Background
The World Health Organization (WHO) has called for the elimination of cervical cancer by 2030, through vaccination, screening and effective treatment.  Elimination should be possible due to the key etiological role of the human papilloma virus (HPV) in this cancer. In Canada, the national strategy for cervical cancer elimination is focusing on prevention and screening, specifically HPV vaccination rates of 90% and HPV-based screening rates of 90%.  Despite progress in these areas, cancer registry data have shown that nationally, cervical cancer rates are no longer falling. 

Objectives
We used data from the Manitoba Cancer Registry, the provincial cervical screening program and school-based vaccination programs to understand progress and challenges in cervical cancer elimination in our Canadian province, Manitoba.
 
Methods
Joinpoint was used to analyze cervical cancer incidence data (2000-2024) from the Manitoba Cancer Registry.  Work is underway to investigate drivers of the trends, including the role of demographics, immigration status, and HPV type. While these results are still pending, we have proactively used randomized trials to determine the acceptability, feasibility and effect of two cancer control measures:  1) invitation letters on HPV vaccination uptake among unimmunized women eligible for the publicly funded immunization program (n=13,950 women receiving either no letter, a prompting letter, or a prompting letter plus a reminder), and 2) HPV self-testing for screening (n=35,000 women who were un- or under-screened, divided into control, opt-in [brochure offering a kit] or opt-out [kit included with the letter] groups).   Outcomes were assessed within the year following each intervention:  vaccine uptake was measured at 6 and 12 months, and screening uptake was assessed after 12 months.
 
Results
After a long period of decline, cervical cancer incidence in Manitoba began to increase in 2018, with a +7.66 annual percent change (APC) (p<0.05) in the number of women diagnosed with invasive cervical cancer and a +6.25 APC (p<0.05) in age-standardized rates from 2018-2024.  HPV immunization reminder letters increased vaccination uptake in a small but statistically significant way:  at 12 months, compared to women receiving no letter, the benefit was +5.1% for women receiving the vaccination invitation and the reminder (relative risk [RR] 3.2 (95% CI: 2.5–4.2) compared to +3.7% for women receiving the vaccination invitation alone (RR 2.3 (95% CI: 1.7–3.0).  Distribution of HPV self-testing kits to un- and under-screened women increased the screening rate 10-fold, to 22% compared to less than 2% for women who received the usual screening-reminder letter.
 
Conclusions
Despite ongoing efforts, cervical cancer incidence continues to rise in Manitoba, highlighting the need for new strategies.  Randomized trials of invitation letters for HPV vaccination and for HPV self-screening have demonstrated potential for further cervical cancer control in our jurisdiction, but knowledge of sociodemographic factors and HPV type will be key to identify and engage high-risk populations.  Without this broader scope, the elimination of cervical cancer may be out of reach by the target date, even within high-income jurisdictions.