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“With the new measures against human papillomavirus (HPV), we predict that cervical cancer elimination in Sweden could happen 5 years from now. If the pandemic had not occurred, it would have been much, much slower.”
Professor Joakim Dillner is a cancer specialist at the Karolinska Institutet in Sweden. He explains how the country was forced to rethink its approach to cervical cancer screening when non-emergency health care stopped in the capital region in April 2020 due to the COVID-19 pandemic. For 3 months, no one could access cervical cancer screening; then, when the national programme restarted, social distancing requirements meant clinics were unable to provide clinician-led sampling.
To solve the problem, HPV self-sampling kits were sent to all eligible women in the country, including those between 23 and 29 years of age who had previously been offered cytology-based screening (commonly called a Pap smear), which is conducted by a clinician.
The Stockholm region, where 330 000 self-sampling kits were sent out, saw a dramatic 10% increase in population test coverage – from 75% to 85% – in just 1 year.
High coverage, low cost
Even as more women were being screened, results showed that HPV self-sampling picked up fewer HPV infections in those aged 23 to 29, as more of these women had been vaccinated against HPV in school. Previously, this age group had only been offered cytology-based sampling, which is less sensitive and less liable to result in overtreatment. The Swedish Government now includes this group in the national HPV screening programme.
“The self-sampling kit is not highly specialized. It’s basically the same thing as a mascara brush that a woman might use for her eyelashes,” says Professor Dillner. “These are very simple, low-cost sampling kits that are part of the HPV screening test.”
Professor Dillner is also keen to stress that the low cost of the kits could be a crucial factor in rolling out HPV self-sampling on a global scale, as not all countries can bear large expenses. Even considering the cost of laboratory analysis, he says, self-sampling represents a big saving for health services compared to the time costs involved in having a clinician carry out a test.
However, WHO Senior Technical Officer Dr Marilys Corbex explains that HPV self-sampling may meet resistance in many countries where cervical cancer screening is carried out by general practitioners trained in gynaecology, who use it as the basis of their income.
Additionally, Dr Corbex says it is important that women do not self-sample whenever they like, because some will do it too often and others too rarely. She says it must be done within the target population and as part of an organized screening programme to be effective and to ensure that every woman is tested at the right time.
According to WHO recommendations, the target population for screening is women 30 years and older, and women 25 years and older who are living with HIV.
“Every sample needs to be analysed and that involves a cost,” points out Dr Corbex. “Also, if the result is positive, there needs to be adequate diagnosis and treatment follow-up in place for the woman, as part of an organized system.”
Crisis and innovation
“In Sweden, it would probably never have happened unless we had been forced to change. We would have continued to employ a lot of physicians and nurses to take these samples when it was actually not necessary. We even achieved a much higher population coverage by just giving it to the women directly. So that’s something worth thinking about,” Professor Dillner points out.
In addition to reducing the cost burden, he insists that a change in mindset could help to overcome barriers in rolling out HPV self-sampling elsewhere in the world. As part of a national organized screening programme, for example, women do not necessarily have to have a physical address or a mailbox in order to benefit from HPV self-sampling.
“You can show up with a bucket full of self-sampling kits and distribute them in a marketplace or village in the morning, and then wait for them to be returned later that day,” Professor Dillner suggests. He adds, “It’s really quite easy, especially since many low- and middle-income countries have very advanced methods for electronic identification.”
A change in mindset
In July 2022 new government regulations will come into effect in Sweden which allow women to choose whether they want to use a self-sampling kit or be seen by a clinician. This will free up resources so that women coming for their first screening test can also be vaccinated at the same time, and follow-up efforts can be concentrated on those women testing positive for cancer-causing HPV infection.
“It was a mindset change that was needed,” says Professor Dillner. “When everything stopped, we had to think of something completely different. The expectation is that many women will be prevented from developing cervical cancer, and that we will progress faster on the path to reaching the WHO target of elimination of cervical cancer.”
Professor Dillner concludes, “A lot of things are possible when you realize you don’t need to think in the way you always have. It’s important to look at solving issues that come up in an alternative way. I think self-sampling is a huge game changer.”
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