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Mailed HPV tests increase cervical cancer screening
Mailing HPV testing kits to women who were overdue for recommended Pap testing led to 50% more cervical cancer screenings but they did not increase the detection of cervical precancer, according to study results published in JAMA Network Open.
“Underscreened women are a high-priority population to get screened, because half of the 12,000 cervical cancers diagnosed each year in the U.S are in women who are underscreened or have never been screened,” Rachel L. Winer, PhD, MPH, professor in the department of epidemiology at the University of Washington, told Healio Primary Care.
The study follows previous findings that showed nearly 80% of women who were mailed HPV testing kits returned the test, suggesting that programs distributing these tests could improve cervical cancer screening in underscreened women.
Researchers conducted a randomized clinical trial to compare cervical cancer screening uptake and detection and treatment of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) between those who received the mailed HPV test kits and those who received usual care reminders.
The intervention group received mailed HPV kits along with a prepaid return envelope, an information sheet and educational materials in addition to a letter advising women to receive Pap testing. Usual care reminders in the control group included birthday letter reminders to patients about routine Pap testing and automated alerts to clinicians to inform them that their patients were overdue for testing.
The study included almost 20,000 women aged 30 to 64 years who were enrolled in Kaiser Permanente Washington and had not received a Pap test within the last 3 years and 5 months. Of those, 9,960 women were randomly assigned to the intervention group and 9,891 were assigned to the control group.
The screening uptake was higher in the intervention group, with 26.3% uptake among women in the intervention and 17.4% uptake in the control group (RR = 1.51; 95% CI, 1.43-1.6).
CIN2+ was detected in 12 patients in intervention group and eight patients in the control group (RR = 1.49; 95% CI, 0.61-3.64). All patients with detected CIN2+ were treated in the intervention group and seven women were treated in the control group (RR = 1.7; 95% CI, 0.67-4.3).
Winer, who is also an affiliate investigator at Kaiser Permanente Washington Health Research Institute, told Healio Primary Care that the researchers had expected more women in the intervention group to return HPV tests, which might explain why there were not more CIN2+ detected in those women compared with the control group. She also noted that not all women who tested positive for HPV presented to the clinic for recommended follow-up testing, which could also explain why more CIN2+ was not detected.
“U.S. health care systems that are considering implementing home-based HPV screening programs should focus on strategies to increase use of mailed kits and improve follow-up of women with positive kit results,” Winer said. – by Erin Michael
Disclosures: Winer reports receiving grants from NIH and CDC outside the study. Please see study for all other authors’ relevant financial disclosures.
Perspective
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Despite the unequivocal benefits of cervical cancer screening, one out of every four women do not receive the recommending screening. This is due to a bevy of reasons, one of which includes lack of convenience. The public’s health relies upon high compliance with screening recommendations, whether mammography to detect breast cancers, colonoscopy to detect colorectal cancers or, as is the case in this article, Pap/HPV testing to detect cervical cancers. To ensure high levels of screening at a population level, innovative solutions are needed to enable individuals to readily access services: one of those is the idea of home-based testing.
Home-based testing for various diseases and conditions is already an established paradigm. Patients are instructed how to perform self-screening for breast cancer, testicular cancer and skin cancer. Individuals can purchase from their pharmacy screening kits for HIV and other STIs, fertility and pregnancy, alcohol and drug use, and cholesterol, to name a few. The idea that HPV screening could also transition to the home setting offers an opportunity to have women who otherwise do not get screened at a medical office to have agency over their health in the convenience and privacy of their homes.
This randomized clinical trial by Winer and colleagues found that women who received a self-testing kit mailed to their house were more likely have been screened for cervical cancer (either in the medical office or at home) compared to women who did not receive a self-screening kit (and were instead reminded that their screening was overdue). This is important because it offers an opportunity to re-engage these women with care, especially should abnormal results be reported. The study did not detect a difference in the primary outcome of detection of cancer and precancer.
From a public health perspective, prevention is paramount. Preventing HPV infection is possible through vaccination and is a priority of public health immunization programs. But for women who are otherwise unvaccinated or undervaccinated, or who have already been infected with HPV, self-screening could be an option in the future.