The following article is a part of conference coverage from the American Academy of PAs 2021 Conference (AAPA 2021), held virtually from May 23 to May 26, 2021. The team at the Clinical Advisor will be reporting on the latest news and research conducted by leading PAs. Check back for more from AAPA 2021.
Self-screening for human papillomavirus (HPV) is an effective and accurate way to increase screening rates for women who live in underserved rural communities, according to research presented at the American Academy of PAs 2021 Conference (AAPA 2021).
Currently, rates of morbidity and mortality associated with cervical cancer are higher in rural areas of the United States than in urban centers. Barriers to traditional HPV screening methods in rural areas include lack of time, increased travel distance, and lack of available providers. Limitations of traditional, cytology-based human HPV screening (PAP test) include low sensitivity, high costs, and a high burden on the health care system.
Data from multiple studies have demonstrated that HPV self-screening has sufficient sensitivity and specificity for use in low-resource settings and, in some studies, was more accurate in detecting cervical cancer than cytology alone, reported Nicolette Baharie, PA-S, and Jennifer Erickson, PA-C, MPH, coauthors of the study.
The presenters reviewed the literature on studies involving cervical cancer self-screening in adult women published between 2015 and 2020. Studies were evaluated for data on screening rates, cost-effectiveness, acceptability of self-samples, and follow-up after positive results.
Screening rates: HPV self-screening increased participation rates for women in hard-to-reach areas; these women would traditionally remain underscreened or not screened at all. Studies showed a significantly increased screening rate when self-sampling kits were mailed directly to the homes of underscreened women compared with mailed reminders to attend appointments for traditional screening.
Cost-effectiveness: Self-screening for cervical cancer can potentially reduce the overall screening costs for women because there is no need for an initial clinical encounter. In an analysis of 13 studies comparing cytology to HPV self-testing, self-collected HPV testing was found to be cost-effective when it “yielded higher population coverage.” This screening is most cost-effective when there is a longer gap between PAP smears.
Acceptability of self-sampling: A study of women living in rural Mississippi found that 78% of women preferred self-sampling over traditional PAP testing. Among the women who performed self-screening, 30% tested positive for a high-risk HPV infection. Another study found that rates of embarrassment, pain, anxiety, and discomfort were lower with self-sampling vs PAP testing.
Difficulties associated with the self-testing process included uncertainty of whether the test was performed properly, less trust in the accuracy of the results, and difficulty in inserting the self-collection brush.
Follow-up after positive results: Data on how to best follow-up on a positive screening result are conflicting, with some studies indicating that women who screen positive will follow-up with a health care provider; however, numerous women are still uninsured or underinsured, or experience other barriers to health care access.
Studies that included a direct referral following a positive screening result demonstrated higher rates of follow-up compared with those that used a triage policy or sent reminder letters with provider-explained consequences of not following up.
“HPV self-screening is an adequately accurate way to increase screening rates for women residing in low resource settings, such as rural America, and lack access to traditional screening,” the presenters concluded. “Future efforts should be directed towards research within the US health care system, with focus on [the] best ways for community education, how to identify which women need screening, [and] ways to increase follow-up after a positive result despite certain barriers.”
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Baharie N, Erickson J. Cervical cancer screening via HPV self-testing. Is this a screening method that can be used to increase participation rates for rural US women? Presented at: American Academy of PAs 2021 Conference; May 23-26, 2021. Poster 148.