An equity-driven project inviting women aged over 60 for one HPV cervical screening test is expected to increase coverage in this age range; and with over 26,000 women responding to the invitation from CervicalCheck, the project has yielded interesting clinical results.
By Dr Sarah Fitzgibbon, CervicalCheck GP Advisor
In 2023 we completed a project to invite over 100,000 women between the ages of 60 and 69 to attend for a CervicalCheck HPV screening test.
These women did not have the opportunity to have an HPV screening test because they had already had their final cervical screening test with the programme:
- before HPV screening was introduced in 2020, and
- before the upper age range for CervicalCheck was extended to 65, also in 2020.
Why we did it
Women in this age range contacted us to say they were interested in having the new test. Following an evidence review which showed that under-screened women in this age group could benefit from one HPV screening test[1], we decided to support this call from women by offering them one free HPV test.
We also wanted specifically to give under-screened or never-screened women in this age range, who had previously been invited for cytology screening, a choice to have one HPV screening test.
The challenges
Reactivating a large group of women on our screening register is a complex process and involves many manual processes and checks.
We know from our data that women aged over 50 are less likely to come for screening, so we would have to adapt our communications and use a targeted approach to ensure we would reach women with our information.
We would also need to seek guidance from our GP partners, sample takers and colposcopy colleagues, as their input and feedback would be crucial to the project’s success.
What we did
We established a multi-disciplinary project team including: CervicalCheck programme management and register department, Information and Communication Technology (ICT), our primary care and colposcopy advisors, public health, communications and behavioural science experts.
The project team reported to the CervicalCheck senior management team on progress and sought advice throughout the project.
We identified the women and reactivated them on our screening register.
We developed a communications approach which included:
- Stakeholder engagement with healthcare professionals, advocacy groups and our patient and public partnership
- Consultation with the women who had contacted us asking for the HPV test
- Information development for women, and for healthcare professionals involving our patient and public partnership (PPP), our screening participants and with behavioural science input
- Media and campaign planning
- Evaluation and next steps.
Engagement
We engaged with our colleagues in general practice, laboratories and colposcopy to tell them about the scope and rationale for our initiative and ask them for their views and support. GPs told us they were interested in helping us reach out to these women to explain the new test, the benefits and limitations, and how they could make it easier for women in this age range to attend for the test. Women in this age group can be more reluctant to come for screening because of concerns around discomfort when having the test. Some women believe they are not likely to have HPV if they have not been sexually active recently.
We know that half of all cervical cancers are detected in women over 50, emphasising the importance of screening in this age group.
Communications
We adopted an equitable approach by writing out to all women in the project’s age range and inviting them for one HPV screening test.
Our research tells us that the reasons women over 50 are less likely to come for screening are fear of the test and the fact that the test can become uncomfortable after menopause. We used this evidence-based information to develop our communications.
We created a bespoke letter for the women to let them know why we were specifically inviting them at this time. We developed a one-page leaflet to accompany the letter, to let women know how the test could be made more comfortable for them. We used behavioural science insights to help activate the women to find out more about the test and choose to come for screening. We tested the letter and the leaflet with members of our PPP panel and with women in the same age range who had contacted the programme enquiring about their eligibility for HPV testing.
We developed a bespoke communication for healthcare professionals which incorporated the information in our leaflet, to support GPs and general practice nurses in their communication with women in this age range and address any concerns they had about the test.
We developed a country-wide communications information campaign to run at the same time the invitation letters were being released. The campaign informed all women of the benefits and limitations of HPV screening, who was eligible, and how to book the test. We reached out to our stakeholders and gave them an information pack to share with women.
Activation and results
Between October and November 2023, we sent out 106,000 invitations to women who were 60 to 65 years of age in 2020, and who had not had the opportunity to have a HPV screening test. In March 2024 we found that:
- Over 26,000 women of the 106,000 invited chose to have screening – an attendance of 24.9%.
- 195 (0.73 %) of these women had an ‘unsatisfactory result’ and had to return for a repeat test after 3 months. This was in line with the equivalent rate for the overall screening population in 2023.
- 967 women had a ‘HPV found’ result (3.6%); 302 of these also had positive cytology and required referral to colposcopy. These referrals did not have a significant impact on colposcopy clinic capacity. The remainder will be called for repeat HPV screening in 12 months.
- Some early reports suggest that this project has led to an increase in detection of cervical cancer in this cohort.
Evaluation
We are now working to evaluate the project. We hope to apply learnings from the project to help women aged 50 to 65 to choose screening. We will report on our evaluation when it is complete.
[1] https://www.sciencedirect.com/science/article/pii/S0091743521002097
Cervical cancer elimination
Cervical cancer could be the first cancer ever to be eliminated globally. Ireland is on track to eliminate cervical cancer by 2040. It is a real possibility for women in Ireland because we have the tools we need to achieve the global targets for elimination. A combination of HPV vaccinations, screening, and increasing awareness of symptoms and access to early treatment opportunities are key to getting us there. Working together, we can each play a part with ensuring that everyone eligible benefits from these vital services.