Can self-collection help overcome cervical screening barriers?

As it stands, self-collection under the National Cervical Screening Program (NCSP) is a pathway only available to women over the age of 30 who are at least two years overdue for screening or who have never been screened, and decline a traditional test.
 
Under the current system, everyone else is required to have their sample taken by either a doctor or a nurse, involving a speculum, which can be a major barrier for some women.
 
But self-collection could soon become an option for all women, thanks to a recommendation made by the Medical Services Advisory Committee (MSAC) in May.
 
Since its introduction in December 2017 as part of the renewed NCSP, the self-collection policy has not been extended to all women due to evidence suggesting there is a loss in sensitivity compared to a sample collected from the cervix by a clinician.
 
However, updated evidence suggests that is no longer the case.
 
‘At the time, we didn’t want to offer all women a test that was not quite as good. Whereas for women who would otherwise have no screen at all, it’s definitely better than nothing,’ Associate Professor Julia Brotherton, an Honorary Principal Fellow at the Melbourne School of Population and Global Health at Melbourne University, told newsGP.
 
‘A year after the program started, new data came in that conclusively showed that that’s not the case as long as you use a PCR-based test.’
 
Despite the updated findings, Associate Professor Brotherton says there are still clinicians under the impression that self-collection isn’t as accurate, and hesitate to recommend it.
 
Recent research found that between 2017 and 2019, just 6000 self-collection tests were conducted in Australia, out of an estimated one million eligible women.
 
But with a pilot study demonstrating that up to 85% of women who have refused a speculum exam would be willing to do a self-collect screen, Associate Professor Brotherton says there is clear potential to reach under-screened women.
 
‘The benefit of a self-collect is of course the privacy and autonomy of the woman in that she can just go behind a screen or in the bathroom and swirl the swab around her vagina,’ she said.
 
‘It’s good to communicate to them that that swab is exactly like the one they have stuck up their nose for COVID; we’re all pretty familiar with it now, but it’s obviously a lot more gentle in their own hands.
 
‘It’s actually really small, it’s non-threatening and all the research around the world has shown that women find it pretty acceptable and really like that agency over their own body. But it really relies on practitioners being confident and comfortable to use it.’
 
The one disadvantage to self-collection is that it cannot get a reflex cytology, as it is only sweeping up any human papillomavirus (HPV) DNA that’s come off the cervix and into the vagina.
 
Associate Professor Brotherton says that makes no difference for women who return a negative result, nor for those who are found to be 16 and 18 positive, as they can be recommended to go straight to colposcopy.
 
‘It’s the 6% of women whose screening test has a non-16 or 18 HPV detected, so one of the less oncogenic types – the ones that we are less worried about, but we still would like to follow up,’ she said.
 
‘They’re the ones who the pathway currently says need to have that reflex cytology to decide if they’re high grade, and then of course they go straight on to further assessment. But if they’re low grade or negative, we’d bring them back in a year.’
 
This group of women, Associate Professor Brotherton says, need to have ‘really strong engagement’ from their practitioner to take the next step to have a cervical speculum exam.
 
‘Preparing them for that idea so that they don’t think they’ve got cancer, and also that they don’t completely freak out and run away, because often these will be women for whom a speculum is something that they’ve been very fearful of, and they may need a lot of support,’ she said.
 
‘In the future, we might have more flexible models of care, where perhaps certain groups could go straight to colposcopy if that was their strong preference. Or, hopefully, we’ll have better reflex tests that could be done on a self-collect. But we’re not there yet.’
 
However, for the vast majority of women – the up to 92% who will test negative – Associate Professor Brotherton says the self-collect option will give them peace of mind if they have never been unable to bring themselves to have a cervical screening test.
 
‘To give them that relief is a hugely valuable thing that you can do for women in your practice,’ she said.
 
‘Even women who are comfortable with a speculum, of course, may end up deciding, “I want to give this a go” and that’s okay as well.’
 
If the Federal Government endorses MSAC’s recommendation to expand the eligibility criteria for self-collection, it could be introduced as soon as 2022.
 
To get a better understanding of GPs’ perspectives on the pathway, particularly those who have reservations about it, Associate Professor Brotherton is part of a team currently undertaking a rapid consultation to gain insight on what it will take to support doctors to comfortably offer self-collection as part of their routine practice if the program moves to open access.
 
‘The model of care that Australia has always had for cervical screening places the GP right at the middle of it,’ she said.
 
‘That connection and trust in the provider is fundamental to engaging women in cervical screening, and the model for self-collect that we have in our program absolutely recognises that.
 
‘So that context of support and explaining the test. And certainly, if the woman has a positive screening test, they need that support and referral to make sure they then go on to diagnosis and treatment if needed.
 
‘Fundamentally, that’s why the offer of self-collect will stay within general practice. And so GPs will need to be able to explain quite clearly to women what the difference between the two tests is, and what the issues might be around making that choice.’
 
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