Doctors and patients are still unsure about self-collected cervical screening tests, but should they be?

When the cervical screening HPV test replaced Pap smears in 2018, there was discussion of patients collecting their own samples, but it was widely discouraged and reserved for only certain under-screened patients who would otherwise not test at all.

“Now almost anybody’s suitable for self-collection,” says Dr Rebecca South, Clinical Lead of the Inner West Women’s Health Centre.

So why has the advice changed?

“We didn’t have the same evidence that we have now,” says Professor Deborah Bateson, Medical Director of Family Planning NSW. “We were using different types of tests that actually weren’t quite as accurate.”

The original signal amplification tests have been replaced with the same PCR as used in a clinician-collect sample, and a 2018 meta-analysis showed them to be equivalent in sensitivity and accuracy. “We should all feel very comfortable and confident that the accuracy is there,” says Professor Bateson.

When they say anybody is suitable, do they really mean anybody?

Professor Bateson says there are very few exceptions. Essentially, any patient who requires a co-test cannot self-collect.

Patients Ineligible for Self-Collect

• patients with symptoms, e.g. post coital bleeding (this is no longer a screening test)
• patients undergoing a test of cure for previous abnormalities
• patients who were exposed to diethylstilbestrol (DES) in utero
• patients with a total hysterectomy AND history of high grade squamous intraepithelial lesion

These patients require a clinician-collected cervical sample.

Patients opting to self-collect need clear and detailed instructions on how to collect the sample. “They sometimes cannot believe how easy it is,” says Dr South.

Most pathology labs now offer tear off sheets the GP can use to explain to the patient. Dr South also recommends a poster in the practice bathroom.

It’s worth noting that different labs have different requirements. While most take just the red-topped swab, some may require it to be swirled in a ThinPrep vial.

There’s hope that self-collection can screening in patients who have never been screened, especially those with prior trauma. Professor Bateson says more male GPs may now be comfortable discussing and organising screening with patients. “It opens up the possibility to alternative models of care like telehealth,” she says.

The self-collect swab technique can also be used by the doctor or nurse for a patient unable to take their own sample, for example due to disability. This would still be listed as self-collect on the order form, but may be more appropriate for the patient than a speculum exam.

Potential test outcomes and their implications should be explained before the test is taken, whether self-collected or clinician collected. GPs may find the flowcharts in the guidelines useful, or the healthcare provider toolkit from the screening programme.

“The majority are going to be negative,” says Professor Bateson. Over 90% of screened patients will be told to repeat the screen in 5 years.

Patients who test positive for HPV 16 or 18 on self-collect need to be sent straight for colposcopy (there is no need for cytology). “With non 16 or 18 HPV, we need cytology for risk categorisation,” says Professor Bateson. These patients will need to return to the GP for a speculum exam.

Many doctors have expressed concerns that self-collection prevents opportunistic vulval and cervical examination. Professor Bateman says this examination was never the intent of cervical screening speculum use. The speculum is to ensure “cells from the cervix, ideally from the transformation zone.”

Dr South thinks vulvas are “probably not examined enough”, and she stresses the importance of asking about vulval symptoms such as itch or change in discharge. “Symptoms need to be examined, but we don’t necessarily need to cloud that issue with cervical screening,” she says, explaining that the doctor can examine the vulva, and the patient can still self-collect.

Cervical screening is safe in pregnancy, and Dr South says pregnant women are likely to prefer to self-collect. In fact, the technique is almost identical to the third trimester vaginal swab.

What about vaccinations?

“In line with the WHO recommendations, we’ve now gone to a single dose of HPV vaccination,” Dr South says. The nine-valent Gardasil will continue to be offered in schools, or available as a catch up dose at the GP until the age of 26.

Patients who are vaccinated after 26, or younger patients who are immune compromised, still need three doses, says Professor Bateson. She recommends keeping up to date with the relevant section in the Australian Immunisation Handbook.

Can we eliminate cervical cancer?

The World Health Organisation aims to eliminate cervical cancer by 2035, and Professor Bateson says Australia is on track to becoming the first country in the world to do so.

“Elimination doesn’t mean eradication,” she clarifies. It means fewer than 4 cases per 100,000 women per year.

The vaccination programme and improved cervical screening tests have already made a significant difference to cervical cancer rates in Australia, and Professor Bateson sees self-collect samples as the last piece in the puzzle.

“We now have the tools and the technology to eliminate a cancer,” she says.