate of new cervical cancer cases in 2015 to 2019 combined did not significantly differ from the age-standardized rate for 2020: 8.2 vs. 8.1 per 100,000 (rate ratio = 1.01, 95% CI: 0.95, 1.08). This was the case for each province contributing to the national estimate as well as the territories combined. However, we must consider the potential impact of reporting delay and that Canadian rates of cervical cancer were on the rise prior to 2020. Additional years of data will be needed to accurately measure the overall impact of the pandemic in Canada.

In the United States, rates of new cervical cancer cases varied little between 2015 and 2019 (7.7 to 7.9 per 100,000). In contrast to Canada, the rate decreased significantly to 7.0 per 100,000 (95% CI: 6.9, 7.2) in 2020^{Footnote 31}.

COVID-19 and HPV vaccination

Select provincial data show that public health measures disrupted HPV vaccination programs in schools. Public health measures included school closures and moving immunization staff to COVID-19 vaccinations. Follow-up reporting was done on the impacted school cohorts. It indicates that catch-up immunization activities increased HPV coverage rates. For some jurisdictions, efforts need to continue to reach pre-pandemic vaccination coverage rates (Tables 1 to 3).

Table 1: Percentage of age- and grade-eligible students with a complete HPV vaccine series, Alberta

Data source: Government of Alberta, 2024^{Footnote 60}

Table 2: Percentage of 12-year-olds with a complete HPV vaccine series, Ontario

Data source: Ontario Agency for Health Protection and Promotion, 2024^{Footnote 61}

Table 3: Percentage of grade 4 students with at least 1 dose of HPV vaccine series, Quebec

Data source: Dionne et al., 2024^{Footnote 62}

Conclusion

High-quality, population data show that significant progress has been made against cervical cancer over the past 7 decades. Cervical screening and advances in cancer treatment have substantially reduced the age-standardized rate of new cervical cancer cases and deaths. Further progress will be made as the impact of HPV vaccination programs become more apparent and more provinces and territories transition to HPV primary screening.

However, the age-standardized rate of new cervical cancer cases has recently started an upward trend, and the COVID-19 pandemic appears to have negatively impacted cervical screening and HPV vaccination. In addition, sub-optimal cervical screening rates for certain populations were highlighted. These populations include immigrants and those with lower educational attainment or income. Provinces and territories are addressing these issues with interventions such as:

• catch-up screening activities that initially target higher risk females not recently screened
• catch-up vaccination programs
• transitioning from Pap tests to HPV primary screening including HPV self-screening
• population outreach to increase screening rates in under-screened populations

Community-led projects are also taking place across Canada to address barriers to HPV vaccination^{Footnote 63}. All of these activities will be important to meet Canada’s goal of eliminating cervical cancer as a public health problem by 2040.

Technical notes

This section outlines the data sources, definitions, and methods used.

Data sources and definitions

This report uses data from several administrative databases and surveys.

New cervical cancer cases

Data for new invasive cervical cancer cases were obtained from:

• share files of the National Cancer Incidence Reporting System (1969 to 1991) and Canadian Cancer Registry (1992 to 2019)
• the Canadian Cancer Registry master file (1992 to 2020) accessed through the Research Data Centre^{Footnote 64}
• Statistics Canada Table 13-10-0747-01 (1992-2021)^{Footnote 65}

Age-standardized rates of new cervical cancer cases over time were based on the National Cancer Incidence Reporting System (1969 to 1991) and Statistics Canada Table 13-10-0747-01 (1992-2019) to provide the most up-to-date publicly available estimates at the time of analysis. More detailed estimates by age groups, stage at diagnosis, urban and rural residence, and income quintile are based on share files of the National Cancer Incidence Reporting System and Canadian Cancer Registry.

Estimates involving stage at diagnosis are limited to those years with more complete national data (2011 to 2017) captured using the Collaborative Stage system. They exclude New Brunswick which did not capture cervical cancer stage at diagnosis.

For examining the impact of the pandemic on the rate of new cervical cancer cases in 2020, we used the Canadian Cancer Registry master file (1992 to 2020). It was accessed through the Research Data Centre. This allowed for the exclusion of both Quebec and Nova Scotia that did not have complete data available, and the more complex estimation of a 5-year pre-pandemic rate (2015 to 2019) for comparison with 2020. The master file was also used to estimate rates by province and for the territories using the most recent combined 5 years of pre-pandemic data available for each jurisdiction. Cervical cancer cases are defined according to Table 4.

Table 4: Case defintions for new cervical cancer cases

Note:

• ICD-9 = International Statistical Classification of Diseases and Related Health Problems, Ninth Revision
• ICD-O-3 = International Classification of Diseases for Oncology, Third Edition

Area of residence and income

Postal code of usual residence at time of cervical cancer diagnosis was linked to urban or rural status and pre-tax area-based neighbourhood household income quintile by using the appropriate version of the Postal Code Conversion File Plus (PCCF+) for the vintage of the postal code^{Footnote 66} (Table 5). For cervical cancer cases diagnosed between 1992 and 2018, the PCCF+ provided neighbourhood income quintile and urban or rural residence for 98.2% and 97.6% of cases, respectively. Urban residences were defined as those situated in census metropolitan or agglomeration areas (CMA/CA) while all other residences were defined as rural and small town. Rural and small town Canada refers to towns or municipalities (census subdivisions) that are outside the commuting zone of larger urban centres (less than 50% of the workforce commutes to the urban centre)^{Footnote 67}.

Table 5: Versions of PCCF+ used for cervical cancer cases

Note:

• PCCF+: Postal Code Conversion File Plus

Mortality

Data on deaths with an underlying cause of cervical cancer were obtained from:

• a share file of the Canadian Vital Statistics Death Database (1950 to 1999)
• Statistics Canada Table 13-10-0142-01 (2000 to 2022)
• the Canadian Vital Statistics Death Database master file (2018 to 2022) accessed through the Research Data Centre^{footnote 68footnote 69}

The master file was used to estimate rates by province and for the territories using the most recent combined 5 years of data available for each jurisdiction. Cervical cancer deaths are defined according to Table 6.

Table 6: Case definitions for deaths due to cervical cancer

Note:

• ICD: International Statistical Classification of Diseases and Related Health Problems (numerical suffix indicates revision)

Our analysis excludes deaths among non-residents of Canada and deaths of Canadian residents dying abroad. Since deaths occurring in Yukon territory were not available for 2017 to 2022, these cervical cancer deaths were imputed. Briefly, deaths with an underlying cause of cervical cancer occurring in Yukon territory residents during the most recent available 6 years of data preceding 2017 were randomly assigned to death years 2017 to 2022 and then added to the final analytical death file.

Population estimates

Population estimates for 1950 to 2022 are based on Census data. Estimates for 1950 to 1970 are not adjusted for census net undercoverage and exclude non-permanent residents^{Footnote 70}. Estimates for 1971 onward are adjusted for census net under coverage and include non-permanent residents in 1991 onward^{footnote 71Footnote 72Footnote 73}.

Population estimates by area-based neighbourhood household income quintile were obtained from Statistics Canada through a custom tabulation request that used Census data and the PCCF+ to obtain the estimates^{Footnote 74}. Neighbourhood household income is based on household income, as measured in the Census, adjusted for household size. Area-based neighbourhood household income quintiles are constructed separately for each census metropolitan area, census agglomeration, and all other residual areas within each province or territory. Specifically, neighbourhoods within each area are ranked from the lowest to highest neighbourhood household income and then divided into 5, such that each group contains approximately one-fifth of the total population in the area. Statistics were presented by area-based neighbourhood household income quintiles rather than national neighbourhood household income quintiles because housing and other costs vary enormously across Canada.

Cervical screening

Population-based estimates of the percentage of females aged 25 to 69 years reporting a Pap test in the past 3 years in the Canadian provinces between 1996 and 2017 were obtained from:

• the National Population Health Survey 1996-1997 and 1998-1999^{Footnote 75}
• the Canadian Community Health Survey 2000-2001, 2003, 2005, 2008, 2012, and 2017^{footnote 76}

We did not use data prior to 1996 because it did not allow estimates to be corrected for females who had hysterectomies. For all surveys except the National Population Health Survey 1998-1999, we corrected estimates for hysterectomy by removing from the analysis all females who reported not having a Pap test in the past 3 years because they had a hysterectomy. Since this question was not asked in the 1998-1999 survey, we removed all females who reported having a hysterectomy. For those survey years that allowed the calculation of estimates using both approaches, age-standardized estimates differed by less than 0.8 percentage points at the national level.

Trends are presented for Canada, excluding the territories, for 1996 to 2017 because the territories were not in the target population of the National Population Health Survey. However, the detailed presentation of Canadian Community Health Survey 2017 estimates includes data captured for the territories in 2017 and 2018.

Methods

Analytical methods included age-standardization and trend analysis.

Age-standardization

Rates were age-standardized using the direct method and the final 2011 Canadian postcensal population structure^{Footnote 77}.

Trends analyses

To quantify trends in rates, we used the Joinpoint Regression Program version 5.0.2 with default settings^{Footnote 78}. Specifically, we used the weighted Bayesian information criterion method for model selection. Confidence intervals were calculated using the empirical quantile method.

Reliability and confidentiality

All reported cervical cancer cases and deaths have been rounded using unbiased random rounding with a base of 5. Presented age-specific rates are based on rounded counts whereas age-standardized rates use the observed counts.

All estimates based on Statistics Canada’s surveys adhere to recommended release guidelines for the number of respondents contributing to an estimate and the coefficient of variation for the estimate. When examining estimates over time, the strictest release guidelines in place over the period are used.

Limitations

Several limitations should be acknowledged when interpreting the results in this publication. First, Canadian Cancer Registry and Vital Statistics Death data are subject to reporting delay. Undercounts of new cancer cases are more pronounced in the most recently reported diagnosis year, generally between 2% and 3% nationally. Death data for 2019 to 2022 are considered preliminary. Second, population estimates were not adjusted for hysterectomies so incidence and mortality rates will be biased downward. Third, data on cervical screening and HPV vaccination coverage were obtained from population-based surveys which are vulnerable to error due to non-response, social desirability bias, and recall error.

Acknowledgements

The Public Health Agency of Canada (PHAC) gratefully acknowledges the insightful feedback provided on earlier versions of this report by PHAC colleagues, the Canadian Partnership Against Cancer, and members of the Canadian Council of Cancer Registries.

This report uses data from several administrative databases and surveys: National Cancer Incidence Reporting System, Canadian Cancer Registry, Canadian Vital Statistics Death Database, National Population Health Survey, and Canadian Community Health Survey. Statistics Canada collects and manages these data and provides access to PHAC with the knowledge and consent of those who supply the data to Statistics Canada (provinces and territories, survey participants). Their cooperation is gratefully acknowledged.