HPV self-testing in Sweden leads to faster elimination of cervical cancer
“With the new measures against human papillomavirus (HPV), we predict that cervical cancer will be eliminated in Sweden 5 years from now. If the pandemic had not happened, it would have gone much, much slower.”
Professor Joakim Dillner is a cancer specialist at the Karolinska Institute in Sweden. He explains how the country was forced to rethink its approach to cervical cancer screening when non-acute care services ceased 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 program restarted, social distancing requirements meant clinics could not provide clinic-led sampling.
To address the problem, HPV self-test kits were sent to all eligible women in the country, including those between the ages of 23 and 29 who had previously been offered cytology-based screening (commonly called a Pap smear), which is performed by a clinician.
The Stockholm region, where 330,000 self-sampling kits were sent out, saw a dramatic 10% increase in population testing – from 75% to 85% – in just 1 year.
High coverage, low cost
Even when more women were screened, the results showed that HPV self-tests picked up fewer HPV infections in those aged 23 to 29, because more of these women had been vaccinated against HPV at school. Previously, this age group had only been offered cytology-based sampling, which is less sensitive and less likely to lead to overtreatment. The Swedish government now includes this group in the national HPV screening program.
“The self-test kit is not very 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, inexpensive sampling kits that are part of the HPV screening test.”
Professor Dillner also wants to stress that the low cost of the kit could be a decisive factor in rolling out HPV self-testing on a global scale, as not all countries can bear the high costs. Even considering the cost of laboratory analysis, he says, self-sampling represents a major savings to health care compared to the time costs of having a doctor perform a test.
However, WHO senior technical officer Dr Marilys Corbex explains that self-testing for HPV can face resistance in many countries where cervical cancer screening is carried out by general practitioners trained in gynecology, who use it as the basis of their income.
In addition, Dr. Corbex says it’s important that women don’t self-exam whenever they want, as some will do it too often and others too infrequently. She says it needs to be done within the target population and as part of an organized screening program to be effective and to ensure 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 living with HIV.
“Each sample has to be analyzed and that comes at a cost,” Dr. Corbex points out. “If the result is positive, there must 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 if we hadn’t been forced to change. We would have continued to hire many doctors and nurses to take these samples when it was not actually necessary. We even achieved a much higher population coverage by just giving it to the women directly. So it’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 overcome barriers to the rollout of HPV self-testing elsewhere in the world. As part of a nationally organized screening program, for example, women do not necessarily need to have a physical address or a post office box to benefit from HPV self-testing.
“You could turn up with a bucket full of self-test kits and distribute them in a marketplace or village in the morning and then wait for them to be returned later that day,” suggests Professor Dillner. He adds, “It’s really quite simple, especially since many low- and middle-income countries have very advanced methods of electronic identification.”
A change in mindset
In July 2022, new government regulations will come into force in Sweden that allow women to choose whether they want to use a self-sampling kit or be seen by a doctor. This will free up resources so that women presenting for their first screening test can also be vaccinated at the same time, and follow-up efforts can be concentrated on those women who test positive for cancer-causing HPV infection.
“It was a change of mind that was needed,” says Professor Dillner. “When everything stopped, we had to think about something completely different. The expectation is that many women will be prevented from developing cervical cancer, and that we will move more quickly towards the WHO’s goal of eliminating cervical cancer.”
Professor Dillner concludes, “Many things are possible when you realize that you don’t have to think the way you always have. It’s important to look at solving questions that come up in an alternative way. I think self-sampling is a big game changer .”