With longstanding concerns about cervical cancer being a disease of inequity, the impending launch of self-collection cervical screening requires concerted efforts to ensure equitable implementation of this “game changer” policy development, according to University of Melbourne researchers.
Nicola Creagh and Claire Zammit write:
Australia could be one of the first countries in the world to eliminate cervical cancer as a public health problem, defined as occurring at a rate of less than four cases per 100,000 women and people with a cervix each year.
This is thanks to public health strategies of vaccination against human papillomavirus (HPV) and regular cervical screening.
Vaccination rates in Australia are fairly high but cervical screening rates are lower, particularly among some groups, with most cases of cervical cancer occurring in people who don’t screen.
New strategies are needed to engage women and people with a cervix who do not screen, or do not screen regularly – and we now have a new option for screening that is just that: self-collection cervical screening.
Game changer
Self-collection cervical screening has been described as ‘a game changer’ with its introduction into Australia’s cervical screening program predicted to save lives.
Traditionally, a cervical screening test requires women and people with a cervix to attend a GP or nurse who performs a pelvic examination, using a speculum to visualise and collect cell from the cervix. Cervical screening is recommended every five years for women and people with a cervix aged between 25 years and 74 years.
Many people, however, experience substantial barriers to this procedure due to past trauma, cultural reasons or embarrassment, with some avoiding the procedure all together.
Self-collection allows a person to perform their own test by inserting a thin swab, which is very similar to a COVID-19 swab, into the vagina and gently rotating it. The aim is not to collect cells from the cervix but a sample from the mid to lower vagina.
This test looks for the presence of cervical cancer-causing HPV types and is just as accurate as traditional cervical screening.
If HPV is present in the cervix, it is also detectable in the low-mid cavity of the vagina.
Self-collection can overcome barriers to a practitioner-collected test. From 1 July this year (2022), self-collection will be a screening option for all women and people with a cervix due for screening.
This differs from the current policy where self-collection is only available to people aged 30 years or more who had never screened or are overdue for screening by at least two years. Access to self-collection is facilitated by a doctor or nurse who provides cervical screening to ensure that participants are supported in understanding the test and any follow up that is needed.
Highly acceptable
In our research at the University of Melbourne and Australian Centre for the Prevention of Cervical Cancer, we spoke to under-screened women and people with a cervix who used self-collection, and found it was highly acceptable.
People reported that self-collection was “just so easy and just so simple” to do and enabled them to have greater control over their health. People also said that the availability of self-collection and choice in the type of screening test provided people with a sense of empowerment, which has been linked to a greater intention to undertake cervical screening.
Practitioners also played an important role in informing participants’ decisions to undertake screening, which supports the model of engagement used in Australia where people receive the kits from their doctor or nurse.
Likewise, doctors and nurses who have offered self-collection as part of their practice have reported very high acceptance of self-collection because it enabled them to engage patients who wouldn’t otherwise have screened.
Barriers
Despite equivalence in accuracy and very high acceptance of self-collection, the uptake of self-collection in Australia has been very low. Nationally, one million people were estimated to be eligible for self-collection between 2018-19, but less than one percent of them performed self-collection. Many factors have contributed to this.
Firstly, the restrictive eligibility criteria has been a major hurdle for practitioners in being able to offer self-collection in practice.
About one-third of all self-collection samples sent to VCS Pathology (the first pathology laboratory accredited to test self-collection samples) up until 30 June 2021 were rejected; the most common reason being because participants did not meet the eligibility criteria (54.1% of rejected samples; 18.5% of all samples). The upcoming policy change, which removes the strict eligibility criteria, should remove this barrier entirely.
Secondly, not all practitioners who provide cervical screening have adopted self-collection as part of their clinical practice.
Practitioners in rural NSW reported very limited experience facilitating self-collection. Another study reported that only 65 percent of practitioners believed self-collection was a suitable screening option.
Practitioners’ capacity to provide self-collection in practice has been hindered by confusion about the accuracy of the test and how to offer it in practice, a clunky roll-out with delays, and limited availability of laboratories accredited to test self-collection samples.
The Australian National Cervical Screening Program needs to prioritise more education and communication targeting practitioners, together with having the majority of pathology providers who process cervical screening samples being able to test self-collected samples.
Thirdly, knowledge of the availability of self-collection among women and people with a cervix is low. To date, the roll-out of self-collection has been driven by early adopting practitioners with limited consumer demand. We need to capitalise on the upcoming change in policy to promote self-collection to the community.
Equity matters
Cervical cancer is a disease of inequity.
While Australia is expected to reach elimination targets sometime within the next decade, if there are not more targeted efforts to ensure equitable access to screening, the low incidence will mask inequities that exist for priority populations. These include Aboriginal and Torres Strait Islander women, some culturally and linguistically diverse groups, gender and sexuality diverse individuals, people in the lowest socioeconomic bracket and people living in rural and remote Australia.
Self-collection is an effective, acceptable and innovative way to engage people who are not screening at all, or at recommended intervals.
This means that self-collection can be the important innovation to increase access to cervical screening accessibility and progress the elimination of cervical cancer for everyone.
Nicola Creagh and Claire Zammit are PhD candidates at the Centre for Health Policy at the University of Melbourne. They acknowledge and thank colleagues Dr Claire Nightingale, Professor Julia Brotherton and Professor Marion Saville whose work has contributed to this article.
See Croakey’s archive of articles on cancer.
