Results of a Pilot Study of a Mail-Based Human Papillomavirus Self-Testing Program for Underscreened Women From Appalachian Ohio

The Acceptability and Feasibility of Self-Collected HPV Testing for Cervical Cancer Screening Among Black and Latinx Women in Chicago: Perspectives from the Community

Introduction

Cervical cancer disproportionally affects Black and Latinx women in Chicago. Black and Latinx women have a higher incidence of cervical cancer diagnosis and lower rates of cervical cancer screening than non-Latinx White women. Self-collected high-risk human papillomavirus (HPV) testing has been proposed as a method to address these barriers to screening and prevent cervical cancer.

Objective

This study aimed to understand the feasibility and acceptability of self-collected HPV testing as a novel approach to address barriers to cervical cancer screening for Black and Latinx women in Chicago.

Methods

Semistructured interviews with 17 Black and Latinx community members of the greater Chicago area were conducted. Thematic analysis using inductive and deductive coding was completed.

Results

Findings from qualitative interviews indicate strong support for self-collected HPV testing among community members. They expressed a preference for self-collected HPV testing due to the comfort, control, and reduced anxiety it offers. Financial constraints, prioritization of other life demands, and past trauma were identified as substantial barriers to traditional cervical screening.

Conclusion

Self-collected HPV testing could address barriers to cervical cancer screening by providing a less-invasive, patient-centered alternative to traditional methods. Self-collected HPV testing should be made accessible, be integrated into existing cervical cancer screening programs, and be covered by health insurance.

"It Feels Like Health Care with the Patient in Mind": VA Patient and Staff Perspectives on Self-Collected HPV Testing

PURPOSE

Self-collected testing for human papillomavirus (HPV) is poised to transform cervical cancer screening. Self-tests demonstrate similar accuracy to clinician-collected tests, but for the half a million women served by the Veterans Health Administration (VA) and their clinicians, self-collected cervical cancer screening would be a new practice. We examined VA patient and staff perspectives to inform future implementation.

METHODS

Semi-structured telephone interviews were conducted between 2021 and 2022 with female veterans receiving VA care (n = 22) and VA women's health nurses, clinicians, and administrators (n = 27). Interviews were audio-recorded and transcribed. Interview questions addressed knowledge and interest, potential advantages or disadvantages, and any questions participants had about self-collected screening. Responses were analyzed using rapid qualitative methods.

MAIN FINDINGS

Five overarching themes were identified. Both patients and staff indicated high interest and enthusiasm for self-collected HPV testing, tempered by questions about test accuracy and logistical considerations. Familiarity with self-testing for other conditions such as colon-cancer screening or COVID made self-collection seem like a simple, convenient option. However, self-testing was not viewed as a good fit for all patients, and concerns about lost opportunities or missed incidental lesions were raised. Patients and staff described challenges with pelvic examinations for patients with past sexual trauma, particularly in the male-dominated VA environment. Pelvic exams can leave patients feeling vulnerable and exposed; self-collected testing was seen as a mechanism for patient empowerment.

PRINCIPAL CONCLUSIONS

Veteran patients and VA staff shared common perspectives about potential advantages and disadvantages of self-collected HPV testing. Self-collected HPV testing has the potential to improve trauma-informed preventive health care for veterans.

Self-sampling tools to increase cancer screening among underserved patients: a pilot randomized controlled trial

BACKGROUND

Screening can reduce cancer mortality, but uptake is suboptimal and characterized by disparities. Home-based self-sampling can facilitate screening for colorectal cancer (with stool tests, eg, fecal immunochemical tests) and for cervical cancer (with self-collected human papillomavirus tests), especially among patients who face barriers to accessing health care. Additional data are needed on feasibility and potential effects of self-sampling tools for cancer screening among underserved patients.

METHODS

We conducted a pilot randomized controlled trial with patients (female, ages 50-65 years, out of date with colorectal and cervical cancer screening) recruited from federally qualified health centers in rural and racially segregated counties in Pennsylvania. Participants in the standard-of-care arm (n = 24) received screening reminder letters. Participants in the self-sampling arm (n = 24) received self-sampling tools for fecal immunochemical tests and human papillomavirus testing. We assessed uptake of screening (10-week follow-up), self-sampling screening outcomes, and psychosocial variables. Analyses used Fisher exact tests to assess the effect of study arm on outcomes.

RESULTS

Cancer screening was higher in the self-sampling arm than the standard-of-care arm (colorectal: 75% vs 13%, respectively, odds ratio = 31.32, 95% confidence interval = 5.20 to 289.33; cervical: 79% vs 8%, odds ratio = 72.03, 95% confidence interval = 9.15 to 1141.41). Among participants who returned the self-sampling tools, the prevalence of abnormal findings was 24% for colorectal and 18% for cervical cancer screening. Cancer screening knowledge was positively associated with uptake (P < .05).

CONCLUSIONS

Self-sampling tools can increase colorectal and cervical cancer screening among unscreened, underserved patients. Increasing the use of self-sampling tools can improve primary care and cancer detection among underserved patients.

CLINICAL TRIALS REGISTRATION NUMBER

STUDY00015480.

"Black Women Don't Always Put Our Healthcare First": Facilitators and Barriers to Cervical Cancer Screening and Perceptions of Human Papillomavirus Self-Testing Among Church-Affiliated African American Women

Background: African American women are at greater risk for cervical cancer incidence and mortality than White women. Up to 90% of cervical cancers are caused by human papillomavirus (HPVs) infections. The National Institutes of Health (NIH) co-developed HPV self-test kits to increase access to screening, which may be critical for underserved populations. Purpose/Research Design: This mixed methods study used the Theory of Planned Behavior to examine attitudes, barriers, facilitators, and intentions related to receipt of cervical cancer screening and perceptions of HPV self-testing among church-affiliated African American women. Study Sample/Data Collection: Participants (N = 35) aged 25-53 participated in focus groups and completed a survey. Results: Seventy-four percent of participants reported receipt of cervical cancer screening in the past 3 years. Healthcare providers and the church were supportive referents of screening. Past trauma and prioritizing children's healthcare needs were screening barriers. Concerns about HPV self-testing included proper test administration and result accuracy. Conclusions: Strategies to mitigate these concerns (e.g., delivering HPV self-test kits to the health department) are discussed.

Assessing and Addressing the Determinants of Appalachian Population Health: A Scoping Review

Introduction

Residents of Appalachia experience elevated rates of morbidity and mortality compared to national averages, and these disparities are associated with inequitable exposures to various determinants of population health. Social and environmental determinants of health are a useful lens through which to develop and evaluate programs to mitigate regional health disparities.

Methods

This 2023 scoping review was conducted of studies linking determinants of Appalachian health with leading causes of regional mortality and morbidity. The search strategy employed a keyword search that included geographic terms for the Appalachian Region and the primary adverse health outcomes in that region. Studies meeting the following inclusion criteria were reviewed: original article, published in the last five years, involving an Appalachian population, and includes a rigorous assessment of an association between a population health determinant and one or more leading causes of Appalachian morbidity and mortality.

Results

The search returned 221 research articles, including 30 interventional studies. The top three health outcomes included cancer (43.59%), diseases of despair (23.08%), and diabetes (12.82). Access to care (27.3%), rurality (18.9%), and education (14.8%) were the most common population health determinants identified. Interventional studies were categorized by program types: education, technology, partnerships, and multilevel interventions. Due to the heterogeneity of study types, the studies were combined using a narrative synthesis.

Implications

The results of this work can inform the development and evaluation of additional programs to promote Appalachian population health. Our study team will use these results to inform community-based discussions that develop strategic plans to mitigate health disparities in Central and Southcentral Appalachian Virginia.

Preferred Location for Human Papillomavirus Self-Sampling for Cervical Cancer Screening

OBJECTIVE

To examine associations among women's preferred locations for human papillomavirus (HPV) self-sampling in relation to their demographic, social, and health characteristics and their perceived benefits and concerns regarding this procedure.

DESIGN

Cross-sectional, descriptive survey.

SETTING

Online distribution between March 2022 and April 2022.

PARTICIPANTS

People who were assigned female sex at birth and were eligible for cervical cancer screening (N = 367: cis-gender women, n = 364; another gender identity, n = 3).

METHODS

We used quota sampling to obtain a racially and ethnically diverse sample. We conducted bivariate analyses to examine differences in participants' preferred locations for HPV self-sampling by sociodemographic and health characteristics. We used a multinomial logistic regression model to examine the associations between preferred HPV self-sampling location, characteristics of participants, and perceived benefits and concerns regarding this procedure.

RESULTS

In our sample, 43% (n = 158) of participants preferred HPV self-sampling at the office of a health care provider, 50% (n = 182) preferred HPV self-sampling anywhere (office or home), and 7% (n = 27) did not feel comfortable with HPV self-sampling anywhere. Participants 39 to 45 years of age were more likely to prefer HPV self-sampling anywhere (office or home) than participants 27 to 32 years of age, OR = 2.47, 95% confidence interval (CI) [1.21, 5.06]. Participants who preferred HPV self-sampling anywhere perceived greater benefit related to limited geographic access to a clinic compared to those who preferred office only, OR = 1.82, 95% CI [1.08, 3.07]. Participants who preferred HPV self-sampling anywhere had less concern related to performing the procedure accurately than those who preferred office only, OR = 0.44, 95% CI [0.31, 0.62].

CONCLUSION

HPV self-sampling is an alternative strategy to increase cervical cancer screening. As providers consider implementation of HPV self-sampling, our findings suggest that office and home-based collection strategies should be considered to increase access to cervical cancer screening.

Canadian Guideline on the Management of a Positive Human Papillomavirus Test and Guidance for Specific Populations

The purpose of this paper is to provide evidence-based guidance on the management of a positive human papilloma virus (HPV) test and to provide guidance around screening and HPV testing for specific patient populations. The guideline was developed by a working group in collaboration with the Gynecologic Oncology Society of Canada (GOC), Society of Colposcopists of Canada (SCC), and the Canadian Partnership Against Cancer. The literature informing these guidelines was obtained through a systematic review of relevant literature by a multi-step search process led by an information specialist. The literature was reviewed up to July 2021 with manual searches of relevant national guidelines and more recent publications. The quality of the evidence and strength of recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The intended users of this guideline include primary care providers, gynecologists, colposcopists, screening programs, and healthcare facilities. The implementation of the recommendations will ensure an optimum implementation of HPV testing with a focus on the management of positive results. Recommendations for appropriate care for underserved and marginalized groups are made.

A Scoping Literature Review on Evidence-Based Strategies to Increase Cervical Cancer Screening

Previous reviews of strategies to increase cervical cancer screening are more than 10 years old, the U.S. continues to fall short of the Healthy People 2030 cervical cancer screening goal, and guidelines were revised in 2018, therefore an updated review of the existing literature is needed. We conducted a scoping review using electronic databases PubMed, Scopus, and Ovid Medline that included publication dates between 2012 and 2021 to answer the question, "Which strategies implemented in U.S. primary care settings have been most successful in increasing rates of cervical cancer screening since the 2012 US Preventative Services Task Force cervical cancer screening guidelines were published?" We mapped findings to pre-specified implementation strategy categories. After initially identifying 399 articles, we excluded 350 due to duplicates or not meeting review criteria, leaving 49 articles for full review. We excluded 37 of these during full-text review and identified 2 additional articles from the manual search of reference lists for a total of 14 studies for abstraction. Eleven articles reported on strategies resulting in increased cervical cancer screening, and 3 did not. Clinic workflow re-design strategies showed the greatest promise in improving cervical cancer screening rates, education strategies for patients had mixed results, and quality management strategies were not effective. These findings suggest clinical workflow re-structures and patient education strategies can increase cervical cancer screening in primary care settings. Results are particularly important in settings that care for underserved populations, as these settings may need additional implementation strategies to decrease cervical cancer screening disparities.

Does self-sampling for human papilloma virus testing have the potential to increase cervical cancer screening? An updated meta-analysis of observational studies and randomized clinical trials

Objectives

A meta-analysis was conducted to examine the effectiveness of HPV self-sampling proposal on cervical cancer screening (CCS) uptake when compared with an invitation to have a clinician to collect the sample. Secondary outcomes were acceptability and preference of self-sampling compared to clinician-collected samples.

Methods

The present systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies examining the CCS uptake comparing self-sampling over invitation to be sampled by an healthcare professional and examining the proportion of women accepting or preferring self-sampling vs. clinician-collected sampling were included. The CCS uptake was also explored according to strategy of self-samplers' distribution, collection device type and screening status. Peters' test and Funnel Plot inspection were used to assess the publication bias. Quality of the studies was assessed through Cochrane Risk of Bias and NIH Quality Assessment tools.

Results

One hundred fifty-four studies were globally identified, and 482,271 women were involved. Self-sampling procedures nearly doubled the probability (RR: 1.8; 95% CI: 1.7-2.0) of CCS uptake when compared with clinician-collected samples. The opt-out (RR: 2.1; 95% CI: 1.9-2.4) and the door-to-door (RR: 1.8; 95% CI: 1.6-2.0) did not statistically significant differ (p = 1.177) in improving the CCS uptake. A higher relative uptake was shown for brushes (RR: 1.6; 95% CI: 1.5-1.7) and swabs (RR: 2.5; 95% CI: 1.9-3.1) over clinician-collected samples. A high between-studies variability in characteristics of sampled women was shown. In all meta-analyses the level of heterogeneity was consistently high (I 2 > 95%). Publication bias was unlikely.

Conclusions

Self-sampling has the potential to increase participation of under-screened women in the CCS, in addition to the standard invitation to have a clinician to collect the sample. For small communities door-to-door distribution could be preferred to distribute the self-sampler while; for large communities opt-out strategies should be preferred over opt-in. Since no significant difference in acceptability and preference of device type was demonstrated among women, and swabs and brushes exhibited a potential stronger effect in improving CCS, these devices could be adopted.

HPV knowledge, screening barriers and facilitators, and sources of health information among women living with HIV: perspectives from the DC community during the COVID-19 pandemic

Background

High-risk human papillomavirus (HPV) causes 99% of cervical cancer cases. Despite available prevention methods through the HPV vaccine and two screening modalities, women continue to die from cervical cancer worldwide. Cervical cancer is preventable, yet affects a great number of women living with HIV (WLH). Low screening rates among WLH further exacerbate their already high risk of developing cervical cancer due to immunosuppression. This study explores WLH’s current cervical cancer knowledge, screening barriers and facilitators, and sources of health information.

Methods

Focus group discussions were conducted with 39 WLH aged 21 years old or older, who resided in the Washington-Baltimore Metropolitan Area. Emergent themes were classified and organized into overarching domains and assembled with representative quotations.

Results

The women had limited knowledge of HPV and the cervical cancer screening guidelines for WLH. Coronavirus 2019 (COVID-19) pandemic has amplified screening barriers due to decreased accessibility to usual medical appointment and cervical cancer screenings. Screening facilitators included knowing someone diagnosed with cervical cancer and provider recommendations. WLH indicated that they obtained health information through in-person education (providers, peer groups) and written literature. Due to the pandemic, they also had to increasingly rely on remote and technology-based communication channels such as the internet, social media, television, radio, email, and short message service (SMS) text messaging.

Conclusions

Future health interventions need to explore the possibility of sharing messages and increasing cervical cancer and HPV knowledge of WLH through the use of SMS and other technology-based channels.

Prevalence of High-Risk Human Papillomavirus by RNA Assay in Home Self-Collected Samples Among Underscreened People in North Carolina

BACKGROUND

Low-income and uninsured people with a cervix (PWC) are at the highest risk of being underscreened for cervical cancer. We evaluated the prevalence of high-risk human papillomavirus (hrHPV) on home self-collected samples, as well as rates of in-clinic follow-up and risk factors associated with hrHPV positivity in this at-risk population.

METHODS

My Body My Test 3 was conducted between 2016 and 2019 in North Carolina among individuals aged 25 to 64 years, overdue for cervical cancer screening, and with incomes of <250% of the US Federal Poverty Level. Our analytic sample included participants randomized to the self-collection arm who returned self-collected cervicovaginal brush samples for HPV testing (n = 329). Samples were tested for 14 hrHPV types by an HPV RNA assay and further genotyped for HPV-16 and HPV-18/45. We examined behavioral risk factors for hrHPV positivity using logistic regression and between-subject t tests.

RESULTS

High-risk HPV RNA prevalence was 16% (n = 52/329) in self-collected samples. Of the hrHPV-positive participants, 24 (46%) presented for in-clinic cervical cancer screening, compared with 56 (20%) of hrHPV-negative participants. Those with ≥2 sexual partners in the past year were twice as likely to be hrHPV positive in adjusted analyses (adjusted odds ratio, 2.00 [95% confidence interval, 1.03-3.88]). High-risk HPV-positive and HPV-negative participants had similar attitudes toward screening, with the exception of hrHPV-positive participants who reported a lower perceived risk of cervical cancer than those who were hrHPV negative (P < 0.05).

CONCLUSION

The hrHPV RNA prevalence was similar to findings in other underscreened PWC in the United States. Efforts to reach underscreened PWC are critical for cervical cancer prevention. Future studies aimed at home self-collection should address methods of increasing clinic attendance and completion of treatment among those with HPV-positive results.

Cervical Cancer Prevention and High-Risk HPV Self-Sampling Awareness and Acceptability among Women Living with HIV: A Qualitative Investigation from the Patients’ and Providers’ Perspectives

Routine cervical cancer screening is important for women living with HIV (WLH) due to the greater incidence and persistence of high-risk HPV (HR-HPV) infection. HR-HPV self-sampling has been proposed to overcome barriers to in-office cervical cancer screening in underserved populations. However, little is known about baseline knowledge of HR-HPV and the acceptability of HR-HPV self-sampling among WLH. This paper describes WLH’s experiences and needs regarding cervical cancer screening, specifically HR-HPV self-sampling, and seeks to reconcile their experiences with the views of their providers. In total, 10 providers and 39 WLH participated in semi-structured interviews and group discussions, respectively. Knowledge of cervical cancer and HR-HPV was generally limited among WLH; when present, it was often due to personal experience of or proximity to someone affected by cervical cancer. Most WLH were not familiar with HR-HPV self-sampling but, despite some of the providers’ skepticism, expressed their willingness to participate in a mail-based HR-HPV self-sampling intervention and highlighted convenience, ease of use, and affordability as facilitators to the uptake of HR-HPV self-sampling. The experiences identified can be used to guide patient-centered communication aimed at improving cervical cancer knowledge and to inform interventions, such as HR-HPV self-sampling, designed to increase cervical cancer screening among under-screened WLH.

A novel proteomic-based screening method for ovarian cancer using cervicovaginal fluids: A window into the abdomen

OBJECTIVE

Our objective is to develop a site-specific proteomic-based screening test for ovarian cancer(OC) using the mucus of the cervix and vagina and evaluate a potential means for home testing.

METHODS

Cervicovaginal fluid samples were obtained from ovarian cancer and normal control patients for LC-mass spectrometry(MS) proteomic evaluation. Statistical modeling determined the protein panel with the highest penetrance across ovarian cancer samples. A subcohort of patients consented to provide self-collected vaginal samples at home with questionnaire on feasibility. Cohen's kappa methodology was utilized to determine agreement between physician-collected and patient-collected samples.

RESULTS

A total of 83 consecutive patient samples were collected prospectively (33 ovarian cancer & 50 controls). Thirty patients consented for self-collection. Using LC-MS, 30 peptides demonstrated independent statistical significance for detecting ovarian cancer. Using statistical modeling, the protein panel that determined the best predictor for detecting OC formed a "fingerprint" consisting of 5 proteins: serine proteinase inhibitor A1; periplakin; profilin1; apolipoprotein A1; and thymosin beta4-like protein. These peptides demonstrated a significant increase probability of detecting ovarian cancer with the ROC curve having an AUC of 0.86 (p = 0.00001). Physician-collected and patient-collected specimens demonstrated moderate agreement with kappa average of 0.6 with upper bound of 0.75.

CONCLUSIONS

Using novel site-specific collection methods, we identified an OC "fingerprint" with adequate sensitivity and specificity to warrant further evaluation in a larger cohort. Agreement of physician-collected and patient-collected samples were encouraging and could improve access to screening with a home self-collection if this screening test is validated in future studies.

Assessing the Effectiveness of Cancer Screening Interventions Targeting Appalachian Populations: A Systematic Review

PURPOSE

Appalachian residents have higher cancer prevalence and invasive cancer incidence in almost all cancer types relative to non-Appalachian residents. Public health interventions have been carried out to increase preventive cancer screening participation. However, no studies have evaluated the effectiveness of existing interventions targeting cancer screening uptake in this high-risk population. The main objective of this study is to assess the effectiveness of interventions aimed at increasing uptake and/or continuing participation in screened cancers (breast, cervical, colorectal, lung, and prostate) in Appalachia.

METHODS

We conducted a systematic review of electronic databases and gray literature using a combination of MeSH and free-text search terms related to breast, cervical, colorectal, lung, and prostate cancer; mass screening; health promotion; and Appalachia. We identified 3,014 articles of which 15 articles were included. We assessed methodological quality using validated tools and analyzed findings using narrative synthesis.

FINDINGS

Fifteen studies reported uptake and/or continued participation in screening interventions; these focused on cervical (n = 7), colorectal (n = 5), breast (n = 2), and lung (n = 1) cancers in Appalachia. Interventions included diverse components: mass media campaigns, community outreach events, community health workers, interpersonal counseling, and educational materials. We found that multi-strategy interventions had higher screening uptake relative to interventions employing 1 intervention strategy. Studies that targeted noncompliant populations and leveraged existing community-based organization partnerships had a substantial increase in screening participation versus others.

CONCLUSIONS

There is an urgent need for further research and implementation of effective cancer prevention and screening interventions to reduce disparities in cancer morbidity and mortality in Appalachian populations.

Acceptability of a multicomponent, community-based, HPV self-test intervention among Jamaican women

Jamaican women do not participate in routine Pap test screening as recommended, despite the availability of free Pap test services at community clinics. This low uptake has been associated with cultural and structural barriers such as limited knowledge and awareness, fear of pain associated with Pap tests, fear of diagnosis, modesty or self-consciousness, medical mistrust, and discontent with healthcare services. This study suggests that a multicomponent, community-based intervention that includes education and self-testing for the virus that causes cervical cancer (i.e., Human Papillomavirus, HPV) might increase screening rates. Community outreach workers were hired and recruited 163 women from two low socioeconomic status communities in Kingston, aged 30 to 65 years, and who had not had a Pap test in at least 3 years, to use an HPV self-test kit. Almost all the women (95.6%) used and returned the kit and reported in structured interviews that it was easy to use and preferable to visiting a doctor. Paired samples t-tests revealed that participants perceived higher threat of cervical cancer, greater susceptibility to cancer, greater sense of self-efficacy, and more positive screening social norms at post-test than at pretest. Among returners, 22% had an oncogenic HPV type detected in their sample. Findings demonstrate high acceptability of the HPV self-test among Jamaican women and, therefore, the potential of HPV self-test tools to increase screening uptake. Community-based approaches to disseminate this tool, such as outreach workers and educational small group sessions, appear to be culturally appropriate and effective in this context.