By Dr Laura Heavey, Specialist in Public Health Medicine, National Screening Service
You may have read or heard in the news recently that some countries have started using self-sampling as part of their cervical screening programmes. This is an exciting development that CervicalCheck has been looking into for the Irish programme. I hope this blog will help you understand a bit more about self-sampling and the work CervicalCheck is doing to assess how useful it might be, what people think about it, how reliable it is as part of a screening programme, and the ways it might be added to the CervicalCheck programme in the future.
Most women have their cervical screening test done at their GP practice by a doctor or the practice nurse. It is an important part of looking after your health and for most people it only happens once every three or five years (depending on their age). For some it is embarrassing, for others it can be uncomfortable, especially after menopause. Many people find it hard to fit a clinic appointment in with busy schedules. For other groups there are bigger barriers such as not being able to register with a GP or cultural needs for a female attendant. For all of these reasons and more, a process where you take the sample yourself without a speculum (the instrument that is used to open up the vagina to allow the sample to be taken) is appealing.
In CervicalCheck, we have been assessing the research as it has been published. We have also had discussions with colleagues in other countries where self-sampling is being offered to screening participants. We are now getting ready to do some more research in Ireland and want to talk to women and people with a cervix in Ireland about self-sampling. This will help us to figure out how self-sampling might be introduced here.
How does self-sampling for HPV testing work?
Self-sampling is not like doing a traditional test. Self-sampling involves a swab (like a long cotton bud) or a soft brush that you use to collect a sample from your vagina. You don’t have to touch your cervix with the swab. Across the world, cervical screening programmes offer different ways, but mainly you do it at home. The testing kit can be sent to you or picked up from the doctor’s surgery. The sample is then sent by post to the laboratory for testing. The sample taken will be tested for HPV first, just like a sample taken by your doctor or nurse. If your sample is negative for HPV, you are low risk and you will be called again for another screening test when it is due. If you test positive for HPV, you will then need to have a traditional test, including a speculum, with your doctor or nurse. This is necessary to get a sample from your cervix to check if the HPV has caused any abnormal cell changes in your cervix. You can read more about primary HPV screening here.
Is self-sampling for HPV testing effective?
A systematic review in the British Medical Journal found self-sampling can improve population uptake of cervical cancer screening1. Self-sampling seems to be particularly useful for improving uptake in under-screened people or those who have never taken up an invitation for screening.
Participating in cervical cancer screening, however, is more than just having a sample taken and tested. The consultation with your nurse or doctor is also very important. They will explain the benefits and limitations of cervical screening, as well as concerning symptoms to watch out for, such as bleeding after sex or between periods, that might need urgent investigation. People who use self-sampling kits at home will miss out on the benefit of these consultations. This is why in some countries, like Australia, people are asked to pick up the self-sampling kit from their doctor or nurse.
The findings of a study of the Netherlands’ cervical cancer screening programme, where self-sampling is available to all women, found some differences between the performance of a self-taken test and a traditional test2. The results suggested that that a self-collected sample is slightly less likely than a clinician-collected sample to find abnormalities when they are present. This is called the sensitivity of the test and, although it decreased by 6%, it still met the criteria of tests used in the Netherlands’ programme. But, this may have implications for how often a person has a screening test. There is still more to learn about the best way to use self-sampling as part of a cervical cancer screening programme.
Is CervicalCheck going to introduce self-sampling?
As self-sampling for HPV testing is still quite new, there are some gaps in our knowledge, especially in the Irish context.
So far we only have two studies looking at preferences of women and people with a cervix living in Ireland. One was qualitative research with a sample of 48 women registered with CervicalCheck in 20193 and the other through an online survey of 418 people from the LGBT+ community in 20214.
What the Irish research told us
- Greater interest in using self-sampling from women in the LGBTQ+ community and among women who are less likely to take up their screening invitations
- Many women who attend for screening when invited said they wouldn’t have the confidence to self-sample
- Kits should come with clear step-by-step instructions
What we’d like to know more about in the Irish context
We are planning to do a survey in 2023 about your thought on self-sampling. Some of the questions we hope to answer are:
- Would people prefer to have the sampling kit posted directly to their house?
- Would they prefer if their nurse or doctor met them first to explain how to use it?
- Should self-sampling be made available for all women and people with cervix, or should it be made be available for certain groups first?
- How do we ensure that people who test positive for HPV will attend their doctor or nurse for follow-up testing of their cervical cells for any abnormalities?
There are also technical questions for our scientists to answer, relating to which sampling kits are the best to use and how best to process self-collected samples in the laboratory.
The first step
There is already a high uptake of cervical screening in Ireland. It is important that we implement changes to the programme in a way that complements the existing successful programme. We need to ensure that screening participants continue to come for their cervical screening tests and that they continue to get results that are timely and accurate. Knowing more about the preferences of women and people with a cervix will help us to determine the best way to introduce self-sampling in Ireland. This is the first step. The results of this research will be available in 2023.
For anyone interested in reading more of the science, here are a few references that have informed this blog:
- Yeh PT, Kennedy CE, de Vuyst H, et al. Self-sampling for human papillomavirus (HPV) testing: a systematic review and meta-analysis. BMJ Global Health. 2019;4:e001351.
- Inturrisia F, Aitken C , Melchersd W, et al. Clinical performance of high-risk HPV testing on self-samples versus clinician samples in routine primary HPV screening in the Netherlands: An observational study. The Lancet Regional Health – Europe. 2021;00:100235
- O'Donovan B, Mooney T, Rimmer B, Fitzpatrick P, et al. Advancing understanding of influences on cervical screening (non)‐participation among younger and older women: A qualitative study using the theoretical domains framework and the COM‐B model. Health Expectations. 2021;24:2023–2035.
National Screening Service. LGBT+ cervical screening study, ‘To examine the knowledge, attitudes, participation and experiences of lesbian and bisexual women, trans men, non-binary and intersex people with a cervix in cervical screening in Ireland’. Dublin: HSE, 2021.