The Self-Screening Superpower: Taking Control of Cervical Cancer

A Public Health Crisis

Undressed, legs spread open, lying under fluorescent lights as a stranger pokes and prods at your genitals. This is the uncomfortable experience of many assigned females during their Pap test, a routine but invasive cancer screening examination of the cervix, which connects the womb to the vaginal canal. But what if you could screen cervical cancer from the comfort of your own home? Human papillomavirus (HPV) self-sampling (SS) is an innovative screening strategy to optimize early detection of cervical cancer. As the fourth most common cancer in women worldwide (Arbyn et al., 2020), 99% of cervical cancer is caused by high-risk HPV infection (World Health Organization [WHO], 2022). However, it can be cured if detected and treated early (WHO, 2022). SS kits allow people with a cervix (encompassing women, Two-Spirit, transgender and gender-diverse individuals) to use a swab to collect a vaginal sample at home and mail it to a laboratory for testing (WHO, 2022). If high-risk HPV strains are detected, the patient is connected to follow-up clinical assessments. However, a debate remains: is SS an effective solution to reduce cervical cancer or is it a far-fetched dream that can’t realistically be nationally implemented?

The Superpowers of Self-Sampling

Despite the pervasiveness of cervical cancer, 25% of women in the United States don’t undergo their recommended screening (White, 2017). Individuals from equity-seeking social locations such as 2SLGBTQI+ individuals, Black and Indigenous women, women from a low socioeconomic status, and women with disabilities are disproportionately impacted by cervical cancer, yet they are the least likely to undergo recommended screening (Charlebois & Kean, 2024). They may face obstacles such as difficulties accessing a family physician, incompatible clinic hours, lack of transportation (especially for northern, remote, isolated communities), cultural concerns about modesty, and indirect costs, such as childcare or booking time off work (Madzima et al., 2017).

However, SS is a possible solution to reach these underdiagnosed populations. Completed in the privacy of one’s home, SS has been found to have a high acceptability among under-screened demographics, who report less embarrassment, pain, anxiety, and discomfort than in Pap tests (Madzima et al., 2017). SS has increased screening uptake in underscreened populations, almost doubling participation in cervical cancer screening services (WHO, 2022). In a study of 697 women from low-income backgrounds, mailed SS kits increased uptake of cervical cancer screening when compared to usual care (help scheduling in-clinic appointments), with 78% returning their SS sample for testing (Pretsch et al., 2023).

SS can also be an empowering process. Women that have experienced intimate partner violence (IPV) and sexual trauma face a greater risk of cervical cancer as they are subjected to worse social determinants of health (such as unemployment, limited education, or a low income) yet also have lower cervical cancer screening rates due to feelings of retraumatization during in-clinic pelvic exams (Madding et al., 2024). Interviews of women with a history of IPV found they preferred SS over clinician-administered sampling due to an increased sense of autonomy, safety, and control (Madding et al., 2024).

Furthermore, SS execution is highly feasible, with positive outcomes seen in countries that have already begun to implement it. It has been shown to be more cost-effective and more sensitive at detecting HPV when compared to clinician-collected Pap test samples (Charlebois & Kean, 2024). Australia initiated universal HPV SS in 2022, with 40% of individuals overdue for screening using SS methods and leading to increased rates in remote areas and Indigenous communities (Charlebois & Kean, 2024). By increasing accessibility, convenience, and comfort in a feasible and highly validated method, SS decreases health inequities for individuals who need it the most.

The Struggles of Self-Sampling

            Despite the many benefits it offers for hard-to-reach populations, SS also presents new challenges. Mailed SS kits are not necessarily accessible to all underscreened populations, as they require a mailing address for kit delivery, a safe and private location for sample collection, and transportation to clinics if follow-up care is necessary. Additionally, many women report concerns regarding sampling accuracy, both due to lack of confidence in their own specimen self-collection abilities and lack of trust in the results (Madzima et al., 2017). If samples are inadequately collected, there might be an overreporting of negative tests (indicating no HPV when in reality HPV is present). Even if the test correctly detects the presence of HPV, there are still low rates of follow-up care participation after diagnosis (Wang & Coleman, 2023). Women in the United States report lack of healthcare coverage as a major barrier to follow-up care (Madzima et al., 2017). In Canada, only British Columbia and Prince Edward Island have implemented free SS as the primary screening strategy for cervical cancer (Canadian Partnership Against Cancer, 2024). These obstacles disproportionately impact equity-seeking communities, including Black women or women of low socioeconomic status (Wang & Coleman, 2023). So, although SS increases screening uptake, it may not actually decrease cancer incidence rates if women are unable to access follow-up treatment. SS can also create tensions within marriage, as some women face accusations of untrustworthiness and infidelity when testing for sexually transmitted HPV, leading to avoidance of screening (Madzima et al., 2017). By presenting logistical, systemic, and relationship challenges, SS may perpetuate health disparities in cervical cancer screening.

Somewhere in Between

            SS has been shown to be a highly accessible, acceptable and feasible alternative to Pap tests, with the ability to increase early detection and treatment of cervical cancer within equity-denied populations (Madzima et al., 2017). However, in order to be successfully implemented, SS interventions require more than simply mailing a kit; each stage of the process needs to be considered, from recruitment to screening to follow-up care. Instead of only relying on medical clinic recruitment sources, community outreach programs based on geographical social and material deprivation indexes can help recruit hard-to-reach, underscreened populations (Canadian Partnership Against Cancer, 2024; Pretsch et al., 2023). The dissemination of information about the benefits, efficacy, and the correct specimen collection process should be provided to women to increase confidence in and knowledge of HPV screening, harnessing culturally-relevant communication methods, both formally (public service announcements) and informally (social media and phone texts), to prompt follow-up appointment reminders and provide information on SS guidelines. Policy reforms that facilitate follow-up linkage after a positive test result should be implemented. Using a holistic, multicomponent approach that combines SS with reminder letters and personal contact with physicians to provide explanations of test results has been shown to improve follow-up adherence (Madzima et al., 2017). As well, follow-up participation can be enhanced by enlisting community health workers to encourage feelings of trust and safety, offering mobile treatment to reduce transportation barriers, and pre-booking follow-up appointments. As much of the current research is limited to cisgender women, future studies should include all individuals who have a cervix to ensure the wider generalizability of findings. Ultimately, if appropriately implemented, SS is a self-empowering game changer that can reduce cervical cancer and begin to dismantle systemic health inequities.

Maya Druss-Wong (She/Her), 4th year BSc Psychology, Queen's University. 

References

Arbyn, M., Weiderpass, E., Bruni, L., de Sanjosé, S., Saraiya, M., Ferlay, J., & Bray, F. (2020). Estimates of incidence and mortality of cervical cancer in 2018: A worldwide analysis. The Lancet Global Health, 8(2). https://doi.org/10.1016/s2214-109x(19)30482-6

Canadian Partnership Against Cancer. (2024, September 24). HPV testing. https://www.partnershipagainstcancer.ca/topics/cervical-screening-canada-2023-2024/modalities/hpv-testing/

Charlebois, S., & Kean, S. (2024). To eliminate cervical cancer in Canada, nationwide funding of self-sampling for human papillomavirus is needed. Canadian Medical Association Journal, 196(21). https://doi.org/10.1503/cmaj.240722

Madding, R. A., Currier, J. J., Yanit, K., Hedges, M., & Bruegl, A. (2024). HPV self-collection for cervical cancer screening among survivors of sexual trauma: A qualitative study. BMC Women’s Health, 24(1). https://doi.org/10.1186/s12905-024-03301-x

Madzima, T. R., Vahabi, M., & Lofters, A. (2017). Emerging role of HPV self-sampling in cervical cancer screening for hard-to-reach women: Focused literature review. Canadian Family Physician, 63(8), 597–601.

Pretsch, P. K., Spees, L. P., Brewer, N. T., Hudgens, M. G., Sanusi, B., Rohner, E., Miller, E., Jackson, S. L., Barclay, L., Carter, A., Wheeler, S. B., & Smith, J. S. (2023). Effect of HPV self-collection kits on cervical cancer screening uptake among under-screened women from low-income US backgrounds (MBMT-3): A phase 3, open-label, Randomised Controlled Trial. The Lancet Public Health, 8(6). https://doi.org/10.1016/s2468-2667(23)00076-2

Wang, R., & Coleman, J. S. (2023). The HPV self-collection paradox: Boosting cervical cancer screening, struggling with follow-up care. The Lancet Public Health, 8(6). https://doi.org/10.1016/s2468-2667(23)00094-4

World Health Organization. (2022). Self-care interventions: Human papillomavirus (‎HPV)‎ self-sampling as part of cervical cancer screening and treatment, 2022 update. https://www.who.int/publications/i/item/WHO-SRH-23.1