Background: There are few population-based data on the disease burden of cervical cancer from developing countries, especially South Pacific islands. This study aimed to determine the incidence and mortality associated with cervical cancer and the coverage of Papanicolaou (Pap) cervical cytology in 20- to 69-year-old women in Fiji from 2004 to 2007. Methods: National data on the incident cases of histologically confirmed cervical cancer and the associated deaths, and on Pap smear results were collected from all pathology laboratories, and cancer and death registries in Fiji from 2004 to 2007. Results: There were 413 incident cases of cervical cancer and 215 related deaths during the study timeframe. The annualised incidence and mortality rates in 20- to 69-year-old Melanesian Fijian women, at 49.7 per 100?000 (95% confidence interval (CI): 43.7–56.4) and 32.3 per 100?000 (95% CI: 26.9–38.4) respectively, were significantly higher than among 20- to 69-year-old Indo-Fijian women at 35.2 per 100?000 (P < 0.001, 95% CI: 29.5–41.7) and 19.8 per 100?000 (P = 0.002, 95% CI: 15.1–25.5) respectively. Of 330 cases diagnosed between 2004 and 2006, 186 (56%) had died by 31 December 2006. Pap smear coverage for this period was 8.0% (95% CI: 7.9–8.1) of the target population. Conclusions: The incidence and mortality related to cervical cancer in Fiji is high, whereas Pap smear coverage is very low. Greater investment in alternative screening strategies and preventive measures should be integrated into a comprehensive, strategic cervical cancer control program in Fiji.