Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses

Evidence from Europe on implementation, participation and performance of self-collection for cervical cancer screening

Cervical cancer screening programs reduce the number of cervical cancer cases and deaths, but the success of any screening program is dependent on high participant uptake and coverage and many European countries are observing declining cervical cancer screening coverage to below national targets. Self-collection of vaginal samples for human papillomavirus testing, also termed self-sampling, is one strategy which is being introduced to try to increase screening coverage by removing barriers to participation and it has attracted growing interest and support globally. Informed by peer-reviewed and gray literature, this narrative review starts with a case study from the Netherlands and outlines the self-collection landscape in Europe within the themes of program implementation and relative test performance. It highlights some of the current evidence gaps needed to inform policy decisions on the use of self-collection within screening programs.

High-risk human papillomavirus testing for cervical cancer screening in Uganda: Considering potential harms and benefits in a low-resource setting

OBJECTIVES

The World Health Organization supports both the screen-and-treat (ST) approach and the screen, triage and treat (STT) approach to cervical cancer screening using high-risk human papillomavirus (hrHPV) testing. For Uganda, the sequence of hrHPV-ST and hrHPV-STT could be similar, with visual inspection with acetic acid (VIA) after positive hrHPV tests in both. To consider potential tradeoffs (overtreatment in ST versus missed cancer cases in STT), we compared hrHPV-STT with VIA triage (STT-VIA), and STT with HPV 16/18 genotyping risk stratification, to hrHPV-ST for Uganda, in terms of overtreatment, cervical cancer incidence, and life years, for the general female population of Uganda.

METHODS

A microsimulation model of cervical cancer was adapted. Incremental benefit-harm ratios of STT were calculated as ratios of prevented overtreatment to reduced life years, and to increased cancer cases. Additional scenarios with 20% difference in intra- and inter-screening follow-up between ST and STT were modeled.

RESULTS

Both STT strategies resulted in life year losses on average compared to ST. STT-VIA prevented more overtreatment but led to increased cervical cancer incidence and life year losses. STT-G-VIA resulted in better harm-benefit ratios and additional costs. With better follow-up, STT prevented overtreatment and improved outcomes.

DISCUSSION

For Uganda, the STT approach appears preferrable, if the screening sequences of hrHPV-based ST and STT are similar in practice. While VIA triage alone would reduce overtreatment the most, it could also result in more cancer cases. Risk stratification via genotyping could improve STT. Potential follow-up differences and resource availability should be considered by decision-makers when planning Uganda's hrHPV-based screening strategy.

The Future of Cervical Cancer Screening

Purpose

Cervical cancer remains a significant health concern, particularly in developing countries, where it is a leading cause of cancer-related deaths among women. Innovative technologies have emerged to improve the efficiency, cost-effectiveness, and sensitivity of cervical cancer screening and treatment methods. This study aims to explore the various approaches for the detection and treatment of human papillomavirus (HPV), cervical dysplasia (CD), and cervical cancer, highlighting new technologies and updated screening strategies in developing areas.

Patients and Methods

A comprehensive literature search was conducted using PubMed to identify relevant publications on the subject of cervical cancer screening and HPV detection.

Results

HPV infection and cervical cancer continue to pose significant global health challenges. Emerging technologies such as rapid, low-cost HPV testing combined with high-resolution digital colposcopy and artificial intelligence interpretation hold promise for efficient and sensitive screening. Advancements in HPV vaccine distribution, high-risk HPV screening, DNA methylation assays, dual-stain cytology, lab-on-chip assays, and deep learning technologies offer new avenues for improved detection and risk stratification.Research and innovations in detection and treatment methods are crucial for reducing the burden of these diseases worldwide.

Conclusion

Screening for HPV and CD plays a pivotal role in reducing the risk of cervical cancer-related mortality. The development of novel technologies, along with efforts to enhance global health equity and integrate cervical cancer prevention with HIV screening and treatment programs, represent critical steps toward achieving comprehensive cervical cancer screening on a global scale.

Exploring Factors Influencing Cervical Cancer Screening Participation among Singaporean Women: A Social Ecological Approach

Background/Objectives: Cervical cancer screening uptake in Singapore remains suboptimal. This study employed the Social Ecological Model (SEM) to investigate factors influencing cervical cancer screening participation among Singaporean women. Methods: The study included 665 women, aged 25-69 years, who reported awareness of cancer screening and no personal cancer history. Data were collected through a previously described online survey. Hierarchical logistic regression analysis was conducted to identify significant factors influencing screening participation. Results: Only 30% of participants reported cervical cancer screening participation. Women aged 25-29 years (OR = 0.33; 95% CI = 0.12-0.77), Malay women (OR = 0.42; 95% CI = 0.20-0.83), and unmarried women (OR = 0.30; 95% CI = 0.18-0.48) were less likely to be screened. Positive associations with screening participation were observed with good cervical cancer screening knowledge (OR = 2.90; 95% CI = 1.96-4.32), awareness of primary care providers' role in delivering screening services (OR = 1.94; 95% CI = 1.24-3.10), cancer information seeking behavior (OR = 1.59; 95% CI = 1.07-2.39), and acceptance of self-sampling options (OR = 1.81; 95% CI = 1.22-2.70). Conclusions: Our study highlights the cumulative impact of factors at various SEM levels on screening participation and underscores the necessity for more targeted and multi-pronged strategies to improve cervical cancer screening uptake in Singapore.

Enhancing equity in cervical screening - initiatives to increase screening participation

PURPOSE OF REVIEW

Cervical cancer can be eliminated as a public health problem through a three-pillar approach including high coverage of human papillomavirus (HPV) vaccination and HPV-based cervical screening, and treatment of precancers and invasive cancers. However, access inequities prevent many women and people with a cervix benefitting from these life-saving advances. This review focuses on evidence-based interventions that can improve equity and scale-up of cervical screening.

RECENT FINDINGS

The transition from conventional cytology to HPV screening provides multiple opportunities to address equity and a multipronged approach can be used to identify priority groups, understand barriers and develop tailored solutions. There are proven financing mechanisms, tools, technologies and screening delivery methods to overcome screening barriers in different settings. This includes self-sampling interventions, point-of-care testing, health service integration, consumer-led co-design processes and digital screening registries.

SUMMARY

To achieve cervical cancer elimination globally, cervical screening must be delivered in an inclusive, culturally safe and context-appropriate manner. There are multiple tools and strategies that can be implemented to improve participation of never- and under-screened groups, and to enhance equity in cervical screening.

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.

Evaluation of C-C Motif Chemokine Receptor 5 (CCR5) as a Sample Adequacy Control in HPV Molecular Diagnostics

Background: Reliable Human Papillomavirus (HPV) testing and genotyping are essential for quality assurance in HPV-based primary screening, disease management and for monitoring the impact of HPV vaccination. The clinical validation of HPV molecular diagnostic assays has significantly contributed to these objectives; however, little emphasis has been placed on assuring sample quality. This study aimed to evaluate the accuracy of sample cellularity assessment using the C-C Motif Chemokine Receptor 5 (CCR5) gene target as a marker of sample adequacy in molecular diagnostics. Methods: Jurkat cell line samples were counted using both a Thoma cell-counting chamber and Fluorescence-Activated Cell Sorting (FACS). Jurkat cell line samples at three different concentrations were subsequently evaluated using the OncoPredict HPV Quality Control (QC) real-time PCR assay, employing CCR5 for molecular cellularity quantification. Results: The cellularity values obtained were comparable across the three different methods for all dilutions of the cell line tested. Conclusions: The results obtained from this study show that CCR5 represents a promising molecular marker for the accurate quantification of sample cellularity, confirming its use as a reliable sample adequacy control, thus reducing the risk of "false-negative" results.

Factors associated with clinician willingness to adopt HPV self-sampling and self-testing for cervical cancer screening

Background

Cervical cancer screening rates in the USA fall behind national targets, requiring innovation to circumvent screening barriers. Cervical cancer screening where human papillomavirus (HPV) testing is performed on vaginal samples collected by the patients themselves (self-sampling) are effective and acceptable, and patient-operated rapid HPV tests (self-testing) are currently under development. It is unclear why there is ambivalence toward HPV self-sampling and self-testing among clinicians, an important stakeholder group. We conducted a mixed convergent quantitative and qualitative study to identify the factors influencing clinicians' attitudes toward self-sampling and self-testing.

Methods

A survey of Midwest clinicians distributed by professional group media and a market research firm between May and November 2021 was analyzed (n = 248) alongside in-depth interviews with Midwest clinicians from professional groups (n = 23). Logistic regression models examined willingness to support self-sampling and self-testing across respondent characteristics.

Results

We report that family practice physicians and those in rural areas were more willing to adopt HPV self-sampling (adjusted OR (aOR) = 3.16 [1.43-6.99]; aOR = 2.17 [1.01-4.68]). Clinician willingness to support self-testing was positively associated with current use of self-testing for other conditions and negatively associated with performing 10 or more monthly cervical cancer screenings (aOR = 2.02 [1.03-3.95], aOR = 0.42 [0.23-0.78]). Qualitative data contextualize how clinical specialty and experience with self-sampling and self-testing for other conditions inform clinician perspectives.

Conclusion

These data suggest clinician populations most accepting of initiatives to implement self-sampling and self-testing for cervical cancer screening and highlight that experience with other forms of self-testing could facilitate more widespread adoption for cervical cancer.

Sociodemographic characteristics associated with cervical cancer screening participation by send-to-all and opt-in HPV self-sampling: Who benefits? Results from a randomized controlled trial among long-term non-attending women in Norway

With the objective to investigate associations between sociodemographic characteristics and participation in interventions designed to increase participation in cervical cancer screening among under-screened women, we randomized a random sample of 6000 women in Norway aged 35-69 years who had not attended cervical screening for ≥10 years to receive either (i) a reminder to attend regular screening (control), (ii) an offer to order a self-sampling kit (opt-in), or (iii) a self-sampling kit unsolicited (send-to-all). We analyzed how sociodemographic characteristics were associated with screening participation within and between screening arms. In the send-to-all arm, increased screening participation ranged from 17.1% (95% confidence interval [95% CI] = 10.3% to 23.8%) to 30.0% (95% CI = 21.5% to 38.6%) between sociodemographic groups. In the opt-in arm, we observed smaller, and at times, non-significant increases within the range 0.7% (95% CI = -5.8% to 7.3%) to 19.1% (95% CI = 11.6% to 26.7%). In send-to-all versus control comparisons, there was greater increase in participation for women in the workforce versus not (6.1%, 95% CI = 1.6% to 10.6%), with higher versus lower income (7.6%, 95% CI = 2.2% to 13.1%), and with university versus primary education (8.5%, 95% CI = 2.4% to 14.6%). In opt-in versus control comparisons, there was greater increase in participation for women in the workforce versus not (4.6%, 95% CI = 0.7% to 8.5%), with higher versus lower income (6.3%, 95% CI = 1.5% to 11.1%), but lower increase for Eastern European versus Norwegian background (-12.7%, 95% CI = -19.7% to -5.7%). Self-sampling increased cervical screening participation across all sociodemographic levels, but inequalities in participation should be considered when introducing self-sampling, especially with the goal to reach long-term non-attending women.

Self-Screening for Cervical Cancer Offered through a Digital Platform in a Region of British Columbia with Lower Screening Rates

Cervical cancer is highly preventable through vaccination, early detection, and treatment, yet is the fourth most common cancer globally. HPV testing is superior to cytology for the detection of cervical pre-cancer, and jurisdictions around the world are implementing HPV primary screening, which offers the opportunity for self-screening, an important self-care intervention. Digital health solutions are also increasingly important components of self-care. In this study, we assessed the acceptability and completion of self-screening for cervical cancer offered through a digital platform within a low screening uptake region of British Columbia. The primary objective of this study was to evaluate the acceptability of self-screening for cervical cancer offered through a digital platform as measured by return rates of self-screening kits. Patients due or overdue for cervix screening were invited to participate. Eligible participants registered online to receive a self-screening kit, which included a device for vaginal self-screening, instructions, and a return envelope, sent to their home. After self-screening using the vaginal device, HPV testing was conducted. HPV-negative participants were returned to routine screening, and HPV-positive participants were recommended for cytology or colposcopy. Attendance rates at follow-up were evaluated. Participants were invited to complete an acceptability survey. From April 2019 to December 2023, 283 participants were sent kits, with 207 kits returned for a completion rate of 73%. Of valid samples (n = 202), 15 were HPV positive, and 93% attended follow-up care. Most respondents found the CervixCheck website easy to use, informative, and secure and were satisfied with receiving their results online. CervixCheck had a high completion rate among participants who were sent a self-screening kit. High compliance with recommended follow-up and high acceptability of self-screening for cervical cancer was observed. Most participants indicated they would self-screen again in the future. Innovative approaches to cervical screening, including self-screening and the use of digital health interventions, are ways to enhance equity and improve uptake of cervical screening.

HPV self-collection for cervical cancer screening among survivors of sexual trauma: a qualitative study

Intimate partner violence affects 20-30% of women in the United States. Disparities in routine cervical cancer surveillance have been demonstrated in certain populations, including victims of intimate partner violence (IPV). This study examined and assessed the acceptability of high-risk HPV (hrHPV) self-collection among individuals who have experienced IPV. We conducted an observational study using qualitative data collection and analysis. We interviewed individuals with a history of IPV and who currently reside in Oregon. This study identified key themes describing knowledge and attitudes towards cervical cancer screening for individuals who have experienced IPV. They include: guideline knowledge, prior office-based cervical cancer screening experience, barriers to cervical cancer screening, at-home hrHPV self-collection experience, and testing confidence. Participants experienced fewer barriers and expressed increased comfort and control with hrHPV self-collection process. Individuals with a history of IPV have lower rates of cervical cancer screening adherence and higher rates of cervical dysplasia and cancer than other populations. The patient-centered approach of hrHPV self-collection for cervical cancer screening can reduce barriers related to the pelvic exam and empower patients to reduce their risks of developing cervical cancer by enabling greater control of the testing process.

Invitation strategy of vaginal HPV self-sampling to improve participation in cervical cancer screening: a systematic review and meta-analysis of randomized trials

BACKGROUND

Human papillomavirus (HPV) self-sampling is recognized as a feasible option for enhancing screening for cervical cancer, particularly among hard-to-reach women. The magnitude of the effectiveness of screening participation under different invitation strategies was reported. This review seeks to compare the effectiveness of invitation strategies in increasing screening participation of HPV self-sampling across diverse study settings.

METHODS

A systematic literature search was conducted in Embase, MEDLINE, and PubMed in April 2023. Articles were included if (1) their target participants were aged between 25 and 70 years; (2) participants in the intervention arm were randomized to receive HPV self-sampling devices through various invitation strategies; (3) participants in the control arm who either received invitations for cervical cancer screening other than HPV self-sampling or opportunistic screening as usual care; (4) studies that provided sufficient data on screening participation in HPV self-sampling as outcome measured. The study design of the included articles was limited to randomized controlled trials.

RESULTS

A total of 15 articles were included in this review. Invitation strategies of disseminating HPV self-sampling devices included opt-out and opt-in. Meta-analysis revealed screening participation in the self-sampling group was significantly greater than control arm (OR 3.43, 95% CI 1.59-7.38), irrespective of the invitation strategy employed. Among invitation strategies, opt-out appeared to be more effective on increasing screening participation, compared to control and opt-in strategy (opt-out vs. control OR 3.91, 95% CI 1.82-8.42; opt-in vs. control OR 1.34, 95% CI 0.28-6.39).

CONCLUSIONS

Opt-out strategy is more successful at improving screening participation compared to opt-in and routine invitation to cervical screening. It is therefore a promising way to improve participation in cervical cancer screening. The findings of this review provide important inputs to optimize strategies for inviting women to participate in vaginal HPV self-sampling across the study setting, thus improving participation in cervical cancer screening.

Health Care Provider Willingness to Recommend Self-collected Tests for Human Papillomavirus: A Mixed Methods Examination of Associated Factors

INTRODUCTION

Cervical cancer disproportionately affects those who are underscreened. Human papillomavirus self-collection is a promising tool to expand screening.

OBJECTIVE

Study objectives were to examine 1) factors (provider characteristics and practice type) associated with and 2) attitudes (perceived benefits and concerns) toward using human papillomavirus self-collection for cervical cancer screening in clinical practice.

METHODS

This study had a mixed method design; prior to regulatory approval of self-collection, we conducted a national survey and interviews of health care providers who perform cervical cancer screening. Quantitative measures included provider and practice characteristics, willingness to recommend, and preferences related to self-collection. Qualitative interviews further elucidated provider perspectives.

RESULTS

A total of 1,251 providers completed surveys, and 56 completed interviews. Among survey respondents, 33.4% reported they were likely to offer self-collection, 28.6% were unsure, and 38.0% reported they were unlikely. Most would offer self-collection either in the clinic or at home per patient preference. Male participants, advanced practice providers, internal and family physicians, and those practicing in academic medical center, hospital, or community health settings were more likely than female participants, obstetrician-gynecologist physicians, and those in private practice to indicate they were likely to offer self-collection. Concerns expressed in both surveys and interviews included the adequacy of sample collection and the ability to follow up. Respondents felt that self-collection would be particularly beneficial for those who did not have access to clinician-collected screening, as well as for patients who may have difficulty with pelvic examinations for any reason.

CONCLUSION

Providers considered human papillomavirus self-collection to be a way to expand access for patients with health care barriers and pelvic examination difficulties. They had concerns related to sample adequacy and follow-up after abnormal results.

Cervical Human Papillomavirus Testing: Current and Future Impact on Patient Care

Cervical cancer is the fourth most common malignancy in women worldwide. The identification of human papillomavirus (HPV) as the main etiologic cause of cervical cancer has led to the development and adaptation of HPV molecular diagnostics as a cervical cancer screening and prevention tool. This article highlights six Food and Drug Administration-approved HPV molecular platforms, each with unique advantages and disadvantages. In addition, HPV vaccination and the emergence of HPV self-collection as an alternative testing strategy are discussed.

Effectiveness of self-sampling human papillomavirus test on precancer detection and screening uptake in Japan: The ACCESS randomized controlled trial

Japan is lagging in cervical cancer prevention. The effectiveness of a self-sampling human papillomavirus (HPV) test, a possible measure to overcome this situation, has not yet been evaluated. A randomized controlled trial was performed to evaluate the effectiveness of a self-sampling HPV test on detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and screening uptake. Women between 30 and 58 years old who did not participate in the cervical cancer screening program for ≥3 years were eligible and assigned to the intervention group (cytology or self-sampling HPV test) or control group (cytology). Participants assigned to the intervention group were sent a self-sampling kit according to their ordering (opt-in strategy). A total of 7337 and 7772 women were assigned to the intervention and control groups, respectively. Screening uptake in the intervention group was significantly higher than that in the control group (20.0% vs. 6.4%; risk ratio: 3.10; 95% confidence interval [CI]: 2.82, 3.42). The compliance rate with cytology triage for HPV-positive women was 46.8% (95% CI: 35.5%, 58.4%). CIN2+ was detected in five and four participants in the intervention and control groups, respectively; there was no difference for intention-to-screen analysis (risk ratio: 1.32; 95% CI: 0.36, 4.93). Self-sampling of HPV test increased screening uptake; however, no difference was observed in the detection of CIN2+, probably due to the low compliance rate for cytology triage in HPV-positive women. Efforts to increase cytology triage are essential to maximize precancer detections.

Experiences and Perceptions of Cervical Cancer Screening Using Self-Sampling among Under-Screened Women in Flanders

Primary Human Papillomavirus (HPV) screening on samples collected by women themselves has proven to be an effective strategy for cervical cancer screening (CCS) and may increase participation rates in women who do not partake (regularly) in screening. The aim of this study is to investigate reasons for non-participation and perceptions of CCS using self-sampling methods among under-screened women in Flanders. Individual interviews with 15 underscreened women aged 30-64 years were conducted. During the interviews, participants were given the opportunity to try out a urine and vaginal self-sampling kit. Thematic analysis was based on Ajzen's model of the Theory of Planned Behavior. The results showed that 14 out of 15 participants were more likely to participate in CCS if they had the option to self-sample. One of the main findings was a lack of knowledge on different aspects of cervical cancer. Most women had a positive attitude toward cancer screening and primary prevention such as HPV vaccination. Subjective norms were influenced by healthcare professionals, peers, and organized government initiatives. Informational, organizational, contextual, and emotional factors were mentioned as barriers as well as facilitators for participation. Additionally, high self-efficacy was considered to make self-sampling more convenient. All women showed the intention to use at least one method of self-sampling. We can conclude that women who do not participate in CCS would be more motivated to participate using self-sampling methods. Adequate education and guidance should be provided.

Looking Back, Moving Forward: Challenges and Opportunities for Global Cervical Cancer Prevention and Control

Despite the introduction of Pap testing for screening to prevent cervical cancer in the mid-20th century, cervical cancer remains a common cause of cancer-related mortality and morbidity globally. This is primarily due to differences in access to screening and care between low-income and high-income resource settings, resulting in cervical cancer being one of the cancers with the greatest health disparity. The discovery of human papillomavirus (HPV) as the near-obligate viral cause of cervical cancer can revolutionize how it can be prevented: HPV vaccination against infection for prophylaxis and HPV testing-based screening for the detection and treatment of cervical pre-cancers for interception. As a result of this progress, the World Health Organization has championed the elimination of cervical cancer as a global health problem. However, unless research, investments, and actions are taken to ensure equitable global access to these highly effective preventive interventions, there is a real threat to exacerbating the current health inequities in cervical cancer. In this review, the progress to date and the challenges and opportunities for fulfilling the potential of HPV-targeted prevention for global cervical cancer control are discussed.

Self-collected versus clinician-collected anal swabs for anal cancer screening: A systematic review and meta-analysis

Anal squamous cell carcinoma (ASCC) incidence is increasing globally. International consensus guidelines published in 2024 include HPV and/or cytology testing of anal swabs in those at greatest risk of ASCC. Self-collected anal swabs may be important for increasing screening uptake, but evidence is needed as to their equivalence to clinician-collected swabs. We searched Medline, Embase, Cochrane Library, and CINAHL databases for publications to 13 June 2023. Studies were included if reporting data on HPV testing, cytology testing, or acceptability, for both self- and clinician-collected anal swabs. Risk of bias was assessed using the QUADAS-2 assessment tool. The primary outcome was HPV and cytology sampling adequacy. Secondary outcomes were HPV and cytology results, and acceptability of collection methods. Thirteen papers describing 10 studies were eligible. Sample adequacy was comparable between self- and clinician-collected swabs for HPV testing (meta-adequacy ratio: 1.01 [95% CI 0.97-1.05]) but slightly lower for cytology by self-collection (meta-adequacy ratio: 0.91 [95% CI 0.88-0.95]). There was no significant difference in prevalence (meta-prevalence ratio: 0.83 (95% CI 0.65-1.07) for any HR-HPV, 0.98 (95% CI 0.84-1.14) for any HPV, and 0.68 (95% CI 0.33-1.37) for HPV16), or any cytological abnormality (meta-prevalence ratio 1.01 [95% CI 0.86-1.18]). Only three papers reported acceptability results. Findings indicate self-collection gives equivalent sample adequacy for HPV testing and ~ 10% inferior adequacy for cytological testing. Meta-prevalence was similar for HPV and cytology, but confidence intervals were wide. Larger studies are required to definitively assess use of self-collected swabs in anal cancer screening programs, including acceptability.

[Transmasculine people: Gender affirming hormonal therapy, sexual and reproductive health prevention and care, a medical review and follow-up suggestions]

Transmasculine individuals have a poor access to health care, mostly regarding the sexual and reproductive health. Despite a lack of official guidelines, they need a gynecological follow-up, the aim of this review was to describe it. The present study involved an exhaustive search of MEDLINE, 68 articles were included to analyze the impact of hormonal therapy, prevention, and care regarding sexual and reproductive health of transmasculine individuals. Despite a lack of solid data, the global literature agrees that transmasculine individuals require sexual and reproductive health care. Care must be adapted to each pathway and may be impacted by gender-affirming care. The cancer risk does not seem to be increased in this population, particularly in relation to hormonal therapy. Prevention programs do not differ from those offered to cis women in the absence of gender-affirming surgeries. Transmasculine individuals require follow-up and care adapted to their needs and their pathways. Healthcare professionals must be trained to provide such care.

Understanding the high-risk human papillomavirus prevalence and associated factors in the European country with a high incidence of cervical cancer

BACKGROUND

High-risk human papillomavirus (HR-HPV) is a known cause of cervical cancer (CC). Latvia has a high incidence of CC compared with the average incidence in the European Union. This study aims to fill the data gap on the HR-HPV burden in Latvia, providing information on its prevalence and associated factors.

METHODS

The cross-sectional study was conducted from February 2021 to April 2022. Participants 25-70 years old visiting a general practitioner (general population) or those referred to a colposcopy clinic with changes in their cervical cytology (colposcopy population) collected vaginal self-sample and completed a paper-based questionnaire. Samples were analyzed with Cobas 6800 System (Roche) for HPV16, HPV18 and other HR-HPV (HPV31/33/35/39/45/51/52/56/58/59/66/68). Descriptive statistics for categorical variables were performed. The Chi-square test was used to determine for the statistical significance of differences in the proportions of the dependent variable between subgroups of the independent variable. Univariate and multivariate binary logistic regression were used to identify factors associated with positive HR-HPV status. Results were considered statistically significant at P < 0.05.

RESULTS

A total of 1274 participants provided a valid sample. The prevalence of any HR-HPV infection was 66.8% in the colposcopy group and 11.0% in the general population. Factors associated with positive HR-HPV status were marital status single/divorced/widowed (vs. married/cohabiting) [adjusted OR (aOR) 2.6; P = 0.003], higher number of lifetime sex partners [aOR 5.1 (P < 0.001) and 4.0 (P = 0.001)] for six or more and three to five partners in the general population; in the colposcopy group, the statistical significance remained only for Latvian ethnicity (vs. other) (aOR 1.8; P = 0.008) and current smoking (vs. never) (aOR 1.9; P = 0.01).

CONCLUSION

We documented a comparison to European Union HR-HPV infection burden in Latvia. Any HR-HPV positivity was significantly associated with sexual and other health behavior.

Experiences of Self-Sampling and Future Screening Preferences in Non-Attenders Who Returned an HPV Vaginal Self-Sample in the YouScreen Study: Findings From a Cross-Sectional Questionnaire

BACKGROUND

We assessed experiences of human papillomavirus (HPV) vaginal self-sampling and future screening preferences in an ethnically and socio-economically diverse group of women overdue for cervical screening.

SETTING AND PARTICIPANTS

A postal questionnaire was embedded in the YouScreen self-sampling trial in England: 32.5% (2712/8338) of kit completers returned the survey. Kit non-completers were encouraged to return a questionnaire, but no responses were received. Participants were ethnically diverse (40.3% came from ethnic minority backgrounds), and 59.1% came from the two most deprived quintiles. Differences in confidence in kit completion, trust in the test results and intention to attend a follow-up test if HPV-positive were evaluated using Pearson's χ2 analyses. Binary logistic regression models explored predictors of a future screening choice and preferences for urine versus vaginal self-sampling.

RESULTS

Most kit-completers reported high confidence in self-sampling (82.6%) and high trust in the results (79.9%), but experiences varied by ethnicity and screening status. Most free-text comments were positive but some reported difficulties using the device, pain or discomfort. Most women would opt for self-sampling in the future (71.3% vs. 10.4% for a clinician-taken test) and it was more often preferred by ethnic minority groups, overdue screeners and never attenders. Urine self-tests were preferred to vaginal tests (41.9% vs. 15.4%), especially among women from Asian, Black or Other Ethnic backgrounds.

CONCLUSIONS

Kit-completers were confident, found the test easy to complete, and trusted the self-sample results. However, experiences varied by ethnic group and some women highlighted difficulties with the kit. Most women would prefer self-sampling in the future, but it was not a universal preference, so offering a choice will be important.

PATIENT OR PUBLIC CONTRIBUTION

We did not have direct patient and public involvement and engagement (PPIE) in the questionnaire design. However, patients and public representatives did input into the design of the YouScreen trial and reviewed the wider study materials (e.g. participant information sheet).

TRIAL REGISTRATION

This questionnaire study was embedded in the YouScreen trial. The protocol for the YouScreen trial is available at https://www.isrctn.com/ISRCTN12759467. The National Institute for Health Research 43 Clinical Research Network (NIHR CRN) Central Portfolio Management System (CPMS) ID is 4441934.

HPV self-sampling in organized cervical cancer screening program: A randomized pilot study in Estonia in 2021

BACKGROUND

Cervical cancer incidence in Estonia ranks among the highest in Europe, but screening attendance has remained low. This randomized study aimed to evaluate the impact of opt-in and opt-out human papillomavirus (HPV) self-sampling options on participation in organized screening.

METHODS

A random sample of 25,591 women were drawn from the cervical cancer screening target population who were due to receive a reminder in autumn 2021 and thereafter randomly allocated to two equally sized intervention arms (opt-out and opt-in) receiving a choice between HPV self-sampling or clinician sampling. In the opt-out arm, a self-sampler was sent to home address by regular mail; the opt-in arm received an e-mail containing a link to order a self-sampler online. The remaining 30,102 women in the control group received a standard reminder for conventional screening. Participation by intervention arm, age and region of residence was calculated; a questionnaire was used to assess self-sampling user experience.

RESULTS

A significant difference in participation was seen between opt-out (41.7%) (19.8% chose self-sampling and 21.9% clinician sampling), opt-in (34.1%) (7.9% self-sampling, 26.2% clinician sampling) and control group (29.0%, clinician sampling only). All age groups and regions in the intervention arms showed higher participation compared to the control group, but the size of the effect varied. Among self-sampling users, 99% agreed that the device was easy to use and only 3.5% preferred future testing at the clinic.

CONCLUSION

Providing women with a choice between self-sampling and clinician sampling significantly increased participation in cervical cancer screening. Opt-in and opt-out options had a different effect across age groups, suggesting the need to adapt strategies.

Variables that impact HPV test accuracy during vaginal self collection workflow for cervical cancer screening

Vaginal self collection (SC) is safe and effective for human papillomavirus (HPV) testing and can increase cervical cancer screening coverage for underserved women. To better understand the impact of SC methodology on HPV test outcomes, empirical testing was conducted using different swab collection workflows. Deposition of the collection swab into resuspension buffer resulted in a 2.4-cycle reduction in threshold detection of human beta-hemoglobin during PCR when compared to "swirl-and-toss". In addition, reducing the swab resuspension volume from 10 mL to 3 mL resulted in a 2.6-cycle reduction in threshold detection of human beta-globin. A systematic literature search (01/01/2020 to 08/02/2023) of Ovid Medline and Embase, followed by data extraction and analysis, was conducted to further assess the impact of resuspension volume on performance following SC. HPV test performance for SC, relative to clinician collection (CC), was calculated for detection of cervical pre-cancer. Data were stratified by the resuspension volume ratio of SC to CC being either ≥ 1.0 or < 1.0. SC with a volume ratio of ≥ 1.0 and < 1.0 had a relative ≥ CIN2 sensitivity of 92.0 % (95 % CI: 88.0, 96.0) and 97.0 % (95 % CI: 94.0, 100), respectively. Taken together, these results suggest that SC conditions can be modified to optimize sample recovery and performance, as part of cervical cancer screening.

CER818: A Highly Specific and Sensitive HPV L1 High-Risk Serological Lateral Flow Rapid Test for Early Detection of Cervical Cancer and Its Precursor Lesions

Objective: The objective of the study is to validate a new human papillomavirus (HPV) L1 high-risk specific serological assay in a case-control study. Methods: Serum samples of 138 patients (cervical intraepithelial neoplasia (CIN) 1, 2, and 3 and cervical cancer), 21 vaccinees, and 246 female controls were tested for the presence of HPV L1 high-risk specific antibodies. Results: HPV L1 high-risk antibodies were detected in 100% of the CIN1 and 2, 86.6% of the CIN3 and 82.4% of the cervical cancer cases, 100% of the vaccinees, and 3.9% of the female controls. Area under the curve (AUC) was calculated with 0.91 for controls versus CIN2+, 0.923 for controls versus CIN1+, and 0.968 for controls versus CIN1/2. Conclusion: The HPV L1 high-risk specific serological lateral flow rapid test shows promising data in the field of early detection of HPV high-risk induced cervical cancer and its precursor lesions. This easy-to-use, robust, and affordable approach could offer a chance to reach women in low- or middle-income countries (LMICs) that could not be reached by HPV molecular testing-based cervical cancer screening programs.

Rationale and design of the Self-TI Study protocol: a cross-sectional human papillomavirus self-testing pilot study among transgender adults in England

INTRODUCTION

Persistent infection with high-risk human papillomavirus (HPV) is the causal agent of several cancers including cervical, anal and oropharyngeal cancer. Transgender men and transmasculine non-binary (TMNB) people with a cervix are much less likely to undergo cervical cancer screening than cisgender women. Transgender women and transfeminine non-binary (TWNB) people assigned male at birth may be at increased risk of HPV. Both TMNB and TWNB people face many barriers to HPV testing including medical mistrust due to stigma and discrimination.

METHODS AND ANALYSIS

The Self-TI Study (Self-TI) is a pilot study designed to measure acceptability and feasibility of HPV self-testing among transgender and non-binary people in England. TMNB people aged 25-65 years, with at least 1 year of testosterone, and TWNB people, aged 18 years and over, are eligible to participate. Participants self-collect up to four samples: an oral rinse, a first void urine sample, a vaginal swab (if applicable) and an anal swab. TMNB participants are asked to have an additional clinician-collected cervical swab taken following their routine Cervical Screening Programme sample. TWNB people are asked to take a self-collection kit to perform additional self-collection at home and mail the samples back to the clinic. Acceptability is assessed by a self-administered online survey and feasibility is measured as the proportion of samples returned in the clinic and from home.

ETHICS AND DISSEMINATION

Self-TI received ethical approval from the Research Ethics Committee of Wales 4 and ethical review panel within the Division of Cancer Epidemiology and Genetics at the US National Cancer Institute. Self-TI was coproduced by members of the transgender and non-binary community, who served as authors, collaborators and members of the patient and public involvement (PPI) group. Results of this study will be shared with the community prior to being published in peer-reviewed journals and the PPI group will help to design the results dissemination strategy. The evidence generated from this pilot study could be used to inform a larger, international study of HPV self-testing in the transgender and non-binary community.

TRIAL REGISTRATION NUMBER

NCT05883111.

Opportunistic offering of self-sampling to non-attenders within the English cervical screening programme: a pragmatic, multicentre, implementation feasibility trial with randomly allocated cluster intervention start dates (YouScreen)

Background

Self-sampling has game-changing potential to tackle the declining participation and inequities seen in many organised cervical screening programmes. Wide variation in uptake between settings and mode of kit offer highlight the importance of local piloting. Furthermore, harnessing the benefits of self-sampling in real-world settings has been surprisingly challenging. The YouScreen study estimated the impact of offering self-sampling to non-attenders within the English Programme and evaluated large-scale opportunistic offering of self-sampling in primary care.

Methods

A pragmatic modified stepped-wedge implementation feasibility trial with randomly-allocated cluster intervention start dates at primary care practices in England (133 participating, 62 non-participating). Eligible women were aged 25-64 years and ≥6 months overdue for screening ("non-attenders"). Between January 13, 2021 and 30 November, 2021 self-sampling kits were distributed to non-attenders via an opportunistic offer in primary care when they consulted for any reason and direct mailout to those unscreened 15-months after routine invitation. Primary outcomes were the proportion of non-attenders screened each month; change in coverage; and uptake (90 days). YouScreen is registered with ISRCTN:12759467.

Findings

8338 women provided self-samples following recruitment between January 13, 2021 and 30 November, 2021. Self-samples were returned from 65.5% (6061/9248) who accepted an opportunistically offered kit and 12.9% (2777/17,604) directly-mailed kits. Responders were representative of the ethnically diverse and deprived underlying non-attendee population (64% ethnic minority groups, 60% from the two most deprived national quintiles). The self-sampling intervention resulted in a 22% (95% CI 18-26) increase in non-attenders screened per month (per-protocol analysis) and 12% (95% CI 9-15) (intention-to-treat analysis). Change in coverage at participating (mean intervention duration 7.5 months) vs non-participating practices was 1.6% (95% CI 0.4-2.8). Adverse effects were not formally collected.

Interpretation

Opportunistically offering self-sampling to under-screened women in primary care could increase coverage in England and potentially reach underserved populations.

Funding

North Central London and North East London Cancer Alliance.

Barriers to Cervical Cancer Screening: A Systematic Review

Cervical cancer remains a significant global health concern, particularly in underserved populations. Despite the availability of effective screening methods, uptake remains suboptimal in many regions. This systematic review aims to synthesize the current evidence on barriers to cervical cancer screening across diverse populations and healthcare settings. A comprehensive search of electronic databases was conducted to identify relevant studies published till June 2024. Studies examining barriers to cervical cancer screening in various populations were included. Data extraction and quality assessment were performed independently by two reviewers. A narrative synthesis approach was used to analyze and present the findings. Seventeen studies met the inclusion criteria, encompassing a wide range of study designs and populations. Common barriers identified across studies included lack of knowledge and awareness, economic constraints, access issues, cultural and religious factors, fear and embarrassment, and distrust in healthcare systems. Population-specific barriers were observed among immigrant and ethnic minority women, individuals in low- and middle-income countries, indigenous women, and LGBQ women. Healthcare system factors, socioeconomic influences, psychological and individual factors, and interpersonal and community dynamics also played significant roles in screening participation. This review highlights the complex and multifaceted nature of barriers to cervical cancer screening. Findings suggest that interventions to improve screening rates should be comprehensive, culturally sensitive, and tailored to specific population needs. Addressing both individual-level and systemic barriers is crucial for enhancing cervical cancer screening uptake globally.

Evaluation of a novel vaginal cells self-sampling device for human papillomavirus testing in cervical cancer screening: A clinical trial assessing reliability and acceptability

Cervical cancer is a significant public health concern, particularly in low- and middle-income countries where resources for prevention and treatment are limited. Routine screening, such as the Papanicolaou test (Pap smears) and human papillomavirus (HPV) testing, plays a crucial role in the early detection and prevention of cervical cancer. However, the participation rate in cervical cancer screening programs remains below optimal levels due to various factors. This study aimed to evaluate the reliability and acceptability of the HygeiaTouch Self Sampling Kit for Women in collecting vaginal samples for HPV typing, comparing the results with samples collected by physicians. The study included 1210 women aged 21-65 from three medical centers in Taiwan. The findings indicated that the self-sampling kit was as effective as physician-collected specimens in terms of obtaining valid samples and identifying HPV. The agreement between the two methods was 88%, with a κ value of 0.75. Furthermore, the study assessed the mechanical characteristics of the self-sampling applicator through tensile, bending, and torque tests, and determined that it was safe for intravaginal use. Additionally, the study evaluated the safety and satisfaction of self-sampling and found a low rate of adverse events (0.7%) and high levels of satisfaction (over 90%) among participants. Overall, we demonstrated that the HygeiaTouch Self Sampling Kit for Women is a reliable and acceptable device for HPV testing and cervical screening, providing a convenient, safe, and effective alternative for women.

Attitudes toward the American Cancer Society's 2020 cervical cancer screening guidelines: A qualitative study of a national sample of US clinicians

BACKGROUND

The 2020 American Cancer Society (ACS) guidelines are the most recent national guidelines for cervical cancer screening. These guidelines propose two major changes from current practice: initiating screening at age 25 years and using primary human papillomavirus (HPV) testing. Adoption of guidelines often occurs slowly, and therefore understanding clinician attitudes is important to facilitate practice change.

METHODS

Interviews with a national sample of clinicians who perform cervical cancer screening in a variety of settings explored attitudes toward the two major changes from the 2020 ACS cervical cancer screening guidelines. Clinicians participated in 30- to 60-min interviews exploring their attitudes toward various aspects of cervical cancer screening. Qualitative analysis was performed.

RESULTS

Seventy clinicians participated from across the United States. Few respondents were initiating screening at age 25 years, and none were using primary HPV testing. However, over half would be willing to adopt these practices if supported by scientific evidence and recommended by professional medical organizations. Barriers to adoption included the lack of endorsement by professional societies, lack of laboratory availability and insurance coverage, limited autonomy within large health care systems, and concerns related to missed disease.

CONCLUSIONS

Few clinicians have adopted screening initiation or primary HPV testing, as recommended by the 2020 ACS guidelines, but over half were open to adopting these changes. Implementation may be facilitated via professional organization endorsement, clinician education, and laboratory, health care system, and insurance support.

PLAIN LANGUAGE SUMMARY

In 2020, the American Cancer Society (ACS) released updated guidelines for cervical cancer screening. The main changes to current practices were to initiate screening at age 25 years instead of age 21 years and to screen using primary human papillomavirus (HPV) testing rather than cytology alone or in combination with HPV testing. We performed in-depth interviews with 70 obstetrics and gynecology, family medicine, and internal medicine physicians and advanced practice providers about their attitudes toward these guidelines. Few clinicians are following the 2020 ACS guidelines, but over half were open to changing practice if the changes were supported by evidence and recommended by professional medical organizations. Barriers to adoption included the lack of endorsement by professional medical organizations, logistical issues, and concerns about missed disease.

Are we ready for human papillomavirus testing? Assessment of patient knowledge of and preferences for cervical cancer screening in Ontario

OBJECTIVE

To determine patient knowledge and preferences about primary human papillomavirus (HPV) testing.

DESIGN

Cross-sectional survey.

SETTING

Two family practice clinics (urban and suburban) and the social media platforms of 2 hospitals in the greater Toronto area between January and February 2023.

PARTICIPANTS

A total of 413 Ontario residents aged 25 to 69 years, with a cervix, who qualified for Papanicolaou (Pap) screening and could communicate in English.

METHODS

Electronic survey containing questions about knowledge of, and preferences for, cervical cancer screening, including types of screening and screening intervals, and about education related to HPV and screening intervals.

MAIN FINDINGS

Of 441 potential participants, 426 were eligible and consented to participate in the study; ultimately 413 provided completed or partially completed surveys (96.9% response rate). Of those who completed a recent Pap test, 57.8% (208 of 360) knew of HPV testing. Initially, 27.8% thought HPV testing was better than Pap testing for cervical cancer screening. After learning HPV tests exist and have self-sampling options, most participants preferred HPV testing (self-sampling 46.3%, provider sampling 34.1%). Annual cervical cancer screening was preferred by 50.1% of participants despite knowing that, for most people, Pap tests should be conducted every 3 years (74.8%). After learning about HPV testing, participants were more likely to prefer 5-year screening intervals (43.8%); however, those in the family practice group were still more likely to prefer 3-year intervals compared with those in the social media group (P<.01).

CONCLUSION

Participants in this study identified a preference for HPV testing and self-sampling options. Concerns were raised about extended screening intervals and the safety of self-collected samples that need to be addressed in public health education initiatives during rollout of new screening programs.

Evaluating the effectiveness of cervical cancer screening and prevention in Singapore

Cervical cancer is the fourth most common cancer in women globally, with approximately 660,000 new cases and 350,000 deaths reported in 2022.1 In Singapore, it ranks as the 11th most common cancer among women and the 5th most frequent cancer among young women aged 15–44 years, with 309 new cases and 172 deaths reported in 2023.2 Worldwide, the highest incidence and mortality rates are observed in low- and middle-income countries, such as those in Africa, Melanesia and Southeast Asia, while the lowest rates are found in Western Asia, Australia-New Zealand and North America.1

Performance of CADM1, MAL and miR124-2 methylation as triage markers for early detection of cervical cancer in self-collected and clinician-collected samples: an exploratory observational study in Papua New Guinea

OBJECTIVE

WHO recommends human papillomavirus (HPV) testing for cervical screening, with triage of high-risk HPV (hrHPV) positive women. However, there are limitations to effective triage for low-resource, high-burden settings, such as Papua New Guinea. In this exploratory study, we assessed the performance of host methylation as triage tools for predicting high-grade squamous intraepithelial lesions (HSIL) in self-collected and clinician-collected samples.

DESIGN

Exploratory observational study.

SETTING

Provincial hospital, same-day cervical screen-and-treat trial, Papua New Guinea.

PARTICIPANTS

44 hrHPV+women, with paired self/clinician-collected samples (4 squamous cell carcinomas (SCC), 19 HSIL, 4 low-grade squamous intraepithelial lesions, 17 normal).

PRIMARY AND SECONDARY OUTCOME MEASURES

Methylation levels of CADM1, MAL and miR124-2 analysed by methylation-specific PCRs against the clinical endpoint of HSIL or SCC (HSIL+) measured using liquid-based-cytology/p16-Ki67 stain.

RESULTS

In clinician-collected samples, MAL and miR124-2 methylation levels were significantly higher with increasing grade of disease (p=0.0046 and p<0.0015, respectively). miR124-2 was the best predictor of HSIL (area under the curve, AUC 0.819) while MAL of SCC (AUC 0.856). In self-collected samples, MAL best predicted HSIL (AUC 0.595) while miR124-2 SCC (AUC 0.812). Combined miR124-2/MAL methylation yielded sensitivity and specificity for HSIL+ of 90.5% (95% CI 69.6% to 98.8%) and 70% (95% CI 45.7% to 88.1%), respectively, in clinician-collected samples, and 81.8% (95% CI 59.7% to 94.8%) and 47.6% (95% CI 25.7% to 70.2%), respectively, in self-collected samples. miR124-2/MAL plus HPV16/HPV18 improved sensitivity for HSIL+ (95.2%, 95% CI 76.2% to 99.9%) but decreased specificity (55.0%, 95% CI 31.5% to 76.9%).

CONCLUSION

miR124-2/MAL methylation is a potential triage strategy for the detection of HSIL/SCC in low-income and middle-income country.

Zipime-Weka-Schista study protocol: a longitudinal cohort study and economic evaluation of an integrated home-based approach for genital multipathogen screening in women, including female genital schistosomiasis, human papillomavirus, Trichomonas and HIV in Zambia

INTRODUCTION

Multiplathogen home-based self-sampling offers an opportunity to increase access to screening and treatment in endemic settings with high coinfection prevalence of sexually transmitted (HIV, Trichomonas vaginalis (Tv), human papillomavirus (HPV)) and non-sexually transmitted pathogens (Schistosoma haematobium (Sh)). Chronic coinfections may lead to disability (female genital schistosomiasis) and death (cervical cancer). The Zipime-Weka-Schista (Do self-testing sister!) study aims to evaluate the validity, acceptability, uptake, impact and cost-effectiveness of multipathogen self-sampling for genital infections among women in Zambia.

METHODS AND ANALYSIS

This is a longitudinal cohort study aiming to enrol 2500 non-pregnant, sexually active and non-menstruating women aged 15-50 years from two districts in Zambia with 2-year follow-up. During home visits, community health workers offer HIV and Tv self-testing and cervicovaginal self-swabs for (1) HPV by GeneXpert and, (2) Sh DNA detection by conventional (PCR)and isothermal (recombinase polymerase assay) molecular methods. Schistosoma ova and circulating anodic antigen are detected in urine. At a clinic follow-up, midwives perform the same procedures and obtain hand-held colposcopic images. High-risk HPV positive women are referred for a two-quadrant cervical biopsy according to age and HIV status. A cost-effectiveness analysis is conducted in parallel.

ETHICS AND DISSEMINATION

The University of Zambia Biomedical Research Ethics Committee (UNZABREC) (reference: 1858-2021), the London School of Hygiene and Tropical Medicine (reference: 25258), Ministry of Health and local superintendents approved the study in September 2021.Written informed consent was obtained from all participants prior to enrolment. Identifiable data collected are stored securely and their confidentiality is protected in accordance with the Data Protection Act 1998.

Strategies to accelerate the elimination of cervical cancer in British Columbia, Canada: a modelling study

BACKGROUND

To eliminate cervical cancer in Canada by 2040, defined as an annual age-standardized incidence rate (ASIR) lower than 4.0 per 100 000 women, the Canadian Partnership Against Cancer (CPAC) identified 3 priorities for action: increasing human papillomavirus (HPV) vaccine coverage, implementing HPV-based screening and increasing screening participation, and improving follow-up after abnormal screen results. Our objective was to explore the impact of these priorities on the projected time to elimination of cervical cancer in British Columbia.

METHODS

We used OncoSim-Cervical, a microsimulation model led and supported by CPAC and developed by Statistics Canada that simulates HPV transmission and the natural history of cervical cancer for the Canadian population. We updated model parameters to reflect BC's historical participation rates and program design. We simulated the transition to HPV-based screening and developed scenarios to explore the additional impact of achieving 90% vaccination coverage, 95% screening recruitment, 90% ontime screening, and 95% follow-up compliance. We projected cervical cancer incidence, ASIR, and year of elimination for the population of BC for 2023-2050.

RESULTS

HPV-based screening at current vaccination, participation, and follow-up rates can eliminate cervical cancer by 2034. Increasing on-time screening and follow-up compliance could achieve this target by 2031. Increasing vaccination coverage has a small impact over this time horizon.

INTERPRETATION

With the implementation of HPV-based screening, cervical cancer can be eliminated in BC before 2040. Efforts to increase screening participation and follow-up through this transition could potentially accelerate this timeline, but the transition from cytology- to HPV-based screening is fundamental to achieving this goal.

Performance of urine samples compared to cervical samples for detection of precancer lesions among HPV-positive women attending colposcopy clinic in Mexico City

BACKGROUND

High-risk human papillomavirus (hrHPV) detection in self-collected urine samples (SeCUS) may be a promising alternative for cervical cancer screening because of its greater acceptability, as long as it can offer comparable sensitivity to clinician-collected cervical samples (CCoS) for detecting precancer lesions.

OBJECTIVE

To evaluate the performance of the SeCUS compared to that of the CCoS for cervical intraepithelial neoplasia grade 3 (CIN3) detection among hrHPV-positive women receiving colposcopy in Mexico City using different specific extended HPV typing procedures: HPV16/18, HPV16/18/35/39/68 or HPV16/18/35/39/68/31.

METHODS

From March 2017 to August 2018, 4,158 female users of the cervical cancer screening program at Tlalpan Sanitary Jurisdiction in Mexico City were invited to participate in the FRIDA-Tlalpan study. All participants provided ≥ 30 mL of SeCUS, and then a CCoS was obtained with Cervex-Brush®, which was used for hrHPV typing. Participants who tested positive for hrHPV in CCoS were referred for colposcopy for diagnostic confirmation, and all SeCUS of these women were also tested for hrHPV typing.

RESULTS

In total, 561 hrHPV-positive women were identified by CCoS via colposcopy, and 82.2% of the SeCUS of these women were also hrHPV positive. From both CCoS and SeCUS, 7 cases of CIN3 were detected. Considering HPV16/18 typing, CCoS and SeCUS detected 4 cases of CIN3, but after HPV16/18/35/39/68/31 extension typing, both CCoS and SeCUS detected all 7 of the CIN3 cases among the hrHPV-positive women.

CONCLUSIONS

Using extended hrHPV typing based on HPV16/18/35/39/68/31, our results suggest that the performance of SeCUS may be equivalent to that of CCoS for detecting CIN3 lesions. Although our results are inconclusive, they support the hypothesis that SeCUS may be an attractive alternative worthy of further research.

HPV Self-Sampling in the Workplace: A Qualitative Study of Benefits, Barriers, and Opportunities for Improvement Perceived by Health Professionals and Managers

AIM

To inform the implementation of Human Papillomavirus Self-Sampling (HPV-SS) in the workplace, we assessed the perspectives of healthcare professionals and managers on the benefits, barriers, and opportunities for improvement of a pilot program.

METHODS

A qualitative descriptive study based on in-depth telephone interviews was conducted between June and August 2023. Data were analyzed through inductive thematic analysis. Fifteen health professionals from different companies and fifteen managers from the Mexican Institute of Social Security (IMSS) were interviewed.

RESULTS

Participants identified several benefits of the HPV-SS, including ease of use, privacy, convenience, affordability, reduced workplace absences, and promotion of a prevention culture. However, there were also individual and organizational barriers to program implementation. The former consisted of women's concerns about collecting a reliable sample or injuring themselves, lack of confidence in the HPV test, fear of positive results, and discomfort caused by the brush used to collect the sample. Organizational barriers included failure to follow up on positive test results, lack of knowledge of program indicators, perceived negative impact on the established Pap smear cervical cancer screening indicator, and the lack of government regulations supporting HPV testing. To improve the program, participants suggested disseminating information through mass media campaigns and social networks, providing companies with additional support from IMSS preventive staff, extending the work hours of IMSS Family Medicine clinics, and training IMSS health staff on the follow-up of women with HPV test results.

CONCLUSIONS

The study findings suggest potential areas for improvement in HPV-SS programs.

Comparative evaluation of Anyplex II HPV28 and Allplex HPV28 molecular assays for human papillomavirus detection and genotyping in anogenital cancer screening

Persistent infection with high-risk human papillomavirus (HPV) is recognized as the main cause for the development of anogenital cancers. This study prospectively evaluated the diagnostic performance of the novel Allplex-HPV28 assay with the Anyplex-II-HPV28 to detect and genotype HPV in 234 consecutive swabs and 32 biopsies of the anogenital tract from 265 patients with atypical findings in cytomorphological screening. Agreement in HPV-DNA detection between the Anyplex-II and Allplex-HPV28 assays was 99%. There was a notable diversity in the HPV-virome, with the most prevalent high-risk HPV types being 16, 53, 66, and 68. The agreement rates for detecting these genotypes exceeded 93% between the Anyplex-II and Allplex-HPV28 assays. Discrepancies in test results were solely noted for Anyplex-II-HPV28 results with a low signal intensity of "+", and for Allplex-HPV28 results with cycle thresholds of ≥36. The semi-quantitative analysis of HPV-DNA loads showed significant agreement between the Anyplex-II-HPV28 and Allplex-HPV28 assays (p < 0.001). Furthermore, HPV-DNA detection rates and mean HPV-DNA loads significantly correlated with the grade of abnormal changes identified in cytopathological assessment, being highest in cases of HSIL, condyloma accuminatum, and squamous cell carcinoma. Overall agreement rates for detecting specific HPV-types among the Anyplex-II and Allplex-HPV28 assays exceeded 99.5% in cases of atypical squamous cells, condyloma accuminatum, and squamous cell carcinoma. The novel Allplex-HPV28 assay shows good diagnostic performance in detecting and genotyping HPV commonly associated with anogenital cancers. Consequently, this assay could offer substantial potential for incorporation into future molecular screening programs for anogenital cancers in clinical settings.

What young women (aged 24-29 years) in Australia think about self-collection for cervical screening: a brief report

Background In mid-2022 Australia's National Cervical Screening Program made self-collection of a vaginal sample an option for screening for young women or people with a cervix aged 25 to 29 years for the first time. This study explored what young women thought about, and wanted to know about, self-collection, and what their future screening preferences are. Methods Young women (n =21), aged 24-29years, were recruited through social media. Semi-structured interviews explored screening history, screening preferences and thoughts about self-collection. Data were analysed using an a priori coding framework informed by the Theoretical Framework of Acceptability. Results Young women valued the addition of self-collection to the national cervical screening program, believing it to be less invasive and more convenient. However, they also valued the choice to opt for a clinician-collected specimen if preferred. Conclusions Self-collection is a valuable addition to the National Cervical Screening Program. This study suggests that continued efforts are needed to raise awareness of its availability, and improve understanding about its accuracy, the ease of collection, that you still need to engage with a primary healthcare service to access it and that you can still opt for a clinician-collected test.

Expanding eligibility and improving quality of cervical cancer screening in Estonia: The 2021 reforms

Estonia has one of the highest death rates from cervical cancer in the European Union despite having had a population-based screening programme for over 15 years. In 2021, this high disease burden, alongside a new national cancer prevention plan, prompted a series of cervical cancer screening programme reforms to address low screening uptake and evidence of variable screening test quality. The reforms had three main elements: expansion of eligibility to all women aged 30-65 regardless of insurance status; increasing test provision by enabling family physicians to take screening samples and introducing self-sampling; and improving testing procedures, replacing cytology with HPV testing as the primary screening test. Although the impact of these changes is yet to be seen, early signs suggest increased programme participation. However, at 51 %, further action to address barriers to uptake will likely be necessary. If Estonia is to avoid another period of policy dormancy, as happened between 2006 and 2021, greater clarity on screening programme accountability is required. The establishment of the National Cancer Screening Group may enable this. The first test will be the delivery of an end-to-end evaluation of the reformed programme, with an emphasis on equity of access. The next step will be to develop and deliver solutions that respond to these needs.

Evaluation of two alternative non-alcohol-based media for the suspension of self-collected vaginal swabs for HPV testing in cervical cancer screening

The introduction of Human Papillomavirus (HPV) testing in cervical cancer screening enhanced the opportunity to introduce self-collection as an innovative approach to improve coverage rates. Validation and standardization of the pre-analytical and analytical procedures are crucial for the quality assurance of HPV tests on self-collected samples. This study evaluated the analytical performance and the stability of self-collected vaginal samples resuspended in 5 mL of two non-alcohol-based media, eNat® and MSwab® compared to a professionally collected cervical sample, resuspended in 20 mL ThinPrep®, for the detection of high-risk HPV (hrHPV). The impact of the suspension volumes on analytical performance was also evaluated (2 and 5 ml). A good analytical concordance in hrHPV detection in cervical and vaginal self-collected swabs suspended in 5 ml of both non-alcohol-based media was demonstrated (eNat®: 91.2 %, k = 0.821; MSwab®: 91.4 %; k = 0.798). A similar analytical performance was found for samples resuspended in 2 mL (eNat®: 92.9 %, k = 0.811; MSwab®: 92.9 %, k = 0.811) compared to cervical samples. Good nucleic acid stability was demonstrated for vaginal samples stored at 20-25 °C and 37 °C for up to 4 weeks. Results of this preliminary study support the introduction of these media for vaginal self-sampling-based prevention programs. Nevertheless, further research is necessary to evaluate clinical accuracy in larger settings.

Acceptance of Self-Sampling by Women Not Regularly Participating in Cervical Cancer Screening in Areas with Low Medical Density: A Qualitative Study within the French CapU4 Trial

Cervical cancer (CC) was diagnosed in 3159 women in France in 2023, and 1117 died from it. Organized screening for cervical cancer is potentially very effective for participating women. However, reaching under-screened populations remains a major challenge. The present qualitative study explored women's opinions on what discourages or encourages them to participate in CC screening and assessed the acceptability of two experimental strategies (urinary or vaginal self-sampling kits) to increase the screening coverage in three rural French administrative departments with low medical density and/or low screening participation rates. Forty-eight semi-structured interviews and four focus groups were conducted by a team of psychologists. Results showed that the participants accepted at-home self-sampling to reach non-participating women in medically underserved areas. However, they suggested that the type of kit sent should be adapted to the patient's profile (embarrassment from earlier exams, cultural aspects, fear of invasiveness, etc.), and that kits should be simple to use (in understandable language taking sociocultural aspects into account). Women wished to be assured that testing on self-samples is accurate and needed information about further actions in case of a positive result.

Proof of Concept Study: Comparability of Microbiome Diversity in Self- and Physician-Collected HPV-Positive and HPV-Negative Cervicovaginal Samples

Recent studies have revealed the impact of human papillomavirus (HPV) infections on the cervicovaginal microbiome; however, few have explored the utility of self-collected specimens (SCS) for microbiome detection, obtained using standardised methods for HPV testing. Here, we present a proof-of-concept analysis utilising Oxford Nanopore sequencing of the 16S rRNA gene in paired samples collected either by the patient using an Evalyn Brush or collected by a physician using liquid-based cytology (LBC). We found no significant differences in the α-diversity estimates between the SCS and LBC samples. Similarly, when analysing β-diversity, we observed a close grouping of paired samples, indicating that both collection methods detected the same microbiome features. The identification of genera and Lactobacillus species in each sample allowed for their classification into community state types (CSTs). Notably, paired samples had the same CST, while HPV-positive and -negative samples belonged to distinct CSTs. As previously described in other studies, HPV-positive samples exhibited heightened bacterial diversity, reduced Lactobacillus abundance, and an increase in genera like Sneathia or Dialister. Altogether, this study showed comparable results between the SCS and LBC samples, underscoring the potential of self-sampling for analysing the microbiome composition in cervicovaginal samples initially collected for HPV testing in the context of cervical cancer screening.

Diagnostic Accuracy of DNA-Methylation in Detection of Cervical Dysplasia: Findings from a Population-Based Screening Program

BACKGROUND

Epigenetic biomarkers in cancer have emerged as promising tools for early detection, prognosis, and treatment response prediction. In cervical cells, hypermethylation of the host and viral HPV-genome increases with the severity of lesions, providing a useful biomarker in the triage of hr-HPV-positive women and during treatment. The present study focuses on evaluating the clinical performance of the FAM19A4/miR124-2 methylation test in a population-based cervical screening program.

METHODS

Previously collected cervical samples, after bisulfite-converted DNA, were analyzed by PreCursor-M+ kit (distributed by Fujirebio Europe), for DNA methylation. The sensitivity, specificity, and negative/positive predictive values of DNA methylation were compared to histology, colposcopy, the HPV-DNA test, and cytology results.

RESULTS

Among the 61-sample set, the specificity of methylation vs. positive histology (≥CIN2) and colposcopy (≥G2) were 87% and 90%, whereas the sensitivity was 50% and 33.3%, respectively. The combination of methylation analysis with standard methods increases diagnostic accuracy.

CONCLUSIONS

Overall, we found a good specificity of DNA methylation in comparison to currently used techniques. Further larger studies could support the use of FAM19A4/miR124-2 as reliable biomarkers in the prevention of cervical cancer as triage in the screening protocol.

Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries

This article presents global cancer statistics by world region for the year 2022 based on updated estimates from the International Agency for Research on Cancer (IARC). There were close to 20 million new cases of cancer in the year 2022 (including nonmelanoma skin cancers [NMSCs]) alongside 9.7 million deaths from cancer (including NMSC). The estimates suggest that approximately one in five men or women develop cancer in a lifetime, whereas around one in nine men and one in 12 women die from it. Lung cancer was the most frequently diagnosed cancer in 2022, responsible for almost 2.5 million new cases, or one in eight cancers worldwide (12.4% of all cancers globally), followed by cancers of the female breast (11.6%), colorectum (9.6%), prostate (7.3%), and stomach (4.9%). Lung cancer was also the leading cause of cancer death, with an estimated 1.8 million deaths (18.7%), followed by colorectal (9.3%), liver (7.8%), female breast (6.9%), and stomach (6.8%) cancers. Breast cancer and lung cancer were the most frequent cancers in women and men, respectively (both cases and deaths). Incidence rates (including NMSC) varied from four-fold to five-fold across world regions, from over 500 in Australia/New Zealand (507.9 per 100,000) to under 100 in Western Africa (97.1 per 100,000) among men, and from over 400 in Australia/New Zealand (410.5 per 100,000) to close to 100 in South-Central Asia (103.3 per 100,000) among women. The authors examine the geographic variability across 20 world regions for the 10 leading cancer types, discussing recent trends, the underlying determinants, and the prospects for global cancer prevention and control. With demographics-based predictions indicating that the number of new cases of cancer will reach 35 million by 2050, investments in prevention, including the targeting of key risk factors for cancer (including smoking, overweight and obesity, and infection), could avert millions of future cancer diagnoses and save many lives worldwide, bringing huge economic as well as societal dividends to countries over the forthcoming decades.

Performance of a vaginal self-collection device versus clinician collected cervical samples for the detection of high-risk human papillomavirus

Objective

Screening for cervical cancer requires the participation of target women. Human papillomavirus (HPV) testing can be performed on vaginal self-samples and self-sampling can improve this participation. This study aims to validate the performance of the vaginal self-sampling device (Vitroveil®) to detect high risk human papillomavirus (hrHPV) in comparison to clinician collected samples and evaluate the degree of acceptability of the Vitroveil® device.

Methods

A cross-sectional observational study was carried out in a cohort of 385 participating women (median age of 44 ± 10.47 years) attending primary care centers and cervical pathology services of Granada, Spain. Two paired samples (vaginal self-sample and clinician collected cervical sample) where collected from each participant to compare the detection of HPV with the Vitro HPV Screening assay (Vitro, Granada, Spain). A questionnaire was also provided to the participants to analyze the degree of satisfaction with the device and the preference for sampling method.

Results

Overall concordance for hrHPV detection was substantial (ĸ 0.804). The prevalence of any hrHPV infection was higher in self-collected samples (30.6%) than in clinician-collected samples (24.3%). The participants found the self-sampling device easy to use and preferred self-collection as the collection method.

Conclusion

The Vitroveil® self-sampling device enables safe and accruable hrHPV testing, obtaining equivalent results to those of the clinician collected samples. High acceptability of the device has been demonstrated among women in the study. Nevertheless, additional studies are necessary to verify the efficacy and reliability of the device's performance.

Acceptance of Self-Sampling and Knowledge about Human Papillomavirus among Women in Mongolia

BACKGROUND

Mongolia faces a significant burden of cervical cancer, with the highest prevalence of Human Papillomavirus (HPV) in the region. Cervical cancer ranks as the third most common cancer among women in the country. This study aimed to assess the acceptance of self-sampling among young women in Mongolia and evaluate their knowledge regarding HPV and cervical cancer.

METHODS

In this study, participants provided a self-administered vaginal swabs to detect high-risk HPV genotypes. Both acceptability of self-sampling using swabs and participants knowledge regarding HPV and cervical cancer through a scored questionnaire were assessed.  The knowledge scale was categorized into three groups: low (0-2), moderate (3-4) and high (5-6).

RESULTS

A total of 203 women aged 24-28 years completed the questionnaire and provided self-administered vaginal swabs. The majority (95.1%) found self-sampling technique using Copan Self Vaginal FLOQSwabs® easy to perform. Additionally, 98.5% indicated that the self-swab instructions were clear and comprehensive, while 94.1% reported no pain during the process. Furthermore, 67.8% of participants expressed a preference for performing the swab in a clinic rather than at home. All respondents chose self-sampling due to greater personal privacy, tranquility, reduced anxiety and time optimization. The questionnaire results revealed an overall low level of knowledge about HPV among participants, with a mean score at 1.9 out of 6 [95%CI 1.67-2.21] and a moderate level of knowledge regarding cervical cancer risks, with a mean score at 3.7 out of 6 [95%CI 3.19-4.21]. This pattern was consistent across both vaccinated and unvaccinated cohorts, indicating a strong demand for enhanced awareness of HPV and cervical cancer.

CONCLUSIONS

This study demonstrates the high acceptance of self-sampling among young women aged 24-28 years in Mongolia. However, it also  underscores a significant need for improved awareness initiatives concerning HPV and cervical cancer in Mongolia.

Practitioners support and intention to adopt universal access to self-collection in Australia's National Cervical Screening Program

OBJECTIVE

Primary care practitioners are crucial to engaging people in Australia's national cervical screening program. From July 2022, practitioners have been able to offer all screen-eligible people the choice to collect their own self-collected sample; an option introduced to increase equity. This study explored how practitioners are intending to incorporate universal access to self-collection into their clinical care.

METHODS

Semi-structed interviews with 27 general practitioners, nurses, and practice managers from 10 practices in Victoria, Australia conducted between May and August 2022. Interviews were deductively coded, informed by the Consolidated Framework for Implementation Research. The Diffusion of Innovations theory was used to categorise intention to provide self-collection.

RESULTS

Participants were supportive of universal access to self-collection, citing benefits for screen-eligible people and that it overcame the limited adaptability of the previous policy. Most participants' practices (n = 7, 70%) had implemented or had plans to offer the option for self-collection to all. Participants deliberating whether to provide universal access to self-collection held concerns about the correct performance of the self-test and the perceived loss of opportunity to perform a pelvic examination. Limited time to change practice-level processes and competing demands within consultations were anticipated as implementation barriers.

CONCLUSIONS

The extent to which self-collection can promote equity within the program will be limited without wide-spread adoption by practitioners. Communication and education that addresses concerns of practitioners, along with targeted implementation support, will be critical to ensuring that self-collection can increase participation and Australia's progression towards elimination of cervical cancer.

Feasibility and applicability of self-sampling based online cervical cancer screening: findings from the China online cervical cancer screening trial

OBJECTIVE

This study aims to evaluate the feasibility and applicability of an online cervical cancer screening program using a website as the public platform and self-collected HPV testing as the primary screening method.

METHODS

A website (mcareu.com) was developed to facilitate the online cervical cancer screening program by Peking University Shenzhen Hospital (PUSH). Women in Shenzhen could register for participation on the website by providing essential demographic data. Sampling kits and specimens were delivered through regular logistics. Eligible women collected vaginal samples by themselves using the provided kits and in referring of the graphic guidance. The specimens were tested for HPV at PUSH or a reference lab, and the results were accessible on the website through participants' personal accounts. Participants who tested positive for high-risk HPV were scheduled for colposcopy and biopsies. The demographic and social background data of the eligible participants were analyzed to evaluate the feasibility and applicability of the online screening approach.

RESULTS

A total of 1712 applicants registered for participation, with 99.9% (1710/1712) completing registration with full data. The analysis included 1560 applicants aged 30-59, with an average age of 41.1 (± 7.6) years. Among them, 83.3% (1299/1560) provided self-collected samples for testing. Age-group analysis revealed an overall sample provision rate (SPR) exceeded 80% in all age groups. A significant difference in SPR was observed only between the 30-34 and 45-49 age groups (p < 0.05), while no significant differences were found among other age groups. 99.7% of the samples were tested qualified, and there was no significant difference in sampling failure rate among age groups. Analysis of demographic and social elements showed no significant impact on the rates of sample provision among groups in most of the social elements but the medical insurance and the monthly family-incomes.

CONCLUSION

The findings demonstrate that online cervical cancer screening is reliable for self-registration, self-sampling, and self-ordering for specimen transportation. It is suitable for women of all ages needing to be screened, irrespective of social elements, and effectively facilitates screening for women with limited access to medical resources. Therefore, online screening holds promise as an effective approach to increase screening coverage.