An Australian program that offers cervical-sample self-collection to all women through primary care substantially boosted human papillomavirus (HPV) screening rates in underserved groups, with no difference in the identification of high-grade lesions and cervical cancer, per data published yesterday in The Lancet Public Health.
Led by scientists from Australia’s national cancer screening registry, the study was conducted as part of ongoing quality assurance and safety monitoring of the Australian National Cervical Screening Program. Australia is the first country to offer self-collection as a choice alongside clinician-collected samples at primary care practices as part of an organized screening program, the authors noted.
The program, which originally offered cervical-sample self-collection only to women aged 30 and older who were at least two years overdue for screening or had never been tested in primary care, expanded eligibility to all women aged 25 to 74 years in July 2022.
The researchers analyzed data on women aged 24 years and nine months to 74 years who were enrolled in the cancer screening registry, measuring uptake of self-collected samples as a proportion of all valid HPV tests each quarter from December 2017 to December 2023.
They also compared the identification of high-grade lesions and cancers in self- and clinician-collected cervical samples in women referred for colposcopy (examination of the cervix, vagina, and vulva) for abnormal tissue from July 2022 to June 2023.
Uptake highest in underserved women
Uptake of self-collected samples rose after the eligibility criteria were expanded, from 1.2% in second quarter 2022 to 26.9% in fourth quarter 2023. Participation was highest among women who were more than 10 years overdue for screening (51.9%), those living in very remote (53.9%) and disadvantaged areas (29.1% or higher), and those aged 70 to 74 years (33.5%).
From December 2017 to June 2023, 4.9 million women were tested for HPV, with 9.8% test positivity. From July 2022 to June 2023, 421,511 women were tested, with 15.1% test positivity. HPV positivity was significantly higher in self- than clinician-collected samples (16.4% vs 14.8%), with baseline differences between groups.
Loss to colposcopy follow-up was greater in women who self-collected samples than in those with clinician-collected samples when they were referred for cytology before colposcopy. But among women with high-grade lesions detected in a self-collected sample, most serious cervical abnormalities were identified at colposcopy before the cytology result was available.
To maximise the effect of self-collection, timely follow-up and treatment should be ensured, requiring clinician support and training to promote adherence to guidelines.
Among those referred for colposcopy, identification of high-grade lesions was similar between self- and clinician-collected samples after adjusting for potential confounding factors, both for women with high-grade lesions (adjusted odds ratio [aOR], 0.96) and those with other HPV types, with cytological prediction (microscopic examination of individual cells) of high-grade lesions, atypical glandular cells, or worse (aOR, 0.87).
Histological detection, or microscopic examination of tissue samples, of cancer was comparable between self- and clinician-collected samples for those with high-grade lesions (aOR, 0.71) or other HPV types, with cytology prediction of high-grade lesions, atypical glandular cells, or worse (aOR, 1.20).
“Offering self-collection to every woman is an important addition to cervical screening programmes to improve equity and drive efforts in the global elimination of cervical cancer,” the study authors wrote. “To maximise the effect of self-collection, timely follow-up and treatment should be ensured, requiring clinician support and training to promote adherence to guidelines.”
Faster goal achievement
In a related commentary, K. Miriam Elfstrom, PhD, MPH, and Joakim Dillner, MD, PhD, both of the Karolinska Institutet in Stockholm, Sweden, said that traditional cervical screening programs can take decades to implement and are slow to reach underscreened populations, while sample self-collection can more quickly achieve population coverage, equity, acceptability, and convenience.
“Self-collection provides an easy way to implement HPV screening both quickly and with greater equity and, thus, has the potential to speed up the elimination of cervical cancer,” they wrote. “Australia has the goal to reach cervical cancer elimination in the time span 2028–35. With the successful implementation of self-collection for all women, elimination is likely to occur well before 2035.”
In addition, Elfstrom and Dillner cited a 2015 European survey that found that clinician-collected sampling costs were 2.5 times higher than that of processing the samples. “Therefore, screening strategies that do not involve any clinician-based sampling fees could result in considerable resource savings,” they wrote.
Sample self-collection for other sexually transmitted infections is well-established, and in 2020, the World Health Organization included it in its strategy to eliminate cervical cancer worldwide.
“Among the different strategies for self-collection evaluated in systematic reviews, the most efficient is the dispense and collect strategy,” Elfstrom and Dillner wrote. “If the person dispensing the kit is waiting to collect it, there is an almost complete return rate.”
“Mail-to-all strategies result in large improvements in uptake compared with invitations to in-person screening visits, although this uptake is still not as high as dispense and collect strategies,” they added.
