Preliminary Results of Feasibility and Acceptability of Self-Collection for Cervical Screening in Italian Women

Experiences of Self-Collected Human Papilloma Virus (HPV) Testing Among Women Aged 20 to 65 Years in Ho Chi Minh City, Vietnam

Background/Objectives: To assess the correct sampling rates and self-collection satisfaction levels among female residents aged 25 to 64 years during first-time HPV testing in the communities of Ho Chi Minh City. Methods: An observational study was conducted on self-collection for HPV testing in communities from January to December 2024. The study employed a probability proportional to size sampling method, involving self-collected sampling and post-collection direct interviews. Results: The data show that 99.9% [95% CI = 0.99-1] of 775 women successfully collected their own samples during a first-time HPV testing process. The self-collection satisfaction rate was 80.4% [95% CI = 0.77-0.83]. Conclusions: Self-collected sampling for HPV testing has a very high success rate in communities. Moreover, women who feel confident in self-collection tend to have higher satisfaction rates with this new method. Therefore, self-collection sampling should be widely adopted for early cervical cancer screenings to test for high-risk HPV. It is essential to provide careful instructions and mobilization to encourage women's confidence in performing self-collections.

Effect of time and temperature on the stability of HPV and cellular nucleic acid using simulated dry self-samples

BACKGROUND

Self-sampling is now a key component within HPV-based cervical screening programmes to engage individuals and enhance participation. As self-sampling is relatively new, information on the influence of pre-analytical parameters such as transit-temperature and time between sampling and testing on HPV test results requires detailed investigation.

METHODS

FLOQSwabs® and Evalyn Brushes® were used to assess HPV and cellular stability over a 30-week period (0w,4w,12w,30w) at 4 °C, ambient, and 37 °C. Vaginal self-samples were simulated by inoculating the devices with an HPV16-positive cell-line suspension. Devices were tested using two DNA-based (Anyplex™ II HPV28, Papilloplex® HR-HPV), one mRNA-based (APTIMA HR-HPV,) and one in-house beta-globin qPCR assay.

RESULTS

No loss of qualitative HPV detection was observed after 12-weeks storage at ambient or 4°C irrespective of device or assay. For DNA-based assays, no loss of qualitative HPV detection was observed over time (30w) irrespective of temperature/device. Loss of qualitative mRNA signal was observed when devices were stored at 37°C for 12-weeks or longer; however, no loss of detection was observed at 30-weeks when either device was stored at 4°C.

CONCLUSION

HPV nucleic acid is stable on proxies of self-taken samples, however, the duration of stability was affected by the device and storage conditions. Such differences should be considered when optimising self-sampling exercises.

Molecular Detection of Human Papillomavirus (HPV) and Other Sexually Transmitted Pathogens in Cervical and Self-Collected Specimens

This study investigated the detection of high-risk Human Papillomavirus (hrHPV) and seven other pathogens associated with sexually transmitted infections (STIs) in matched clinician-collected cervical samples and self-taken vaginal and urine specimens collected from 342 asymptomatic women referred to colposcopy to evaluate (i) the concordance in the molecular detection of investigated pathogen in three different sample types; (ii) the analytical sensitivity and specificity of STIs detection on self-samples; and (iii) the distribution of STIs in hrHPV-positive and hrHPV-negative women. Pathogens detection was performed using Anyplex™II HR and Anyplex™II STI-7e, respectively. Good/substantial agreement was observed between cervical and self-taken samples in detecting hrHPV (κ = 0.870 and κ = 0.773 for vaginal and urine). The agreement between cervical and self-taken samples for detecting STIs was found to be significant (κ = 0.779 and κ = 0.738 for vaginal and urine), with almost perfect agreement between urine and vaginal specimens (κ = 0.899). The positivity rate for all investigated STIs was found to be higher in hrHPV-positive compared to hrHPV-negative women. In conclusion, self-sampling proved to be a valid alternative to cervical samples to detect hrHPV and STIs, but further studies are required to evaluate the role of STI coinfections in cervical lesions development and progression.

Beliefs and Perceptions in Attending the Cervical Screening: The COMUNISS Project Experience

BACKGROUND

Several studies highlighted that tailored health communication interventions improve cervical screening participation, vaccination coverage, and awareness about self-sampling benefits. The "COMUNISS" project was aimed at increasing awareness about cervical cancer prevention, identifying barriers to screening, and promoting screening uptake in under-screened women.

METHODS

A dedicated website with a Q&A session regarding HPV-associated diseases has been set up. Participants were invited to complete a questionnaire to gather demographic information, knowledge about HPV and cervical cancer, and attitudes toward screening based on the Health Beliefs Model (HBM). Women can also require a vaginal self-sampling kit at your home to perform the HPV-DNA analysis.

RESULTS

The website registered over 1000 users over 6 months, and 256 women completed the survey. Nearly half were under-screened. The HBM revealed a high susceptibility and severity perception of diseases, regardless of screening participation, whereas older women declared a high perception of barriers. One-quarter of the women who had requested the self-collection kit returned it for the HPV-DNA testing.

CONCLUSIONS

The project found significant gaps in knowledge regarding extra-cervical HPV-related cancers, interpretation of screening results, and effectiveness of self-collection. These findings highlight the need to plan targeted information campaigns to enhance awareness and adherence to screening programs.

Addressing COVID-19 Screening Delays: The Impact of HPV Self-Sampling on Non-Attenders in a Cervical Cancer Screening Program

Background/Objectives: Self-sampling is recognized as a viable alternative to clinician-sampling for HPV primary screening. This study aimed to assess, within an Italian organized cervical cancer screening program, the acceptance and ease of use of self-sampling and the adherence to follow-up. The prevalences of HPV infection, cervical dysplasia, and cancer were contextually evaluated. Methods: Electronic records of 19,327 women, 30-64 years-old, residing within the Bologna Local Health Authority territory, who were offered self-sampling as an alternative to clinician-sampling, were retrospectively reviewed. They had never or irregularly attended and were overdue for a screening invitation due to the COVID-19 pandemic. An opt-in approach was adopted, involving local pharmacies for kit delivery and sample collection. Initially, HPV-positive results led to direct referral to colposcopy; later, cytological triage on clinician-samples was provided. Results: Self-sampling reached over twice as many women (11.5%) compared to historical clinician-sampling alone (<5%), showing high acceptance. Additionally, a high screening completion level was observed, with 79.5% of self-samples returned to pharmacies. A low percentage of self-samples resulted in inadequate results (1.1%), suggesting the method's ease of use. HPV-positivity was 13.1%, higher than the 9.9% recorded in the ordinary screening population in 2019 (p < 0.001), the last year before the pandemic. Compliance to both immediate colposcopy and cytology triage exceeded 90% (p = 0.675). The rate of cervical adenocarcinoma was twice as high as in the routinely screened population in 2019 (0.9‱ versus 0.4‱). Finally, 6% of women opted for clinician appointments. Conclusions: Self-sampling proved to be an easy-to-use and effective tool for reaching non-attenders, who are at high risk of cancer. Cytology triage on clinician-samples did not negatively impact follow-up adherence. It seems appropriate to maintain a clinician-collection option even among non-attenders.

Evidence from Europe on implementation, participation and performance of self-collection for cervical cancer screening

Cervical cancer screening programs reduce the number of cervical cancer cases and deaths, but the success of any screening program is dependent on high participant uptake and coverage and many European countries are observing declining cervical cancer screening coverage to below national targets. Self-collection of vaginal samples for human papillomavirus testing, also termed self-sampling, is one strategy which is being introduced to try to increase screening coverage by removing barriers to participation and it has attracted growing interest and support globally. Informed by peer-reviewed and gray literature, this narrative review starts with a case study from the Netherlands and outlines the self-collection landscape in Europe within the themes of program implementation and relative test performance. It highlights some of the current evidence gaps needed to inform policy decisions on the use of self-collection within screening programs.

Self-Screening for Cervical Cancer Offered through a Digital Platform in a Region of British Columbia with Lower Screening Rates

Cervical cancer is highly preventable through vaccination, early detection, and treatment, yet is the fourth most common cancer globally. HPV testing is superior to cytology for the detection of cervical pre-cancer, and jurisdictions around the world are implementing HPV primary screening, which offers the opportunity for self-screening, an important self-care intervention. Digital health solutions are also increasingly important components of self-care. In this study, we assessed the acceptability and completion of self-screening for cervical cancer offered through a digital platform within a low screening uptake region of British Columbia. The primary objective of this study was to evaluate the acceptability of self-screening for cervical cancer offered through a digital platform as measured by return rates of self-screening kits. Patients due or overdue for cervix screening were invited to participate. Eligible participants registered online to receive a self-screening kit, which included a device for vaginal self-screening, instructions, and a return envelope, sent to their home. After self-screening using the vaginal device, HPV testing was conducted. HPV-negative participants were returned to routine screening, and HPV-positive participants were recommended for cytology or colposcopy. Attendance rates at follow-up were evaluated. Participants were invited to complete an acceptability survey. From April 2019 to December 2023, 283 participants were sent kits, with 207 kits returned for a completion rate of 73%. Of valid samples (n = 202), 15 were HPV positive, and 93% attended follow-up care. Most respondents found the CervixCheck website easy to use, informative, and secure and were satisfied with receiving their results online. CervixCheck had a high completion rate among participants who were sent a self-screening kit. High compliance with recommended follow-up and high acceptability of self-screening for cervical cancer was observed. Most participants indicated they would self-screen again in the future. Innovative approaches to cervical screening, including self-screening and the use of digital health interventions, are ways to enhance equity and improve uptake of cervical screening.

Evaluation of two alternative non-alcohol-based media for the suspension of self-collected vaginal swabs for HPV testing in cervical cancer screening

The introduction of Human Papillomavirus (HPV) testing in cervical cancer screening enhanced the opportunity to introduce self-collection as an innovative approach to improve coverage rates. Validation and standardization of the pre-analytical and analytical procedures are crucial for the quality assurance of HPV tests on self-collected samples. This study evaluated the analytical performance and the stability of self-collected vaginal samples resuspended in 5 mL of two non-alcohol-based media, eNat® and MSwab® compared to a professionally collected cervical sample, resuspended in 20 mL ThinPrep®, for the detection of high-risk HPV (hrHPV). The impact of the suspension volumes on analytical performance was also evaluated (2 and 5 ml). A good analytical concordance in hrHPV detection in cervical and vaginal self-collected swabs suspended in 5 ml of both non-alcohol-based media was demonstrated (eNat®: 91.2 %, k = 0.821; MSwab®: 91.4 %; k = 0.798). A similar analytical performance was found for samples resuspended in 2 mL (eNat®: 92.9 %, k = 0.811; MSwab®: 92.9 %, k = 0.811) compared to cervical samples. Good nucleic acid stability was demonstrated for vaginal samples stored at 20-25 °C and 37 °C for up to 4 weeks. Results of this preliminary study support the introduction of these media for vaginal self-sampling-based prevention programs. Nevertheless, further research is necessary to evaluate clinical accuracy in larger settings.

Acceptance of Self-Sampling by Women Not Regularly Participating in Cervical Cancer Screening in Areas with Low Medical Density: A Qualitative Study within the French CapU4 Trial

Cervical cancer (CC) was diagnosed in 3159 women in France in 2023, and 1117 died from it. Organized screening for cervical cancer is potentially very effective for participating women. However, reaching under-screened populations remains a major challenge. The present qualitative study explored women's opinions on what discourages or encourages them to participate in CC screening and assessed the acceptability of two experimental strategies (urinary or vaginal self-sampling kits) to increase the screening coverage in three rural French administrative departments with low medical density and/or low screening participation rates. Forty-eight semi-structured interviews and four focus groups were conducted by a team of psychologists. Results showed that the participants accepted at-home self-sampling to reach non-participating women in medically underserved areas. However, they suggested that the type of kit sent should be adapted to the patient's profile (embarrassment from earlier exams, cultural aspects, fear of invasiveness, etc.), and that kits should be simple to use (in understandable language taking sociocultural aspects into account). Women wished to be assured that testing on self-samples is accurate and needed information about further actions in case of a positive result.

Diagnostic Accuracy of DNA-Methylation in Detection of Cervical Dysplasia: Findings from a Population-Based Screening Program

BACKGROUND

Epigenetic biomarkers in cancer have emerged as promising tools for early detection, prognosis, and treatment response prediction. In cervical cells, hypermethylation of the host and viral HPV-genome increases with the severity of lesions, providing a useful biomarker in the triage of hr-HPV-positive women and during treatment. The present study focuses on evaluating the clinical performance of the FAM19A4/miR124-2 methylation test in a population-based cervical screening program.

METHODS

Previously collected cervical samples, after bisulfite-converted DNA, were analyzed by PreCursor-M+ kit (distributed by Fujirebio Europe), for DNA methylation. The sensitivity, specificity, and negative/positive predictive values of DNA methylation were compared to histology, colposcopy, the HPV-DNA test, and cytology results.

RESULTS

Among the 61-sample set, the specificity of methylation vs. positive histology (≥CIN2) and colposcopy (≥G2) were 87% and 90%, whereas the sensitivity was 50% and 33.3%, respectively. The combination of methylation analysis with standard methods increases diagnostic accuracy.

CONCLUSIONS

Overall, we found a good specificity of DNA methylation in comparison to currently used techniques. Further larger studies could support the use of FAM19A4/miR124-2 as reliable biomarkers in the prevention of cervical cancer as triage in the screening protocol.

HPV and Cervical Cancer: Molecular and Immunological Aspects, Epidemiology and Effect of Vaccination in Latin American Women

Cervical cancer is primarily caused by Human Papillomavirus (HPV) infection and remains a significant public health concern, particularly in Latin American regions. This comprehensive narrative review addresses the relationship between Human Papillomavirus (HPV) and cervical cancer, focusing on Latin American women. It explores molecular and immunological aspects of HPV infection, its role in cervical cancer development, and the epidemiology in this region, highlighting the prevalence and diversity of HPV genotypes. The impact of vaccination initiatives on cervical cancer rates in Latin America is critically evaluated. The advent of HPV vaccines has presented a significant tool in combating the burden of this malignancy, with notable successes observed in various countries, the latter due to their impact on immune responses. The review synthesizes current knowledge, emphasizes the importance of continued research and strategies for cervical cancer prevention, and underscores the need for ongoing efforts in this field.

Comparison of diagnostic accuracy and acceptability of self-sampling devices for human Papillomavirus detection: A systematic review

Objective

Cervical cancer screening coverage remains low in many countries worldwide. Self-sampling approach for cervical cancer screening has a good potential to improve the screening coverage. This study aims to compare different types of HPV self-sampling devices for cervical cancer screening to identify the most accurate and acceptable device(s).

Methods

A systematic review was performed on data extracted from all studies specific to HPV self-sampling devices by searching relevant articles in PubMed, Google Scholar, Scopus, Web of Science, ScienceDirect, Cochrane Library, and EBSCO published from 2013 to October 2023. The study was registered in PROSPERO (CRD42022375682).

Results

Overall, 70 papers met the eligibility criteria for this systematic review and were included in the analysis: 22 studies reported self-sampling devices diagnostic accuracy, 32 studies reported self-sampling devices acceptability and 16 studies reported both (accuracy and acceptability). The most popular self-sampling devices were Evalyn Brush, FLOQ Swab, Cervex-Brush, and Delphi Screener. Out of overall 38 studies analyzing self-sampling devices' diagnostic accuracy, 94.7% of studies reported that self-collected specimens provided sensitivity and specificity comparable with clinician-collected samples; acceptability of Evalyn Brush, FLOQ Swab, Delphi Screener, and Colli-Pee, varied between 84.2% and 100%.

Conclusion

The self-sampling approach has a good potential to increase cervical cancer screening coverage. Evalyn Brush, Cervex-Brush, FLOQ Swab, and Delphi Screener self-sampling devices for HPV detection were the most commonly utilized and found to be the most accurate, and patient-acceptable. HPV detection accuracy using these self-sampling devices had no significant difference compared to the sampling performed by healthcare providers.