Page 0056

driven by persistently higher levels of cervical cancer

mortality in the poorer states. The women living in these

states, the poorest in the country, continue to face a double

cancer burden. Yet, deaths from cervical cancer are

beginning to decline even in the poorer regions and the gap

between rich and poor states for cervical and breast cancer

mortality in Mexico will likely narrow further in the future.

Over time, and especially with the recent introduction of

national coverage of HPV vaccination to prevent cervical

cancer, breast cancer will dominate both in incidence and

mortality.

38

Conclusions and policy recommendations

The global cross-sections, historical data and within-country

trends clearly illustrate the transition in women´s cancers.

Low- and middle-income countries, and especially poorer

women, face a double burden of cervical and breast cancer

and strategies are required to meet the challenge of both

diseases in the context of programmes that promote the

health of women.

Health systems must offer prevention, treatment and

palliation responses that are appropriate to each disease. In

the absence of efforts in vaccination, screening and

treatment of precancer lesions, cervical cancer mortality will

become a persistent burden restricted increasingly to the

poorest countries and the poorest women. It is a moral and

equity imperative to prevent cervical cancer through HPV

vaccination and screening for precancerous lesions, while

offering treatment to those women affected by cervical

cancer.

There is reason to hope that with increased community

health measures for detecting and managing precancerous

lesions of the cervix, and expanded coverage of the HPV

vaccine, that cervical cancer mortality will continue to decline

globally.39 The remaining challenge is one of equity, and the

imperative will be to ensure that cervical cancer does not

become another neglected "tropical" disease of the poor.

At the same time, breast cancer is likely to increase and

CANCER MANAGEMENT

CANCER CONTROL 2014 55

The challenge of the transition in

women's cancers is further

illustrated by analysing trends in

mortality rates separately for

cervical and breast cancers within

Mexico at the sub-regional level

Health systems must offer prevention,

treatment and palliation responses

that are appropriate to each disease.

In the absence of efforts in

vaccination, screening and treatment

of precancer lesions, cervical cancer

mortality will become a persistent

burden restricted increasingly to the

poorest countries and the poorest

women

mortality rates between cervical and breast cancer increase

steadily with marginalization. The states in the highest

marginalization category had the greatest difference in C-V

rates.

The challenge of the transition in women's cancers is

further illustrated by analysing trends in mortality rates

separately for cervical and breast cancers within Mexico at

the sub-regional level. There is a clear progression in the

cervical-breast cancer transition by category of state

marginalization. In poorer states, cervical cancer continues to

be the primary cause of cancer-related mortality for women,

although the gap has narrowed significantly. In wealthier

parts of the country, breast cancer is the dominant cause of

death from cancer in women. In some states, this has been the

case since the late 1980s (Figure 3). In states with the highest

levels of marginalization (represented by Oaxaca), cervical

cancer mortality rates continue to be almost double those of

breast cancer, although the gap has closed substantially from

the fourfold difference of the early 1990s. Indeed, in Oaxaca

in the early 1990s, the difference between the cervical and

breast cancer mortality rate reached up to fivefold with a

high of close to 20 deaths per 100,000 women from cervical

cancer compared to rates of breast cancer mortality of less

than 5.

The smallest C-V (cervical-breast or C-V) differences

occurred in the wealthiest states where the rates were close

to inverting. In these states, the twofold gap that was evident

in the early 1980s had closed by the early to mid-1990s. By

2008, the inverse was true: breast cancer mortality was

approximately double that of cervical cancer with rates of

over 13 per 100,000 for breast cancer compared to below 7

per 100,000 for cervical cancer. In the case of Nuevo León,

one of the wealthiest states of Mexico, the crossover in

mortality rates occurred prior to 1985.

In the two decades spanning 1990 to 2010, the relative

levels of mortality for women's cancers in Mexico were

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