Q&A: US cervical cancer screening, treatment, at-home HPV tests

Key takeaways:

• HPV vaccination and routine cervical cancer screening are the main methods of prevention.
• At-home HPV screening is underway, which can eliminate cervical cancer diagnosis and treatment disparities.

Vaccination against HPV and routine screening are the primary methods for cervical cancer prevention, and the convenience of at-home HPV tests may increase screening and lower cervical cancer prevalence in the U.S.

“There’s always this weird stigma with cervical cancer because of its association with HPV, an incredibly common virus, and it’s really important for us to make sure that we minimize the stigma,” Mark H. Einstein, MD, MS, professor and chair in the department of obstetrics, gynecology and reproductive health at Rutgers New Jersey Medical School, told Healio. “Nobody wants cancer, and nobody wants cervical cancer, so it is our goal and our job to make sure that we encourage conversations about HPV and about HPV prevention. This is a ubiquitous virus, but very few people that have this virus will get a clinically relevant disease like a precancer or cancer.”

Healio spoke with Einstein about cervical cancer prevalence, current recommendations from screening guidelines and treatment options in the U.S.

Healio: How prevalent is cervical cancer in the U.S.?

Einstein: Cervical cancer used to be the No. 1 cancer killer of women in the early 1900s in the U.S. Now, it doesn’t even make the top 10, and the reason for this is because we have organized screening programs that include a PAP and HPV test. While cervical cancer doesn’t make the top 10, unfortunately, rates have plateaued in the last few decades, and we still have a tremendous number of individuals that are suffering from cervical cancer, despite having the tools to essentially prevent cervical cancer.

Healio: What do current cervical cancer screening guidelines recommend?

Einstein: There’s primary prevention, which is vaccination against HPV, and there’s also secondary prevention, which is routine cervical cancer screening. All cervical cancers must start with an HPV infection. At some point in time, during cervical cancer development, which takes many years, decades even, someone has to have an HPV infection. We can stop those infections with a vaccine and then we could prevent a lot more cervical cancer.

Focusing on primary prevention is important, but secondary prevention is cervical cancer screening. There are a couple of guidelines that are out there.

The American Cancer Society (ACS) guidelines from 2020 are that cervical cancer testing should begin at age 25 years, and those aged 25 to 65 should have a primary HPV test. This is a bit of a shift away from what how we’ve always done it, which is with cytology-based guidelines, either a PAP alone or a PAP with an HPV test. If that testing is not available, which it’s not in a lot of places, then we could do a co-test with an HPV and a PAP every 5 years. If there are abnormalities, that must be managed as clinically recommended.

The reasons for this big shift are a few-fold. First, an HPV test is far more sensitive than a PAP test. Secondly, an HPV test not only tells us the risk of what’s going on now, but it also tells us the risk of what might go on in the very near future, whereas the PAP only tells us what’s going on now. PAPs have done a wonderful job in decreasing mortality and morbidity from cervical cancer, not only in the U.S., but all over the world where there are organized screening programs. But now that we have HPV testing, and it is so easy to test for it, we can do better for our patients with HPV testing. In addition, there are other guidelines, like the U.S. Preventive Services Task Force, which is co-testing starting in women ages 30 to 65 years and a PAP and HPV test in ages 21 to 29 years. They could also just have a PAP alone every 3 years.

Healio: What will be different in the 2023 vs. 2024 cervical cancer screening guidelines?

Einstein: The U.S. Preventive Services Task Force is currently doing an update on their guidelines, and it has been suggested, albeit it is not finalized, that they will align very well with the American Cancer Society guidelines. This means that both guidelines will look very similar with primary HPV testing. So, most individuals with a cervix will potentially be getting primary testing with an HPV test alone when available.

Healio: Is at-home HPV screening currently approved or imminent? What are the implications of an at-home screening?

Einstein: This is very exciting news for many of us that have worked in the cervical cancer space for years in many high-income countries or places that have a long-standing organized screening programs — such as the Netherlands, Scandinavia, Australia, New Zealand, the U.K. — they’ve all been shifting to self-sampling. With a self-sample, you use a brush device that is self-inserted and done at home, and the primary HPV test and follow-up guidance is based on the same screening guidance as a primary HPV testing.

In the U.S., there is an initiative required by the FDA to lead to the approval of self-sampling. This is being led by the National Cancer Institute and is called the “Last Mile” initiative, like this is the “last mile” to get to the point where we could have home testing for an HPV test and only when there’s an abnormality that someone must come in for secondary management or active surveillance. Rutgers is a site for the “Last Mile” initiative, and we are one of 40 sites in the U.S. that is anticipated to be indicated in 2024.

There are some things that the FDA wants to know that will be fleshed out within the course of this trial. Also, since the U.S. system is different than the types of health care systems in other countries, the FDA also wants to know if patients will be able to get the care that they need once found to have a positive screen.

So, there are clinical opportunities in screening and in people that have poor access to screening, and there are individuals that might have poor access for several different reasons such as lack of time to go to a provider. Also, there are a lot of people that are in active management that require frequent surveillance. It’s sometimes very difficult for somebody to get to the doctor’s office just for a quick PAP between child care, elder care or deal with the consequences of missing work. The convenience factor [with self-screening] will be super important as an option for patients. We are all eagerly looking forward to the study that will hopefully lead to a label of being able to do self-sampling at home.

Healio: How is cervical cancer treated and what is the likelihood of treatment success?

Einstein: Most cervical cancer in the U.S. is diagnosed as early stage, and many early-stage cervical cancers can be treated surgically. These types of surgeries are often done by a gynecologic oncologist. These are specialists that are highly trained to do radical pelvic surgeries, and these are specialty procedures.

In addition to the radical hysterectomy, we perform a lymph node dissection similar to other types of cancers where you not only remove the tumor and the margins around the tumor, but also the local regional lymph nodes. If it’s slightly bigger, but still confined to the pelvis, we call that locally advanced cervical cancer and those tumors are typically treated with radiation therapy. Not only do we use radiation therapy, but we also use a touch of chemotherapy, not the full-dose systemic therapy, but we use a little bit of chemotherapy because it makes the radiation more effective at curing the cancer. It acts synergistically with the radiation to make it better. This is called concomitant chemoradiotherapy and these tumors melt away with concomitant chemoradiotherapy.

If someone presents with very advanced cervical cancer, the treatment options are more limited. They’re limited to systemic therapy using a combination of chemotherapeutic agents. The earlier we can pick it up, then obviously it is far better for the patient’s disease-specific survival. The best way to pick it up is when it’s in the precancer stage where we can do simple office procedures and remove the cells.

Typically, patients are cured in stage 1 or stage 2. Disease-specific survival with appropriate treatment and appropriate management by appropriate physicians, such as gynecologic oncologists, is extremely high, around 90% and higher. When the disease is presents in a more advanced state, then the survival drops considerably.

For more information:

Mark H. Einstein, MD, MS, can be reached at me399@njms.rutgers.edu.