Cervical cancer is a common disease caused by the Human papillomavirus (HPV) that is highly preventable through vaccination, screening for abnormal cells and treatment of precancerous lesions. But there are a host of reasons why women may not get screened for cervical cancer.
Perhaps they are scared, self-conscious or embarrassed about the procedure, which involves inserting a speculum into the vagina and taking a swab of the cervix to test for abnormal cells or pre-cancerous lesions. They might be too busy or have difficulty in booking a test, or they might not have access to a clinic offering these services at all. In many countries, cultural barriers, stigma and harmful social and gender norms also prevent women and people with a cervix from accessing cervical cancer screening programs. And for those that have experienced sexual violence, having a regular ‘pap smear’ or ‘smear test’ from a doctor can feel traumatic.
Research shows that in the UK, 1 in 4 women did not attend their smear test when invited. The COVID-19 pandemic has also led to a substantial reduction in preventive healthcare globally, including HPV vaccinations and cervical cancer screenings.
Detecting and treating pre-cancerous cells can be life-saving. Not attending a screening can increase one’s risk of developing cervical cancer; the fourth most common cancer among women globally. In 2020, there were an estimated 604,000 new cases and 342,000 deaths globally, about 90% of which occurred in low- and middle-income countries and reflects the limited equitable access to vaccination, screening and treatment programs.
It is crucial that we find ways to make screening easier, more dignified and person-centred.
Cervical cancer self-sampling is compatible with the WHO’s guidelines on self-care to improve health and well-being. Fortunately, its expansion in a growing number of countries around the world is also proving to be a game-changer in eliminating cervical cancer.
What is cervical cancer self-sampling?
A new method of HPV testing can be performed on vaginal samples collected by the patient in a process known as self-sampling. The swab used to collect the sample has been likened to a small mascara brush or a COVID test swab, which is then sent to a lab for analysis.
This is a safe and easy approach that can reach women that otherwise would not participate in a clinician-based screening or have access to a screening test.
According to one study conducted in the UK, 51% of eligible women aged 25-64 chose self-sampling as their preferred method for cervical screening. If more people around the world are given this choice, we could see an even greater number of clients choose to self-sample.
Papua New Guinea, for example, has among the highest rates of cervical cancer globally, but currently has no national screening or HPV vaccination programme. Catherine Totona, a health extension officer who manages the cervical cancer clinic at Madang provincial hospital in Papua New Guinea, says the self-sampling method is helping to reach more women across the country.
“Most women were reluctant or ashamed to come for screening thinking that we clinicians will examine them or use speculums to collect their vaginal specimens,” she said. “However, when their friends came and told them about using the self-sampling method, more women were flexible and came for screening and testing.”
Juliana Kajoi, a midwife at the clinic, has used the self-sampling method herself.
“I felt the self-sampling method is more convenient than clinician-collected specimens where we women do not expose our body, thus encouraging more women to come for screening,” she said.
In addition to self-sampling and smear tests, other methods for cervical cancer screening include visual inspection of the cervix with acetic acid and Lugol’s iodine (VIA/VILI) and cytology, which is the examination of cells. If abnormal or precancerous lesions are detected through self-sampling or by a clinician, they are treated with techniques to destroy the cells such as through cryotherapy (freezing the cells) or surgical techniques to remove them.
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I felt the self-sampling method is more convenient than clinician-collected specimens where we women do not expose our body, thus encouraging more women to come for screening.
Where is self-testing being rolled out?
According to a 2022 study, 17 of the 48 countries with HPV-based programs have introduced self-sampling in their national programs or guidelines. This option is available for underscreened populations in eight countries (Argentina, Australia, Denmark, Ecuador, Finland, France, Myanmar and Sweden) and it is the primary screening option for all women in nine countries (Albania, Kenya, Guatemala, Honduras, Malaysia, Netherlands, Peru, Rwanda and Uganda). Eight additional countries are also piloting self-sampling, including Brunei, Mexico, Italy, Spain, El Salvador, Greece, Mexico, Portugal and the United Kingdom.
And there is evidence that the self-sampling method is working in reaching more at-risk groups.
When self-sampling kits were distributed in the Stockholm region in Sweden, there was a 10% increase in population test coverage in just one year. Studies from across Latin America and the Caribbean showed high approval rates for self-sampling among women and target populations.
In Australia, which introduced self-sampling last year, it is expected to increase the rates of cervical cancer screening for women from culturally and linguistically diverse backgrounds, as well as gender diverse people who face barriers in accessing traditional screenings.
Duncan Mosigisi, a nurse at the Reproductive Health Network Kenya, an IPPF Member Association, says that self-sampling also provides a more discrete and comfortable choice.
“I believe self-sampling can be used especially for women who are uncomfortable with gynecological tests or who want to have their privacy as they collect the sample at home,” he said.
Similarly, clinicians at the Albanian Center for Population and Development have observed 'vast improvements' in access and services for cervical cancer screenings, thanks in part to self-testing options.
"HPV self-sampling testing significantly improved participation among women who did not routinely attend cervical cancer screening programs," said Hatixhe Gorenca, a gynecological nurse.
I believe self-sampling can be used especially for women who are uncomfortable with gynecological tests or who want to have their privacy as they collect the sample at home.
Expanding choice
It is estimated that around 8 out of 10 sexually-active people will be infected with HPV at some point in their lives. There are more than 100 types of HPV, and a few of them can be cancer-inducing. IPPF recommends that all young people aged 9-14 years – regardless of their sex – receive the HPV vaccination, as anyone can carry or transmit HPV and vaccination reduces the risk of HPV-related cancer by at least 90%.
The global use of self-sampling is likely to increase in the coming years, partly as a result of the COVID-19 pandemic which has accelerated self-testing generally. The challenges will be in ensuring these programs reach the most marginalized and vulnerable people in low-resource settings with already low screening rates and high mortality from cervical cancer. It is also important that countries adopt an adequate diagnosis and treatment follow-up for patients whose tests come back positive.
IPPF, with its deep and extensive reach to women, girls, and other affected populations, particularly in low- and middle-income countries, is in a unique position to make a big difference in this initiative.
Comprehensive cervical cancer prevention is part of the more than 1 billion cumulative services our member associations offered between 2016 and 2022.
As we build on the global momentum to eliminate cervical cancer, IPPF is centering care on people, by advancing self-care through advocacy and service delivery. In addition to our existing services, we are committed to diversifying our service delivery models and promoting self-care options like self-sampling that expand choice and ensure dignity for all.
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Dr Nathalie Kapp is the Chief Medical Advisor for IPPF and an obstetrician-gynaecologist specializing in women's health. She has a fellowship in Family Planning and Clinical Research from Boston University, where she also obtained her Masters in Public Health in Biostatistics. Before joining IPPF, she was Medical Director at Ipas, where she spent five years investigating the safe use of medical abortion in over-the-counter settings.
