So you may be aware that HPV self-collection is now an option for underscreened patients through the National Cervical Screening Program… but do you feel hesitant about recommending self-collection to your patients? Do you feel a little sceptical? I know these were the questions which immediately sprang to my mind.
Are self-collected samples accurate and reliable in terms of detecting HPV? Surely it is not as reliable as a clinician-collected sample?
Well, a 2018 meta-analysis has shown that the sensitivity of HPV PCR tests on self-collected vaginal swabs were equivalent to practitioner-collected HPV PCR cervical samples for detecting CIN2+ (Arbyn, 2018).
Won’t there be a significantly higher rate of unsatisfactory results from patient-collected samples?
No! VCS Pathology data, which has been published in the Medical Journal of Australia, indicates that only 2% of self-collected HPV samples were deemed to be unsatisfactory. While this is higher than clinician-collected samples (0.2%), only 2 in 100 participants will be asked to repeat the test by their GP. This is comparable with the rates of unsatisfactory Pap smear results under the previous cervical screening program which was approximately 2 – 5% of all Pap smears collected by practitioners.
If I can’t visualise the patient’s cervix and genital tract, what if I miss an abnormality?
In any discussion about cervical screening, ask your patient about any symptoms which might suggest cervical cancer or an infection. If they are asymptomatic, you can be assured that self-collection is a safe test to offer as there is no evidence to support pelvic examination/visualisation of the cervix as routine practice for asymptomatic, HPV negative patients. Patients in whom HPV (not 16 or 18) is detected will need to come back and see you for a pelvic examination and patients in whom HPV 16 or 18 is detected should be referred to colposcopy.
What if my patient has an adenocarcinoma?
We have failed to prevent adenocarcinomas through cytology-based screening over the years. It’s really good news that most of these cancers are also caused by HPV (Brotherton, 2017) and so can be detected through HPV-based screening. The rarer non-HPV related adenocarcinomas have not been prevented through cytology screening. Always ask your patients about symptoms and if there are symptoms then a physical examination and co-test is appropriate.
Currently, less than 1.4% of all swabs processed by VCS Pathology are self-collected samples. This is thought to be due to a lack of awareness among both doctors and the community that this option is currently available. Offering self-collection is a great way to engage with and screen the people that we’re still not reaching in the National Cervical Screening Program. So, now that we know that self-collection is a reliable testing option… let’s talk through how you can make this part of your routine care for patients in your clinic.
Step 1: Get the facts
- Self-collected samples can be performed by the patient within a clinic setting or they can perform the test at home. While a swab performed within a clinic setting is preferred, it is OK for the patient to take the swab home and return it to you if they are reluctant to do the test in your clinic. You may need to follow up if your patient doesn’t return their sample.
- Home-based self-collection can be offered to underscreened women or people with a cervix anywhere in Australia… including via telehealth! Many patients feel concerned about visiting a clinic in person during the COVID-19 pandemic; offering to have a self-collection kit posted to their home will support people who otherwise may delay screening even longer… and don’t forget participants in rural and remote areas of Australia who may not be able to easily access a medical clinic. These patients need to be able to visit your clinic for follow up tests if they have an HPV positive result.
- Be aware of the current self-collection eligibility criteria:
- Patients who are 30 years or older, are asymptomatic and have either:
- Never been screened, OR
- Are overdue for cervical screening by at least 2 years
- And remember that pregnant women who meet these eligibility criteria can also perform a self-collected HPV test.
- Patients who are 30 years or older, are asymptomatic and have either:
- From 1 July 2022 self-collection will be available to anyone who’s eligible for screening and it will be their choice how the sample is collected. There’ll still be some people who are used to having Pap smears and are comfortable with that process – that doesn’t need to change if that’s what they want. But there’ll be many for whom this makes all the difference between not being screened and being screened. In the meantime, there are very large numbers of under-screened people who are eligible right now for self-collection.
Step 2: Follow these simple steps to arrange the test
- Complete a VCS Pathology Form (you can register as a VCS Pathology practitioner here and order consumables and pathology request forms here).
- If the sample is collected in the clinic setting, then the specimen bag containing both the sample and request form can be placed in an envelope and mailed to “VCS Pathology Reply, Paid 178, Carlton South, VIC 3053”. Or, if you are within Victoria and registered with VCS Pathology, their couriers will pick them up from practices in the greater metropolitan area and some regional areas.
- If you want to request a home-based self-collection kit to be sent to your patient, then on receipt of the request form VCS Pathology will check that the patient is eligible for self-collection via the National Cervical Screening Register before sending a kit to your patient via Express Post.Your patient will complete the testing kit at home and send it back to VCS Pathology within 28 days of taking their sample. The kit contains a Reply-Paid Express Post envelope for patients to return their sample.
Further practitioner and patient resources on self-collection including “How to take your own HPV test guides” in multiple languages are available on the Australian Centre for the Prevention of Cervical Cancer Self-collection resources page here.
Simple, right?! Hopefully this has helped address some of your concerns about HPV self-collection. Yes, it is reliable and yes, the process really is straightforward! It is critical that healthcare practitioners embrace self-collection as a routine part of clinical care so that we help bridge the gap in cervical cancer outcomes in underscreened or never-screened women and people with a cervix in Australia.
Arbyn M, Smith SB, Temin S, Sultana F, Castle P; Collaboration on Self-Sampling and HPV Testing. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. BMJ. 2018 Dec 5;363:k4823 Available at: https://www.bmj.com/content/363/bmj.k4823 International Journal of Cancer. Brotherton, J et al. Looking beyond human papillomavirus (HPV) genotype 16 and 18: Defining HPV genotype distribution in cervical cancers in Australia prior to vaccination. 5th July 2017. Available at: https://onlinelibrary.wiley.com/doi/full/10.1002/ijc.30871
Australian Doctor News. Self-swabbing at home an option under HPV test revamp: expert. 11th November 2021. Available from: https://www.ausdoc.com.au/news/selfswabbing-home-option-under-hpv-test-revamp-expert (requires log-in)
Australian Minister for Health media release. Landmark changes improving access to life saving cervical screenings. 8th November 2021. Available from: https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/landmark-changes-improving-access-to-life-saving-cervical-screenings
Australian Doctor News. Govt seeks feedback on patient self-collection for HPV testing. 29th July 2021. Available from: https://www.ausdoc.com.au/ (requires log-in)
Australian Doctor News. Cervical screening: Patients can self-collect HPV at home, GPs told. 8th July 2021. https://www.ausdoc.com.au/ (requires log-in)
Creagh et al. Self-collection cervical screening in the renewed National Cervical Screening Program: a qualitative study. Medical Journal of Australia. June 2021. Available from: https://www.mja.com.au/journal/2021/215/8/self-collection-cervical-screening-renewed-national-cervical-screening-program
Australian Centre for the Prevention of Cervical Cancer. VCS Pathology Registration. Available from: https://www.vcs.org.au/pathology/for-practitioners/vcs-pathology-registration/
Australian Centre for the Prevention of Cervical Cancer. Consumables Order Form. Available from: https://www.vcs.org.au/pathology/for-practitioners/consumables-order-form/
Australian Centre for the Prevention of Cervical Cancer. Self-collection Resources. Available from: https://www.vcs.org.au/pathology/for-practitioners/self-collection-resources/