GPs are being urged to offer self-collection cervical screening to more of their eligible patients, as evidence shows it does not reduce test accuracy and overcomes significant objections some women have to being screened.
Research published in the MJA has found self-collection is highly acceptable for most screening participants and primary care practitioners, based on interviews with 45 patients and 18 health professionals who engaged with the pathway in Victoria.
Self-collection using a flocked vaginal swab has been available since 2017 as an alternative to speculum testing for underscreened or never-screened women. It is considered useful for those who object to screening for cultural reasons, pain or a history of sexual violence. Only patients who test positive for human papillomavirus (HPV) strains other than 16/18 require an additional clinician-collected cervical sample.
Screening participants in the latest study described having greater control over their own health, and several said they would not have been screened if self-collection was unavailable.
Uptake of self-collection has been poor, however. Only 1067 self-collection tests were performed in Victoria up to April 2019, whereas 290 000 clinician-collected cervical screening tests were reported by VCS Pathology, which undertakes half of the cervical screening tests in Victoria, during the same period.
Study co-author, Professor Marion Saville, Executive Director of the VCS Foundation told InSight+:
“We’ve been a bit disappointed by the low uptake of self-collection. It really has been a missed opportunity, because 80% of cervical cancers occur in underscreened or unscreened women.”
Overall participation in the renewed National Cervical Screening Program (rNCSP) is well below what it should be – only 57.7% of eligible Victorians participated within the recommended interval between January 2016 and June 2017. According to the authors of the MJA study, 80% participation would be a reasonable goal.
Currently, self-screening is only available to women aged 30 years and over who have never been screened or are overdue for screening by 2 years or longer.
Several health practitioners who were interviewed for the latest study expressed frustration at the administrative burden of determining whether a patient was eligible.
Professor Saville said she believed some GPs were also reluctant to offer self-collection because they were unaware of evidence that it is now equally sensitive as clinician sampling.
“It’s true that initially, when self-collection was made available and was based on an earlier generation of HPV test [signal amplification rather than polymerase chain reaction], it was slightly less sensitive than clinician-collection,” she said.
“At a policy level, there was a difficult balance to be struck between improving the reach of the program versus losing the effectiveness of the program if lots of women switched to self-collection – hence, the strict eligibility criteria for self-collection.
“However, since then, an updated meta-analysis has shown that the accuracy of self-collection is virtually identical to clinician-collected samples.”
Taking into account the latest evidence, the Medical Services Advisory Committee (MSAC) in May 2021 advised the Health Minister to expand access to self-collection to include everyone eligible for cervical screening.
Professor Saville told InSight+:
“MSAC’s recommendation to widen the eligibility criteria is very encouraging, and if the Health Minister approves it, it will make it much easier for primary care to implement self-collection. It will also improve availability to underscreened and never-screened people.”
Currently, there are no clear guidelines for practitioners detailing how to offer self-collection. The latest study identified confusion among practitioners about whether patients could do the test at home.
Professor Saville said home-testing was acceptable under the supervision of a health care professional.
“The health care practitioner is responsible to offer, facilitate and supervise performance of the self-collection cervical screening test, but this does not prohibit practitioners from allowing participants, after supported decision making and discussions about the test, to take the test home and later bring it back to the clinic, if that is the approach which is most suitable and practical for the screening participant and/or the practitioner,” Professor Saville said.
“This also means, in the case of COVID-19 restrictions, that a practitioner could provide a consultation via telehealth then send the kit to the woman.”
The latest study identified one group of participants who tended to be less satisfied with self-collection: those who tested positive for HPV types not 16/18 and required a clinician-collected cervical sample in order to be triaged.
In these cases, the participant was more likely to have a positive experience with the follow-up clinician-collected test if they felt the practitioner understood their personal circumstances.
Royal Australian College of General Practitioners board director Dr Lara Roeske is on the expert advisory committee that informed MSAC’s recent recommendation on self-collection.
She told InSight+:
“The self-collection pathway is evidence-based. It will not lead to an increase in rates of false positives or false negatives for those participating.”
Dr Roeske is hopeful the Health Department will support MSAC’s advice and make self-collection available to all people eligible for screening. In the meantime, she urged GPs to find out whether their local laboratory had the capacity to test self-collected samples or send them on to a laboratory accredited to test the samples.
“GPs also have the option of directly posting self-collected samples to one of the larger laboratories – these samples need to arrive at the laboratory within 2 weeks of collection,” Dr Roeske said. “It’s extra work for the GP, but I believe it’s still an excellent option for GPs who want to support underscreened women.
“Key to cancer control is a health professional who is trusted, who will engage those who are eligible both at the entry and exit points of screening, and throughout the screening journey” Dr Roeske said.
“GPs and practice nurses have a really important role to play that doesn’t go away even if we have more patients using self-collection.”
The VCS Foundation has developed an HPV Self-Collection Clinical Audit to equip GPs and Nurse Cervical Screening Providers to offer the service. It can be accessed at: https://www.modmed.com.au/professional-development/hpv-self-collection-clinical-audit/