HPV Self-Sampling: A Promising Approach to Reduce Cervical Cancer Screening Disparities in Canada

Abstract

Human papillomavirus (hpv) is the primary cause of cervical, anal, and other genital cancers, which are preventable through screening and early treatment. Cervical cancer is a major public health problem, with profound individual impacts in terms of life expectancy and quality of life, as well as societal impacts in terms of economic burden [1][2][3][4] . In Canada, an estimated 1,550 women will be diagnosed with cervical cancer in 2017, and 400 will die from it. In Ontario, Canada's most populous and diverse province, 630 women are diagnosed annually with cervical cancer, and 150 die from it 2 . The mean overall health care cost per patient during the first five years after being diagnosed with cervical cancer is projected to be about $68,745 4 in Ontario. This does not include the cost associated with loss of economic productivity and family life disruption related to emotional and psychological stress.Cervical cancer deaths and associated health care and social costs can be avoided through appropriate screening. Currently, screening is performed via the Pap test (cytological examination of the peeled cells from the cervix), which requires a visit to a doctor's office. This approach has shown effectiveness for early identification and removal of precancerous abnormalities 5 and has been considered as the primary reason for the observed reduction in cervical cancer incidence and mortality in high-income countries like Canada 2,3,6-8 . The most current cervical cancer screening guidelines recommend that women be screened by Papanicolaou (Pap) tests at least once every three years starting at 21 years of age if sexually active and discontinuing at age 70 2 . For hiv-positive women, recommendation includes receiving screening at the initial assessment and at six months, with an annual follow-up for women with normal results. Despite these clear screening guidelines and a universal health care system, screening participation has remained lower than desired over the past two decades in Ontario, holding steady at 60% to 65% since 2002 3 .Under/never utilization of cancer screening has been reported to be more predominant among certain vulnerable women, such as immigrants and women of low income, those belonging to visible minority groups, women living with hiv (wlhiv) and those with disability 9-23 . Low levels of screening among these hard-to-reach women have been related to individual-level barriers such as cultural barriers (e.g., modesty, language), lack of knowledge about cervical cancer risk factors and preventive measures, not knowing where to go for the test, and transportation difficulties; physician-level barriers, such as lack of a family physician, lack of physician recommendation, or having a male provider; and system-level barriers, such as inconvenient clinic hours and indirect costs associated with screening (e.g., for childcare, taking time off work) [10][11][12][13][14][15][17][18][19][20][21][22][23][24][25][26][27] . Two Canadian retrospective population-based studies in Ontario showed that cancer...

Predictive Value of HPV Testing in Self-collected and Clinician-Collected Samples Compared with Cytology in Detecting High-grade Cervical Lesions

“…Although cytology continues to be the dominant cervical cancer screening modality in Canada, primary hrHPV testing will eventually replace cytology, paving the way for the implementation of HPV self-sampling nationwide, and for population-based screening programs to reduce cervical cancer screening disparities in Canada (40). It remains to be seen how effective, operational, and sustainable population-based screening for cervical cancer and its precursors will be outside of the clinical setting, especially among disadvantaged women and underserved communities.…”

From Biology to Therapy: The CLL Success Story

“…An ongoing phase II trial is testing whether combined treatment with ibrutinib and FCR (iFCR) will lead to deep and durable remissions and possibly cure in younger TN CLL patients. 88 Patients are initially treated with ibrutinib for 1 week to mobilize CLL cells out of the lymph nodes into the blood, where they are more vulnerable, and then they receive 6 months of iFCR followed by 2 years of ibrutinib maintenance. Preliminary results are promising, as iFCR induced deep responses even though a significant part of the patients had adverse prognostic markers.…”

Development and field testing of a tool to elicit women's preferences among cervical cancer screening modalities

“…With an increased sensitivity to detect precancerous lesions compared with the Pap test but a slight loss of specificity, many guidelines recommend HPV testing in part to address a decline in performance of Pap testing due to HPV vaccination . HPV testing can be performed on self‐collected vaginal samples, which might enable women who face barriers to participate in cervical screening with a health professional . Overall, HPV testing of self‐collected vaginal samples has slightly lower sensitivity and specificity to detect precancerous cervical lesions compared with HPV testing of cervical samples collected by a health provider .…”

“…2,5,6 HPV testing can be performed on self-collected vaginal samples, 1,7 which might enable women who face barriers to participate in cervical screening with a health professional. 1,8 Overall, HPV testing of self-collected vaginal samples has slightly lower sensitivity and specificity to detect precancerous cervical lesions compared with HPV testing of cervical samples collected by a health provider. 9 The "best option" among these modalities and the option to opt out of cervical screening all together is value-dependent: Decision-makers must make trade-offs between the perceived risks and benefits of each option in selecting the preferred option.…”