Prioritising self-sampling and clear guidelines for cervical cancer screening to improve access and diagnosis

Commenting on a survey in the US, UK and Sweden, Dr Jeff Andrews of BD identifies key gaps in cervical cancer screening, including delays due to discomfort and stigma, disparities in access, a lack of awareness about HPV, and the need for better education on HPV testing over traditional Pap smears.

A Harris Poll[i] commissioned by BD (Becton, Dickinson and Company) of women in the US, UK and Sweden shines a spotlight on differences in access to cervical cancer screening and prevention, showing that most women in these countries have delayed a gynaecology visit due to discomfort with pelvic exams or embarrassment.

US women are about twice as likely to say they have delayed a gynaecology visit because they didn’t have an OB/GYN (27% US vs. 16% Sweden, 14% UK) or insurance coverage (19% US vs. 8% UK, 3% Sweden). These results highlight that health equity in the US is lacking, with just 60% of US women reporting that health care in the US provides equal access to all racial and ethnic groups (compared to 79% in Sweden and 76% in the UK).

The study found that the majority of women say they would be comfortable doing a self-collected vaginal test at home to screen for cervical cancer (65% Sweden, 63% UK, 56% US) and most women (70% UK, 69% Sweden and 66% US) would be interested in at-home screening for HPV or cervical cancer.

Reasons given include being more comfortable in the privacy of their own home, having the ability to administer the test themselves (without a doctor) and not having to make time through an appointment to see a health care practitioner. Notably, younger women are more likely to be interested in self-collection across all three geographies surveyed.

Empowering people with a cervix to self-collect for cervical cancer screening, thus removing some of the barriers presented by traditional in-clinic testing, is critical. Being able to collect their own samples without clinician assistance, can help reduce the inconvenience of having to locate and travel to a clinic, and lessen both physical and personal discomfort, since the vaginal swab is less invasive than a cervical swab and the patient is in a less vulnerable position, literally and figuratively. The benefits of self-collection apply even if the self-collection is conducted in a private area within a health care setting.

Clinicians and advocates must also take a step back to recognise that in order to motivate people to get screened, they need to understand what they’re being screened for, why, and how often they need to do it.

Women in the UK are more likely to say they are knowledgeable about how often women their age should be screened for cervical cancer (70% vs. 59% US and 44% Sweden), yet the survey found that 36% of UK women incorrectly believe that women aged 30-65 need a cervical screening test every year. This awareness gap is more strongly present in the US, with 61% whose understanding is incorrect.

Additionally, nearly 9 in 10 women surveyed are not aware that Pap tests are not the most accurate test for detecting cervical cancer (89% in US, 92% in UK, 97% in Sweden). Most women in the US (65%) know that some types of HPV put women at a higher risk for developing cervical cancer than others, but that figure drops to 56% in the UK and 54% in Sweden.

A clear opportunity – a clear imperative – is to educate patients and clinicians alike that an HPV assay is more sensitive than the Pap smear (cytology). Almost all cervical cancer cases (99%) are linked to infection with high-risk HPV:[ii]Cervical cancer is caused by persistent infection with HPV if left untreated[iii].  HPV screening can identify the potential for abnormalities to develop and pre-cancer (whereas the Pap only identifies cervical anomalies once they’re already there).  Over two decades of research have now established that HPV primary screening detects two times more disease than cytology alone.  

When a woman has a positive HPV result, it is important to know what kind of HPV it is, since the risk of progression to cancer varies by type and by duration; persistent infection with the same type can be determined with an HPV assay that reports the types[iv].  Due to its sensitivity, a HPV test is only required every 5-10 years whereas a Pap test is required every three years.  For all these reasons, the WHO and many country guidelines recommend HPV as the primary test, with a Pap smear used only for triaging positive HPV results in some settings[v].

Although the results showed that most women consider cervical cancer screening a critical part of their health management (86% Sweden, 81% UK, 76% US), many find the guidance on cervical cancer screening confusing (59% Sweden, 57% US, 55% UK) and do not understand the difference between a Pap test and an HPV test, despite the fact that HPV is the cause of virtually all cervical cancers.

The health care community has an obligation to educate patients about ways to prevent and options to screen for cervical precancer. Patients deserve more information on how they are being tested, including the type of test, how often they are being tested, and why. Screening techniques advance and guidelines change. More knowledge about high-risk HPV types and cervical cancer screening can empower people with a cervix to take greater control of their own health.

By broadening our definition of 'the diagnostic setting' to include locations like community health caravans, pharmacy or even at-home, self-collection for cervical cancer screening—coupled with better and more clear education about what causes cervical cancer and why and when screening is important—can help bridge gaps between need and access.

The roadmap is clear: The more people with a cervix can get screened, the more we can detect precancer early and prevent cervical cancer. Self-collection as an additional option can lead us in the right direction.  The amount of difficulty people with a cervix experience around cervical cancer screening could be mitigated through better education, more clear guidelines, and expansion of self-collection options.