HPV self-testing: Are we ready?
IN 2018, Dr Tedros Adhanom Ghebreyesus, director-general of the World Health Organization (WHO), issued a call to action for the elimination of cervical cancer. In addition to vaccination and treatment goals, this initiative aims to screen at least seventy per cent of our women with a high-performance test by age 35 and again by age 45 years. The recommended screening test currently is the test for high-risk human papillomavirus (HPV). Achieving these targets by 2030 will place us on the global track toward the elimination of cervical cancer. Furthermore, the WHO equally recommends HPV testing done by a health-care worker or on a self-collected specimen. This recommendation is based on strong research evidence showing that both methods are equally effective.
HPV is responsible for 99.7 per cent of cervical cancers and testing directly for HPV has advantages over Pap smears which indirectly detect HPV by looking for changes in the cells of the cervix caused by HPV. Advantages include higher detection rates for pre-cancerous changes, less false negative results, faster results, and the ability to do self-testing, which is uniquely advantageous. HPV self-testing is one of the health-care modalities highly recommended in the WHO self-care interventions. One justification for this, according to the WHO, is an estimated shortage of 18 million health workers by 2030 and as it is now, at least 400 million people worldwide lack access to the most essential health services. This unmet need is further exaggerated in emergencies, including pandemics like COVID-19 which disrupt routine health services and put a strain on existing health systems.
Several countries, including Denmark, the Netherlands and Australia, have included a self-collection option for routine testing as part of their national screening programmes to reach at-risk patients who decline clinician-collected samples or are remote from access. Research shows that patients participating in self-sampling consistently reported improved convenience, less discomfort, positive attitudes, and overall acceptance compared with clinic-based sampling. Endorsement of self-collection by health-care workers is less certain. Available studies suggests that most clinicians would support a self-collected HPV test if it were highly sensitive and cost-effective.
A recent publication highlighted areas of concern among health-care workers in the United States and one major concern is over women not attending in person and missing opportunities for other important issues to be addressed at the well-woman visit like breast cancer screening. Another was, in which women would self-collection be recommended? Would this test be suitable for all women, including those who have never done a Pap smear or only those who are regularly screened?
The pandemic catapulted us into a virtual age and for health care, it was no different where we saw an expansion of telemedicine services. Some health-care workers are uncomfortable with telemedicine as they are of the view that it lacks some tenets of traditional medical practice — inspect, palpate, percuss, auscultate. Cervical cancer self-screening, they believe, is another modality which may prevent women from being properly managed.
Another concern is access to HPV test kits and infrastructure for testing. Self-testing is attractive as it should be able to reach women in areas remote from health-care facilities. But how exactly will the kits be distributed and collected and how will the samples be processed? Do we have enough laboratory facilities to process these samples?
New initiatives are often met with resistance, but the evidence is clear, with almost 400 new cases of cervical cancer each year and a large unscreened population, there is room for improvement. The start of this new year takes us one year closer to 2030. Jamaica should not be left behind!
Dr Natalie Medley is a consultant obstetrician and gynaecologist and gynaecologic oncologist at the Mona Institute of Medical Sciences, UHWI. She can be contacted at (876) 977-1512, (876) 618- 6048 or nmedsingh@gmail.com.
