Human papillomavirus self-sampling for long-term non-attenders in cervical cancer screening: A randomised feasibility study in Estonia

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.

Citizens' perspectives on relocating care: a scoping review

BACKGROUND

Healthcare systems around the world are facing large challenges. There are increasing demands and costs while at the same time a diminishing health workforce. Without reform, healthcare systems are unsustainable. Relocating care, for example, from hospitals to sites closer to patients' homes, is expected to make a key contribution to keeping healthcare sustainable. Given the significant impact of this initiative on citizens, we conducted a scoping review to provide insight into the factors that influence citizens' attitudes towards relocating care.

METHOD

A scoping review was conducted. The search was performed in the following databases: Pubmed, Embase, Cinahl, and Scopus. Articles had to include relocating healthcare and citizens' perspectives on this topic and the articles had to be about a European country with a strong primary care system. After applying the inclusion and exclusion criteria, 70 articles remained.

RESULTS

Factors positively influencing citizens' attitudes towards relocating care included: convenience, familiarity, accessibility, patients having more control over their disease, and privacy. Factors influencing negative attitudes included: concerns about the quality of care, familiarity, the lack of physical examination, contact with others, convenience, and privacy. Furthermore, in general, most citizens preferred to relocate care in the studies we found, especially from the hospital to care provided at home.

CONCLUSION

Several factors influencing the attitude of citizens towards relocating care were found. These factors are very important when determining citizens' preferences for the location of their healthcare. The majority of studies in this review reported that citizens are in favour of relocating care. In general citizens' perspectives on relocating care are very often missing in articles. It was significant that very few studies on relocation from the hospital to the general practitioner were identified.

Comparison of diagnostic accuracy and acceptability of self-sampling devices for human Papillomavirus detection: A systematic review

Objective

Cervical cancer screening coverage remains low in many countries worldwide. Self-sampling approach for cervical cancer screening has a good potential to improve the screening coverage. This study aims to compare different types of HPV self-sampling devices for cervical cancer screening to identify the most accurate and acceptable device(s).

Methods

A systematic review was performed on data extracted from all studies specific to HPV self-sampling devices by searching relevant articles in PubMed, Google Scholar, Scopus, Web of Science, ScienceDirect, Cochrane Library, and EBSCO published from 2013 to October 2023. The study was registered in PROSPERO (CRD42022375682).

Results

Overall, 70 papers met the eligibility criteria for this systematic review and were included in the analysis: 22 studies reported self-sampling devices diagnostic accuracy, 32 studies reported self-sampling devices acceptability and 16 studies reported both (accuracy and acceptability). The most popular self-sampling devices were Evalyn Brush, FLOQ Swab, Cervex-Brush, and Delphi Screener. Out of overall 38 studies analyzing self-sampling devices' diagnostic accuracy, 94.7% of studies reported that self-collected specimens provided sensitivity and specificity comparable with clinician-collected samples; acceptability of Evalyn Brush, FLOQ Swab, Delphi Screener, and Colli-Pee, varied between 84.2% and 100%.

Conclusion

The self-sampling approach has a good potential to increase cervical cancer screening coverage. Evalyn Brush, Cervex-Brush, FLOQ Swab, and Delphi Screener self-sampling devices for HPV detection were the most commonly utilized and found to be the most accurate, and patient-acceptable. HPV detection accuracy using these self-sampling devices had no significant difference compared to the sampling performed by healthcare providers.

Age-specific and genotype-specific carcinogenic human papillomavirus prevalence in a country with a high cervical cancer burden: results of a cross-sectional study in Estonia

OBJECTIVES

To describe age-specific and type-specific carcinogenic human papillomavirus (HPV) prevalence prior to large-scale effect of HPV vaccines in Estonia and to analyse the risk factors associated with carcinogenic HPV.

DESIGN

Cross-sectional study using self-administered questionnaire and self-collected vaginal swabs for detection of HPV infection.

SETTING

Estonian Biobank database.

PARTICIPANTS

Stratified random sample of women aged 30-33, 57-60 and 67-70 years living in one of the three largest counties in Estonia. Of 3065 women approached, 1347 (43.9%) returned questionnaires and specimens for HPV DNA detection.

OUTCOME MEASURES

HPV prevalence and fully adjusted ORs with 95% CIs for risk factors.

RESULTS

HPV prevalence was highest among women aged 30-33 years (18.7%; 95% CI 15.8 to 21.9) followed by those aged 67-70 years (16.7%; 95% CI 12.4 to 22.0) and 57-60 years (10.2%; 95% CI 7.8 to 13.3). HPV16 and HPV56 were the most common among women aged 30-33 years (both 4.0%; 95% CI 2.7 to 5.9), and HPV68 was the most common among women aged 57-60 years (2.8%; 95% CI 1.5 to 4.7) and 67-70 years (6.4%; 95% CI 3.6 to 10.4). Vaccination with nonavalent vaccine would have halved the carcinogenic HPV prevalence among women aged 30-33 years. The odds of infection with carcinogenic HPV were higher among women with six or more sexual partners among younger (OR 2.99; 95% CI 1.54 to 5.81) and older (OR 3.80; 95% CI 1.25 to 11.55) women and lower (OR 0.35; 95% CI 0.17 to 0.72) among younger married women.

CONCLUSIONS

This study demonstrated U-shaped age-specific genotype profile of carcinogenic HPV prevalence, indicating that public health providers should focus on developing exit strategies for the cervical cancer screening programme in Estonia with a possible extension of HPV testing beyond the current screening age of 65 years. Generalisability of the findings of this study may be affected by the low response rate.

Facilitators and Barriers to HPV Self-Sampling as a Cervical Cancer Screening Option among Women Living with HIV in Rural Uganda

Background: There is a paucity of studies exploring women living with HIV's (WLWH) experiences relating to human papillomavirus (HPV) self-sampling as cervical cancer (CC) screening approach, either at the clinic or at the home setting, using qualitative methods. Our study explored facilitators and barriers to HPV self-sampling as a CC screening approach among human immunodeficiency virus (HIV)-infected women, as supported by the new WHO guidelines of using the HPV test as a screening modality. Methods: The study was guided by the health promotion model (HPM), which helps individuals achieve higher levels of well-being. The phenomenology design was used to explore the deeper facilitators and barriers of women regarding self-sampling, either at home or in clinical settings, at Luweero District Hospital, Uganda. The in-depth interview (IDI) guide was translated from English to Luganda. Qualitative data analysis was guided by content analysis techniques. The transcripts were coded in NVivo 20.7.0. The coded text was used to generate categories of analytically meaningful data that guided the formation of themes, the interpretation of results, and the final write-up. Results: WLWH were motivated to screen for HPV using the clinic-based approach because of perceived early diagnosis and treatment, visualization of the cervix, and free service, while reduced distance, privacy and the smooth sample collection kit were motivators for the home-based approach. A barrier that cut across the two HPV self-sampling approaches was a lack of knowledge about HPV. The barriers to clinic-based HPV self-sampling screening included lack of privacy, perceived painful procedures for visual inception under acetic acid (VIA), and fear of finding the disease. Stigma and discrimination were reported as the major barriers to the home-based HPV self-sampling approach. The major reasons why some WLWH refused to screen were fear of finding the disease, stress, and financial disruptions related to being diagnosed with CC disease. Conclusions: Therefore, early diagnosis for HPV and CC enhances clinic-based HPV self-sampling, while privacy enhances the home-based HPV self-sampling approach. However, fear of finding a disease and the lack of knowledge of HPV and CC hinders HPV self-sampling. Finally, designing pre- and post-testing counselling programs in HIV care is likely to increase the demand for HPV self-sampling.

Offering HPV self-sampling kits: an updated meta-analysis of the effectiveness of strategies to increase participation in cervical cancer screening

BACKGROUND

Human papillomavirus (HPV) testing on self-samples represents a great opportunity to increase cervical cancer screening uptake among under-screened women.

METHODS

A systematic review and meta-analysis on randomised controlled trials (RCTs) were performed to update the evidence on the efficacy of strategies for offering self-sampling kits for HPV testing compared to conventional invitations and to compare different self-sampling invitation scenarios. Four experimental invitational scenarios were considered. Women in the control group were invited for screening according to existing practice: collection of a cervical specimen by a healthcare professional. Random-effects models were used to pool proportions, relative participation rates and absolute participation differences.

RESULTS

Thirty-three trials were included. In the intention-to-treat analysis, all self-sampling invitation scenarios were more effective in reaching under-screened women compared to controls. Pooled participation difference (PD) and 95% confidence interval (CI) for experimental vs. control was 13.2% (95% CI = 11.0-15.3%) for mail-to-all, 4.4% (95% CI = 1.2-7.6%) for opt-in, 39.1% (95% CI = 8.4-69.9%) for community mobilisation & outreach and 28.1% (23.5-32.7%) for offer at healthcare service. PD for the comparison opt-in vs. mail-to-all, assessed in nine trials, was -8.2% (95% CI = -10.8 to -5.7%).

DISCUSSION

Overall, screening participation was higher among women invited for self-sampling compared to control, regardless of the invitation strategy used. Opt-in strategies were less effective than send-to-all strategies.

Cervical cancer screening history among women diagnosed with cervical cancer in Estonia 2017-18

BACKGROUND

Despite the national cervical cancer screening programme launched in 2006, Estonia has one of the highest cervical cancer incidence rates in Europe. While the overall coverage of cervical cytology is high, the factors related to cancer screening history prior to cancer diagnosis need to be studied.

METHODS

In this study, we aimed to examine the 10-year screening history of women diagnosed with cervical cancer in Estonia in 2017-18, using data collected from laboratory reports from 2007 to 2018. From each report, we extracted information on the date and result of cytology and on the laboratory where the sample was assessed. We analysed these data across cancer histology, the time interval between the last test result and cancer diagnosis and the laboratory type (local or regional).

RESULTS

Among 319 women with cervical cancer, 181 (56.7%) did not have any cytology reports available. Among 138 women with at least one cytology, 60% had 1-3, 24% 4-6 and 16% ≥7 tests (mean 3.7) before cancer. In 78% of women, the last test was performed less than 5 years before cancer diagnosis and 62% of these tests did not report any abnormalities. The last cytology results differed significantly between the regional and local laboratories (P = 0.028).

CONCLUSION

Women received the cervical cancer diagnosis in Estonia despite having several screening tests 10 years prior to the diagnosis. The proportion of cytology tests without any abnormalities less than 5 years before the diagnosis was worryingly high and needs further investigation together with the difference between laboratory types.

Inequalities in reported use of cervical screening in Estonia: results from cross-sectional studies in 2004-2020

BACKGROUND

Despite the national cervical cancer (CC) screening program established in 2006, the CC incidence in Estonia in 2020 was still one of the highest in Europe. To better understand the possible barriers among women, the aim of this study was to describe the inequalities in the Pap smear uptake trend in 2004-2020 and to analyse the associations between different factors in Estonia.

METHODS

Weighted data of 25-64-year-old women (N = 6685) from population-based cross-sectional studies of Health Behaviour among Estonian Adult Population in 2004-2020 was used. Linear trends in uptake of Pap smear over time were tested using the Cochrane-Armitage test. Binary logistic regression with interactions was performed to analyse associations between the uptake of Pap smear and sociodemographic, socioeconomic, health-related and lifestyle factors. Crude and adjusted odds ratios with 95% confidence intervals were calculated.

RESULTS

Prevalence of lifetime uptake of Pap smear increased in 2004-2020 from 50.6 to 86.7% (P < 0.001). From 2004 to 2020, uptake of Pap smear increased significantly among women aged 25-34, 35-44, 45-54 and 55-64, in both ethnicity groups and among women with basic, secondary and higher education (P < 0.001). The gap in Pap smear uptake increased between Estonians and non-Estonians but decreased between education levels over time. Lower lifetime uptake of Pap smear was associated from sociodemographic factors with younger age, being non-Estonian and single, from socioeconomic factors with lower educational level and unemployment, from health indicators with higher body mass index indicating overweight and obesity, presence of chronic disease and depressiveness, and from lifestyle factors with non-smoking.

CONCLUSIONS

Although Pap smear uptake among 25-64 year old women increased significantly in Estonia in 2004-2020, inequalities were found indicating an opportunity for development of targeted CC prevention strategies.

Design of a pragmatic randomized controlled trial of home-based human papillomavirus (HPV) self-sampling for increasing cervical cancer screening uptake in a U.S. healthcare system: The STEP trial

BACKGROUND

Mailing HPV self-sampling kits to overdue individuals increases cervical cancer screening adherence; offering self-sampling to previously adherent individuals has not been evaluated in the U.S. Given heterogeneity of the U.S. health system and population, data are needed to optimize how HPV self-sampling is offered to individuals who are overdue, due after successful past screening, or have an unknown screening history.

METHODS

STEP is a pragmatic randomized controlled trial set within a U.S. integrated healthcare delivery system, designed to compare different outreach approaches for offering HPV self-sampling in populations defined by prior screening behavior (previously-adherent, overdue, or unknown screening history). Over 14 months, eligible individuals were identified through electronic medical record (EMR) data and randomized to Usual Care (UC), Education (UC + educational materials about cervical cancer screening), Direct-Mail (UC + Education + a mailed self-sampling kit) or Opt-In (UC + Education + option to request a kit), depending on screening history. The primary objective is to compare screening completion by outreach approach and screening history. Secondary objectives include evaluating incremental cost-effectiveness of outreach approaches, and identifying patient preference for, and satisfaction with, HPV self-screening, and barriers to abnormal results follow-up (measured through interviews and focus groups).

CONCLUSIONS

The trial was designed to generate data that U.S. health systems can use to inform primary HPV screening implementation strategies that incorporate HPV self-sampling options to improve screening access, adherence, and patient satisfaction. The objective of this report is to describe the rationale and design of this pragmatic trial.