cervical cancer is a public health problem predominantly in developing countries where the incidence and mortality rates are high . globocan data regarding this malignancy for peru describe a total of 4,636 novel cases with 1,715 mortalities in 2012 ( 1 ) . peru is located on the west coast of south america with ~31 million inhabitants , where one - third of the total population lives in lima , the capital city . this concentration of population in only one city contributed to the establishment of structural , infrastructural and procedural barriers for the peruvian health system . geographically , peru have three well defined regions by the andean mountains , the coast , and the mountains and the jungle , where the population from each region is exposed to different environmental conditions and risk factors . with regards to lima , located in the coast of peru , data from the metropolitan cancer registry describes a cervical cancer age - standardized rate ( asr ) incidence of 19.2 new cases per 100,000 women annually , quite different to the national incidence that is 32.7 new cases per 100,000 women ( 2 ) . this difference is explained by lifestyles and socio - cultural inequalities between lima and the other regions of peru . notably , decades ago , lima had a higher incidence of cervical cancer where a progressive decrease through the time was observed , while the incidence of breast cancer continues to increase due to the process of epidemiological transition ( fig . the cancer registry of meteropolitan lima describes different cervical cancer incidences in the different districts of metropolitan lima , where the higher income districts have the lowest cervical cancer incidence ( 2 ) . with regards to other peruvian cities , the latest report of the cancer registry of trujillo ( located at north ) described an incidence asr of 43.2 new cases per 100,000 women annually in the period 19962002 , showing a decrease compared with the period 19911995 ( incidence , 52.4 ) . by contrast , the cancer registry of arequipa ( south of peru ) reported an incidence of 43.2 new cases per 100,000 women annually in the period 20042007 , higher compared with that reported in the period 20022003 ( 35.2 ) ( 3,4 ) . the differences in the decrease of cervical cancer incidence in other peruvian regions compared to lima highlights disparities in education and access to specialized healthcare services . conventional cytology ( pap ) and visual inspection following the application of acetic acid or white vinegar ( via ) are currently used in primary screening , while hpv molecular sub - typing is offered only by a few laboratories . although the pathogenic role of hpv16 , 18 and 32 is well understood , other subtypes also have a pathogenic role in cervical cancer . a report by halec et al ( 5 ) describes the hpv subtypes 26 , 53 , 66 , 67 , 68 , 70 , 73 and 82 as the only infectious agents in several cervical cancer samples , indicating their potential carcinogenic role . this fact could estimate the prevalence of carcinogenic hpv . in an analysis of 10,575 cases of invasive cervical cancer , where our country included 770 cases , a frequency of 85% of samples positive for hpv dna were reported , and the most common hpv types were 16 , 18 , 31 , 33 , 35 , 45 , 52 and 58 ( 91% of all hpv dna - positive cases ) ( 6 ) . a time trend study revealed that hpv16 and 18 were the most common in cervical cancer , with not significant changes since 1940 ( 7 ) . with regards to hpv prevalence in peru , earlier reports by santos et al ( 8) described that in a population of metropolitan lima a prevalence of 95.3% was observed in women with squamous cell carcinoma and in 92.0% in women with adenocarcinoma / adenosquamous tumors ( hpv 16 , 18 , 31 , 52 and 35 were most frequent ) , while the frequency the hpv infection in healthy women was 17.7 ( 8) . the tati project ( spanish acronym for  screening and immediate treatment of cervix uteri lesions ) that screened 5,435 women from the peruvian jungle ( san martin ) in 2001 demonstrated a high - risk hpv frequency of 12.6% ( 9 ) , while a recent report evaluating 2,247 samples from screened women aged 1779 years from urban areas of iquitos , cajamarca , piura , chiclayo , lima , arequipa , cuzco and juliaca described a high - risk hpv distribution of 34.5% . of these , 82.7% of cases had single infections and 17.3% had multiple infections ( 10 ) . a study by bautista et al ( 11 ) in 1,142 mothers from the social program el vaso de leche of the surquillo district in the region of lima found a prevalence of high - risk hpv of 15.2% ( 11 ) . with a small sample size of female sex workers ( n=87 ) , montano et al ( 12 ) reported a 50.6% of infection with hpv with a 35.6% of infection with high - risk hpv , while brown et al ( 13 ) found in 184 female sex workers ( 1826 years old ) a 65.8% rate of hpv infection in cervical samples , where 8.3% of these women also exhibited oral hpv ( 12,13 ) . the cancer control first initiative in peru was launched 1935 with taxes on ice and refrigerator devices with the aim of collecting money to build the first cancer hospital . the first initiative for a massive plan for prevention of gynecological cancer was launched in 1998 for breast and cervical cancer , while in 2000 the first guidelines for cervical cancer prevention , including the use of pap test as screening method and cryotherapy for treatment , were published . in 2002 , the program for health promotion and cancer control was launched . with regards to the concern about the public health problem that cancer represents , in 2005 the multisectoral coalition  peru against cancer , a multi - institutional initiative of peruvian institutions with the support of the american cancer society , the union for international cancer control , the world health organization / pan american health organization and the washington cancer institute was created . this led to the development of the first national plan for cancer control launched in 2006 under the title strategic plan 20062016. in 2007 , a landmark in latin america was established with the launch of the first comprehensive national cancer control plan , where treatment of low - income patients was for free ( covered by a comprehensive health insurance ) . budget by results , which means more objectives accomplished and more money for funding . in 2012 , the current cancer control plan named plan esperanza (  hope plan in spanish ) was launched , which also promotes and supports cancer advisory groups ; the social promotion of cancer prevention and development of training programs for thousands of health professionals across the country ( 14 ) . in 2014 , the  plan esperanza provided cervical cancer screening to > 2.3 million women in peru ( 15 ) . in peru , well - identified geographical , cultural , structural , infrastructural and procedural barriers exist for plans of cervical control cancer . disparities also exist between the regions , predominantly due to the centralization and concentration of population in the coast . with regards to cultural barriers , fears and concerns remain a problem for the gynecological examination , including the sampling for the pap smear . medrano et al ( 16 ) demonstrated , in a survey of 225 women attending the public clinic in los olivos district , that the fear and shame of the examination , neglect to attend to the gynecological control and laziness to take the screening were factors identified for the non - compliance of the cervical cancer screening ( 16 ) . support from husbands or partners is also important for individuals to attend their screen ( 17 ) . there are few trained specialists in cancer screening and this is more evident in remote villages , and educational levels are higher in the coast compared with the mountains and jungle ( 18,19 ) . a previous study by paz - soldan et al ( 20 ) in 6,712 women between 18 and 29-years - old in 20 peruvian cities demonstrated by multivariate analysis that women who are more likely to have a pap smear were those with high levels of education , were married / co - habiting , were at lower age at first intercourse and living by the coast ( 20 ) . since 2007 when the process of decentralization of cancer care was initiated , the current infrastructure is not enough to cover the nationwide demand . a wide gap exists between supply and demand of laboratories , cytopathologists and centers for the management of dysplasias and cancer detection . by contrast , the social structure of remote villages may provide a real barrier to health care intervention at these locations , where leaders of the communities must be identified and involved . the self - sampling test for molecular prevention of hpv has novel devices with similar sensitivity to a direct endocervical specimen obtained by a physician . this approach is being used in the cervical cancer control strategies , predominantly in locations where cultural factors are identifiable or where there are long distances between the home of patients and the laboratory ( or hospital ) facilities ( 21 ) . in a community - based participatory research ( cbpr ) in the peruvian jungle , abuelo et al ( 22 ) , described 99.7% of high satisfaction with the self - sampling for hpv detection , while , 100% of women invited to be involved ( n=320 ) gave an hpv sample ( 22 ) . in other community - based participatory research peformed in manchay , a city near to lima , it was demonstrated that the health promoters from the community had an important role in the success of the project , where 97% of registered participants gave an hpv sample and 90% of women returned for a 6-month follow - up ( 23 ) . the insurance coverage appears to be another factor affecting the realization of the pap test . a cross - sectional test by barrionuevo - rosas et al ( 24 ) , in a sample of 12,272 women aged 3049-years - old demonstrated that women without insurance were the least likely to be screened compared with patients with public insurance ( odds ratio=1.27 ; 95% confidence intervals , 1.241.31 ) and patients with private insurance , ( odds ratio=1.52 ; 95% confidence intervals , 1.461.58 ) ( 24 ) . with regards to high - grade hpv detection , several molecular methods must be evaluated in a cost - effective manner . there is an experience in peru with self - sampling and solid media specimen cards and with centralized high - throughput processing with maldi - tof , where the samples were sent to china for analysis and the results were delivered 4 days later ( 25 ) . this technology must be implemented in strategic regions and can also be cost - effective if laboratories process a great number of samples . vaccination campaigns must also be established with community involvement in order to gain high rates of adherence to cycle dose schedules . in a cbpr , 318 girls from iquitos ( peruvian jungle ) assented for vaccination , 98% received the first dose of vaccine , 88 and 65% received the second and third doses , respectively . completion rates in this study were two times higher than reported in other countries ( 26 ) . another interesting strategy is implementation of school - based vaccination programs , which was shown feasible in peru ( 27 ) and where the experience in brazil demonstrated a three - dose completion rate of 97.2% , with a parental acceptance rate of 91.8% ( 28 ) . in addition to these strategies , it is important to develop nationwide programs of formative research to identify and overcome local barriers to developing and performing successfully vaccination programs ( 29 ) . by contrast , gutierrez - aguado ( 30 ) demonstrated that in peru , hpv vaccination can be cost - utility compared with not vaccinating , with an incremental cost - utility of 6775 usd / qaly ( 30 ) . in 2015 , in peru , it is possible to decrease the incidence of cervical cancer by detecting high - grade hpv and/or intraepithelial cervical neoplasms . several efforts from the government , non - governmental organizations and individual researchers have determined the epidemiology and identified several barriers and future challenges to reduce the cervical cancer burden in peru ( table i ) . the case of the cohort of oncosalud is interesting . with ~750,000 affiliates enrolled in a pre - paid system for cancer care ( around half are women ) , the incidence of cervical cancer is 5.8/100,000 women , a lower rate compared with the national incidence ( 32.7/100,000 ) or the incidence to metropolitan lima ( 19.2/100,000 ; fig . the affiliates to oncosalud are predominantly in the a and b socioeconomic status , and in the context of cancer prevention in this group , screening for free is offered , including mammograms , pap smear and colposcopy for women . by contrast to the low incidence of cervical cancer , a higher incidence compared with the national values is observed in breast cancer ( 52.7/100,000 vs. 28/100,000 women ) . the funding for cancer care is important to improve the outcomes of cervical cancer . in 2014 , 64.31% of patients who attended the national cancer institute of peru were covered by comprehensive health insurance in the context of however , the level of coverage for cancer in lima should improve , since 41% of the national budget for cervical cancer screening is being spent in lima , according to the ministry of economy and finances data ( 32 ) . establishment of cancer preventoria has provided the infrastructure to empower the screening strategies for the early detection of malignancies , predominantly for breast and cervical cancer . these services should be massively widespread and in addition , the involvement of the mass media in highly important in order to educate the population .
cervical cancer is the leading malignant neoplasm in peruvian women . 
 this malignancy is a public health problem and several efforts were previously performed to develop cancer control plans . 
 geographical , cultural , structural , infrastructural and procedural barriers can limit the implementation of such strategies . 
 several previous studies have characterized human papilloma virus ( hpv ) epidemiology , where prevalence of high - risk hpv in adult females is ~12% and the prevalence in cervical cancer is 9095% . 
 the predominant barriers for the control of cervical cancer are lack of specialists in remote villages , education / cultural issues , loss of patients in follow - up , lack of access to hpv testing and lack of compliance for hpv vaccination . 
 a good strategy for the prevention and early detection of high - risk hpv , pre - malignant neoplasms and cervical cancer , identified by interventional studies , is the self - sampling test , which assists with overcoming the cultural and geographic barriers . 
 the current cancer control plan , termed 
 plan esperanza , is performed with massive training of health professionals and social sensitization campaigns leading to filling the gaps regarding education and , in addition , it provides cancer care coverage for poorer individuals . in our experience at oncosalud - auna , with a cohort of ~750,000 affiliates using a pre - paid system with annual screenings for cervical cancer for women , offered free - of - charge , a lower incidence of this malignancy ( 5.8/100,000 ) is now observed compared with the national incidence ( 32.7/100,000 ) . as in other countries , 
 the hpv vaccination can be a cost - utility strategy to reduce the high burdens of cervical cancer in peru , a rapid and cheap hpv molecular sub - typification is rapidly required .