Self-Sampling for Cervical Cancer Screening: Empowering Women to Lead a Paradigm Change in Cancer Control

Abstract

In this new era of precision medicine and patient-centred care, the advent of self-sampling in cervical cancer screening is among the most disruptive innovations in cancer control and prevention. However, it has taken a long time to mature as an idea. The concept of self-sampling with swabs or brushes as a reliable substitute for providercollected cervical specimens has been the focus of at least 25 years of research. Although obtaining an adequate cytology specimen for cervical cancer screening served as the initial rationale 1 , it was the pragmatic goal of obtaining repeated samples for studying the natural history of genital human papillomavirus infection that drove much of this research 2,3 . The original aim of making the experience of participating in cervical cancer screening less daunting to women failed to be realized initially because the tradeoff between convenience to the woman and quality of the cervical sample was far from ideal.Given that it is an intuitively simple and attractive idea, why did it take so long for self-sampling to mature as a technological innovation? During most of the last 70 years, cervical cancer screening has been based on the Papanicolaou (Pap) cytology technique, which relies on the microscopic identification by a cytotechnician or cytopathologist of cellular abnormalities in optimally stained cervical samples smeared on glass slides. These samples must be representative of the ecto-and endocervix to be deemed adequate. For this to happen, a properly trained health care provider, i.e., a physician or nurse, must use a speculum to visualize the cervical os and transformation zone and collect cellular samples from the inner and outer perimeter of the latter using devices such as a wooden spatula, cytobrush, or broom-like device. The transformation zone perimeter is the origin of most neoplastic cervical lesions. Samples that do not properly reflect the cellular composition of the ecto-and endocervix are thus likely to yield false-negative cytology results in women with precancerous or cancerous lesions. Exceptionally, a cytotechnician reading such a Pap smear with meticulous attention to detail may fortuitously find an isolated cluster of dysplastic or malignant cells. However, an exhaustive smear scanning takes time. In the high-volume routine of most cytopathology laboratories, not more than a few minutes are spent per slide, which makes sample quality paramount in cervical cancer screening via cytology. The advent of liquid-based cytology improved the efficiency and ease of smear processing and reading but did not eliminate the need for a speculum-assisted and properly collected cervical sample by a health care provider. It is thus of no surprise that under the stringent quality control of specimen adequacy for cytology screening self-sampling never became much of a promise.The advent of molecular testing for nucleic acid of oncogenic genotypes of human papillomavirus (hpv) made self-sampling an attractive idea for cervical cancer screening again. Clinically validated hpv...

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

“…Many organized cervical cancer screening programmes are considering molecular tests for oncogenic types of human papillomavirus (HPV) as a replacement for the longstanding cervical cytology test (also known as the Pap test) . Thus, the focus is changing from early detection of cellular changes to testing for sexually transmitted infections that are associated with high risk of cervical neoplasia .…”

“…Many organized cervical cancer screening programmes are considering molecular tests for oncogenic types of human papillomavirus (HPV) as a replacement for the longstanding cervical cytology test (also known as the Pap test) . Thus, the focus is changing from early detection of cellular changes to testing for sexually transmitted infections that are associated with high risk of cervical neoplasia . 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 .…”

“…We used these criteria to develop a person‐centred and evidence‐informed preference‐elicitation tool to elicit women's preferences among available cervical cancer screening options . The tool, once refined and validated, could be used to help individuals understand the decision that they face prior to their encounter with a health professional . This tool could also be used in research surveys to determine the “prevalence” of different preferences in a population, which could inform development of clinical practice guidelines …”

“…1,2 Thus, the focus is changing from early detection of cellular changes to testing for sexually transmitted infections that are associated with high risk of cervical neoplasia. 1,3 With an increased sensitivity to detect precancerous lesions compared with the Pap test but a slight loss of specificity, 4 many guidelines recommend HPV testing in part to address a decline in performance of Pap testing due to HPV vaccination. 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.…”

“…1,3 With an increased sensitivity to detect precancerous lesions compared with the Pap test but a slight loss of specificity, 4 many guidelines recommend HPV testing in part to address a decline in performance of Pap testing due to HPV vaccination. 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.…”