Current Status of Cervical Cancer Prevention and Screening in Myanmar.

In Myanmar, the cervical cancer burden is still noticeably high, and it is still a leading cause of cancer-related deaths among Myanmar women. According to the GLOBOCAN 2020,1 age-standardized incidence of cervical cancer in Myanmar was 22.6/100,000 women, whereas it was 14.5/100,000 for mortality. It was said to be the first most common female cancer. However, according to executive report of Yangon PBCR,2 age-standardized incidence was 19.5/100,000 in 2018 for Yangon region. Naypyidaw PBCR report of 5 consecutive years from 2013 to 2017 stated that age-standardized rate (ASR) was 14.1/100,000, and it is the eighth leading cause of cancer death in both sexes combined and the fourth in female.3 According to hospital statistics, cervical cancer is the second most common female cancer after breast cancer.4 Myanmar was selected as one of the countries for United Nations Global Joint Program (UNGJP) for cervical cancer prevention and control since 2017. With the technical assistance of UNGJP,Myanmar tries to improve all the three pillars of cervical cancer prevention, that is, primary, secondary, and tertiary preventions, as well as development of palliative care centers and population-based cancer registries. As for primary prevention, human papillomavirus (HPV) vaccination was first introduced in Expanded Programme of Immunization (EPI) program as 13th new vaccine for 9-yearold girls as a single age cohort since 2020. First dose of HPV vaccine was planned to be introduced in 2020 with both school-based and community-based strategies. For secondary prevention, guidelines for screening and treatment of cervical precancer in public health care facilities were published and launched in 2018. In this guideline, hybrid approach based on both HPV DNA and visual inspectionwith acetic acid (VIA) testing is adopted. Since 70% of the eligible population resides in the rural areas, VIA testing is not feasible to apply for those regions with limited human resource. HPV DNA testing with self-collected samples is planned to be used in rural areas. In urban and suburban areas where there are enough health care personnels who can performVIA testing, the primary screening test would be with VIA. HPV testing is aimed to be used for the whole country when enough resources are available. In community setting, screening age is 30 to 49 years, while in hospital setting, up to 65 years are screenedmainlywith cytology and HPV tests if it is readily available. Treatment of the screen-positive women is mainly by the ablative method for both VIA and HPV testing in community settings. Thermal coagulation is the preferred ablative treatment after visual assessment test (VAT) in HPV-based screening. Here, ablation of the whole transformation zone even without obvious lesion after VAT is also offered after thorough counseling for those women from remote areas who prefer less frequent visits. Precancerous lesions which are not eligible for ablative treatment or suspicious of cancer are referred to tertiary care centers where colposcopy and large loop excision of the transformation zone (LEETZ) procedure surgery as well as laboratory facilities are available. Myint Myint Thinn Cervical Cancer