Cervical cancer is a significant global health issue, leading to high morbidity and mortality among women (1). In 2022, global cervical cancer cases reached 661,000 with 348,000 deaths (2, 3), with an estimated 44.4 million cases during 2020–2069 without further intervention (4). Fortunately, cervical cancer is preventable and curable with actively HPV vaccination, early screening, and effective management of cervical lesions. In 2018, the WHO called for action to eliminate cervical cancer (5), presenting a global strategy in 2020 to reach the 90-70-90 targets: vaccinating 90% of girls against HPV by age 15, screening 70% of women with a high-performance test by ages 35 and 45, and treating 90% of women with cervical disease. Achieving these targets could reduce annual new cases to ≤ 4 per 100,000 women in most countries (6), meeting the 2030 UN Sustainable Development Goal (7).

In 2020, cervical cancer incidence and mortality varied widely across countries, ranging from 2.2 to 84.6 and 1.0 to 55.7 per 100,000 women-years, respectively (8). This discrepancy is partially explained by regional development levels; for example, incidence, mortality, and disability-adjusted life years (DALYs) decreased with increasing Socio-Demographic Index (SDI) levels (9). Globally, the estimated annual percentage change (EAPC) of age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) reduced by 0.38% and 0.93% per year from 1990 to 2019 (10). The above metrics were negatively correlated to Human Development Index (HDI) (11), due to the high-income countries usually possess the resources and ability for well-established programs of vaccination and screening (4). Moreover, effective treatment strategies could improve survival and mortality, influencing prevalence, an indicator of cervical cancer's burden on healthcare systems and society (7). However, previous studies have provided limited information on prevalence (9, 10, 12–15) and transition patterns in different age groups or countries (16).

In addition to epidemiological burden, cervical cancer imposes a substantial economic burden on health systems and families, particularly in low-resource settings. However, global evidence on cervical cancer–related direct medical costs remains limited and fragmented. Most existing cost-effectiveness or budget impact studies focus on single-country analyses or specific vaccine interventions (17), lacking harmonized methodologies to allow for global cross-country comparisons. Systematic estimates of direct treatment costs using consistent frameworks are needed to inform equitable policy decisions.

We hypothesize that cervical cancer burden varies significantly by geography, age, and socio-demographic development, with temporal trends reflecting differential access to prevention and care. Leveraging the Global Burden of Disease (GBD) 2021 framework (18, 19), this study provides the most updated assessment of global cervical cancer epidemiology, reporting 2021 prevalence, incidence, mortality, and DALYs, and analyzing trends from 1991 to 2021 stratified by age and SDI. Additionally, we estimate the direct medical costs across 194 countries (1990–2021) by integrating GBD incidence data, WHO health expenditure trends, and published treatment costs—addressing a critical gap in understanding the disease's financial toll. These findings aim to inform targeted resource allocation and policy prioritization.

Our study presents an updated and comprehensive overview of global, regional, and national trends in cervical cancer burden across 204 countries and territories from 1991 to 2021. In 2021, the global burden of cervical cancer remained substantial, with 12 countries in North Africa and Middle East achieving fewer than 4 new cases per 100,000 women. Despite the significant decreases in global ASIR, ASMR and ASDR over the past 30 years, the ASPR has increased, particularly in high-middle and middle SDI regions. The onset risk shifted toward younger women, while the mortality risk remained relatively high in older women. The association between AAPC and SDI exhibited a threshold effect, with more pronounced AAPC decreases when SDI exceeded 0.60.

The upward prevalence of cervical cancer could be attributed to the high incidence in younger women and the high mortality in older women, potentially due to early detection through screening (22, 23). Globally, 139 of 202 countries and territories had issued screening guidelines up to 2021 with coverage ranging from 84% in high-income countries to 9% in lower-middle-income countries (24). However, insufficient screening coverage in low-middle and low SDI regions may have led to an underestimation of incidence. Advancements in cervical cancer therapies and improved survival, especially for early-stage cases (25, 26), could also contribute to the increasing prevalence. Also, the health care quality for cervical cancer was found to increase during 1990 to 2019 particularly for younger individuals (14).

North Africa and the Middle East had the lowest cervical cancer incidence [(4.72, 95% UI: 4.04, 5.50) per 100,000 people], with 12 out of 21 countries (Kuwait, Qatar, Saudi Arabia, Jordan, Oman, Iran, Iraq, Palestine, Syria, Egypt, Sudan, and Yemen) meeting the elimination threshold. However, this burden may be underestimated due to the lack of population-based cancer registries, wars disrupting cancer management, and insufficient data quality in countries such as Palestine, Yemen, Syria, Jordan, Iraq, and Iran (27–29). HPV infections are relatively low in this region, likely due to conservative sexual behaviors linked to religious beliefs, but there is no conclusive evidence that elimination targets have been met, warranting further assessment (30, 31). In contrast, Sub-Saharan Africa lacks well-established national cancer registries (32), and its ASPR, ASIR, ASMR, and ASDR for cervical cancer remain the highest globally and continue to rise (2, 33, 34). This suggests the actual burden may exceed current estimates. In addition to the high prevalence of HPV infection, human immunodeficiency virus (HIV) significantly contributes to cervical cancer risk in this region (35–37), with approximately 1 in 5 cases attributed to HIV, underscoring the need for improved HIV care and HPV monitoring among women living with HIV (38). The region also faces challenges in cervical cancer prevention and treatment, including low vaccine and screening coverage, delayed diagnosis, and poor adherence to treatment guidelines (39, 40). Despite efforts to promote HPV vaccination and screening, screening uptake was only 12.87% from 2000 to 2019, and HPV vaccines remain unavailable in many countries (41–43). Additionally, health education programs are needed to raise awareness among women and empower them to make informed healthcare decisions (44, 45).

In addition to the epidemiological indicators, our study provides the first systematic estimation of the direct medical cost of cervical cancer across 194 countries from 1990 to 2021. The global cumulative treatment-related burden reached approximately USD 9.26 billion without discounting, and USD 7.21 billion when applying a 3% annual discount rate. These substantial costs reflect not only the high incidence in lower SDI regions, but also the growing treatment needs associated with aging populations and delayed diagnoses. Importantly, this financial burden is concentrated in low- and middle-income countries, where public health budgets are already limited. It is important to note that our estimates may still be conservative. Our methodology is based on direct medical costs only and does not include indirect or non-medical expenditures such as productivity loss, transportation, or informal caregiving. We extrapolated unit costs from 2015 estimates, adjusted by national health expenditure growth rates, which may not capture heterogeneity in cancer care costs across settings (46). Despite these limitations, our findings establish a harmonized baseline for future cost monitoring and scenario modeling. This reinforces the urgency of scaling up cost-effective interventions such as HPV vaccination and cervical screening, which can avert both clinical and economic burden.

Between 1991 and 2021, the association between the AAPC, baseline rates, and SDI was consistent with previous findings (9, 11) . Australasia was among the regions with the lowest cervical cancer burden and the greatest reductions in all indicators. Both Australia and New Zealand have implemented nationwide cervical cancer screening since 1991 and 1990, respectively, and HPV vaccination programs since 2007 and 2008 (47, 48). These combined strategies have led to significant progress, with Australia predicted to be one of the first countries to reach cervical cancer elimination thresholds (49, 50). Differentiated prevention measures have been adopted for Indigenous women, who face a relatively higher burden (51). In China, the AAPC exceeded expectations, despite a low baseline ASIR in 1991, likely due to the launch of the cervical cancer screening program for millions of rural women in 2009. However, HPV vaccines were only approved in 2016, with a first-dose coverage of just 1.59% by 2021 (52–54). The Chinese government issued an Action Plan in 2023 to accelerate cervical cancer elimination, aiming to meet WHO's 2030 targets.

Our study, based on the latest GBD 2021 data, fills the gap in estimating prevalence cases and rates for cervical cancer during 1991–2021, revealing the necessity of proper resource allocation. The time trends in cervical cancer burden by age and SDI provide indirect evidence for the impact of HPV vaccination, screening, and treatment on cervical cancer elimination. There were some limitations in this study. First, the GBD database included multiple data sources, but the limited or low quality of available data in some regions may affect the estimated results of the study. Secondly, the data sources of the GBD study include vital registry, cancer registry and other sources. Countries with low development levels may lack these resources, and statistical data may be inaccurate. Third, our cost projection approach assumed that general health expenditure growth rates (from WHO GHED) reflect cervical cancer treatment cost trends over time. While country-specific rates capture national-level economic shifts, regional variations in medical inflation or disease-specific cost structures may not be fully represented. Future studies with access to localized cost data could refine these estimates.

While global trends show decreasing incidence, mortality, and DALYs rates for cervical cancer, prevalence has risen from 1991 to 2021. Despite the cervical cancer elimination initiative launched in 2018, there has been little change in overall incidence and mortality as of 2021, suggesting a delay in meeting WHO's 2030 targets. Over the past three decades, higher incidence rates have been more pronounced among younger individuals, while mortality has gradually shifted toward older age groups. Significant disparities remain across SDI regions. Although 12 countries have achieved incidence rates below the elimination threshold, the burden in these nations may be underestimated. In Sub-Saharan Africa, all metrics have shown increasingly concerning trends, underscoring the need for tailored strategies in the future. As cervical cancer continues to impose not only health but also growing economic burdens—particularly in resource-constrained settings—investments in prevention, early detection, and universal access to care remain essential to meet global elimination targets.