New guidelines suggest self-screening tests for human papillomavirus (HPV) could be one way to improve access for women otherwise facing barriers.
That comes as several provinces are phasing out the Pap smear in favour of the HPV test for cervical cancer screening.
The guidelines were outlined in a recent edition of the Canadian Medical Association Journal, which focused on preventative care and health care equity, and how to make it more accessible to disadvantaged communities.
It offered 15 screening and other recommendations, and one policy recommendation on improving access to primary care.
HPV is considered one of the most common sexually-transmitted infections in Canada, with more than 70 per cent of sexually active adults estimated to develop it at some point in their lives.
The World Health Organization has said it’s the primary cause of cervical cancer, especially if an infection persists, though most do resolve on their own without symptoms.
The Pap smear has been used for decades and has been recommended for women aged 25 and older every three years. The HPV test, meanwhile, is recommended to occur every five years with the Canadian Cancer Society saying it is most useful for screening in people with a cervix who are 30 years of age or older, though it can be used younger than this.
This test looks at a sample of cells collected by a doctor or nurse from the cervix using a tool called a speculum, which is then tested in a lab to see if it contains the DNA or mRNA of high-risk types of HPV.
The accuracy rate of a Pap smear is only about 60 per cent, which could mean almost half of “existing abnormalities” could be missed, according to a 2022 study in the CMAJ. That same study, however, found HPV tests’ accuracy jumps to just over 90 per cent sensitivity.
As some provinces move to this test, an at-home or self-test version is becoming increasingly available with Dr. Aisha Lofters, one of the co-authors of the CMAJ guidelines, saying it could greatly help those who may not otherwise get a Pap smear or HPV test at a medical clinic or doctor’s office.
“They don’t need to necessarily go to the doctor’s office,” she told Global News in an interview.
“They don’t need to get up in the stirrups and have that uncomfortable speculum exam and could insert a swab themselves, which could address issues of time constraints or convenience of privacy, if we think of people with a history of trauma and there are a lot of barriers that could be addressed with a shift to allowing HPV self-sampling.”
According to multiple studies cited in the CMAJ guidelines, a number of inequities are faced by women trying to seek cervical cancer screening with those with disabilities less likely to attend. In addition, Black women are less likely to have screening than white women, as well as those born outside of Canada and members of the LGBTQ2 community. And a history of sexual trauma can also be a barrier to such a test.
Erika Nicholson, vice-president of Cancer Systems and Innovation at the Canadian Partnership Against Cancer, said that self-testing can be helpful given a number of people have found interactions with the medical system difficult.
In addition, for some people, finding time to get the test itself can be difficult.
“Self-testing is a way that we hope will make it a lot easier for people to take care of themselves because they don’t have to take time off from work, they don’t necessarily have to interact with health-care professionals if that is their choice,” Nicholson said.
As of September, the self-test is only utilized by some jurisdictions, including B.C. which launched the first at-home HPV cervix screening pilots in 2021. New Brunswick also announced last month that as part of its transition to HPV tests, self-sampling will eventually be introduced as well.
A video put out by ScreeningBC notes a person can do the test wherever they feel safe, either at home or a local community health screening. The video says a sample is collected by a person using a swab and rotating it inside the vagina for 20 seconds. Once the sample is collected, it is then placed into a tube and then into packaging provided to then mail to the lab for testing. The sample is then tested for high-risk HPV types and results are provided in four to six weeks after mailing.
Dr. Nav Persaud, another co-author of the guidelines says the self-testing is also a benefit because cervical cancer screening currently involves people booking an appointment, having a pelvic exam and then waiting several weeks for the results to be delivered to the clinician who contacts the patient.
He said this can create issues right at the start due to difficulty booking.
“They’re not connected with a primary care provider or they’re poorly connected with a primary care provider,” he told Global News. “HPV self-testing allows people to administer the test by themselves at home and provide the swab back to a lab that can issue a result.”
Accuracy can also be a benefit, with Nicholson noting that as the HPV test looks for the actual infection as opposed to the Pap smear looking more for pre-cancerous changes, it creates more assuredness over a person’s results.
“By testing for HPV we can better track who may develop cervical cancer, and also more importantly, if you are tested for HPV and found to be negative, we can be a lot more certain that you not develop that cancer within the next three-to-five years,” she explained.
There are still several provinces and territories in Canada that have yet to either make the move from Pap smears or not considered making self-testing available. Quebec, for example, made the shift to HPV testing in mid-2022, but said it did not have plans to provide self-sampling tests at the time.
According to Nicholson, while she does not see necessarily deficiencies in the self-testing procedure itself, she said “more is not necessarily better,” saying the move to HPV testing needs to be done in a “programmatic setting.”
This, she said, means the appropriate people are screened at the right frequency and receive the appropriate follow-up.
“It’s not a matter of flicking the switch to HPV testing,” she said. “There’s a lot of work that goes into that to make sure that the health-care connects and the programs around that are robust, the information systems can measure and monitor the impacts of the switch, and that ultimately people receive the best test and the best follow-up care at the right time for that.”
Persaud said given the access they can provide, more jurisdictions should consider the shift.
“It’s not a new technology, it’s been around for years and in fact, there have been calls for years to provide wider access to HPV self-testing to improve access,” he said.
Lofters notes Canada is not the only one looking at the self-testing route and has been explored in Australia and parts of Europe.
In fact, in the summer of 2022, Australia announced all women across the country would be able to self-collect a sample with it being made available through general practitioner clinics, women’s health clinics, Aboriginal health centres and other health-care providers through its National Cervical Screening Program, which is free under its Medicare plan.
But back at home, Lofters said she wants to see governments doing more than just looking at the possibility.
“We really need to get that to move beyond talking about it and get some investment and figuring out how to best implement it across the country,” she said.
— with files from Global News’ Saba Aziz and Katherine Ward
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