June Y. Hou, MD
Cervical cancer is one of the most preventable and treatable cancers, thanks to the HPV vaccine and regular screening. Despite these advances, one in five people are not getting regularly screened as recommended. Barriers like lack of health insurance, limited access to healthcare, and discomfort with the screening process keep many from getting tested.
Recently, the United States Preventative Services Task Force (USPSTF) issued new guidelines recommending a self-collected HPV test as an option for cervical cancer screening. Unlike the traditional Pap test (also known as Pap smear) - which requires a clinician's visit and an exam that many find uncomfortable - the new test allows people to collect a sample themselves. Countries that have already adopted the self-collected tests have already seen improved screening rates, and some experts suggest that with continued adoption, cervical cancer could even be completely eliminated.
June Y. Hou, MD, associate professor of obstetrics & gynecology at Columbia University Medical Center and director of clinical operations in gynecologic oncology at Columbia University Irving Medical Center/NewYork-Presbyterian, focuses her research on equitable healthcare and innovative screening methods.
In this Q&A, Hou discusses what these new guidelines mean, how self-collection works, and its impact on the future of cervical cancer prevention.
What are the recent changes in cervical cancer screening guidelines, and what evidence supports the shift?
The United States Prevention Services Task Force (USPSTF) recently published a draft of updated recommendations for cervical cancer screening. The proposed updates are based on a comprehensive review of previous evidence as well as new data and findings, including over 300 peer-reviewed studies.
Almost all cervical cancers are caused by human papillomavirus (HPV) infection, and cervical cancer screening aims to detect precancerous lesions of the cervix before they develop into cancer. An HPV test is an extremely sensitive way to detect the presence of high-risk HPV on the cervix. The USPSTF proposes using the HPV test, instead of the Pap test, every five years as the primary way to screen for cervical cancer for women between 30 and 65 years. New research shows that HPV testing alone can pick up more CIN3 (severe precancer lesions) than Pap testing alone.
How are the HPV screening and PAP test different?
HPV screening detects high-risk HPV DNA from cells collected on the cervix and/or vagina, usually via a swab or a brush. If the test is positive, this means that HPV is detected in the sample, which can indicate presence of precancer cells. A Pap test is a collection of cells on the cervix, which is done during a pelvic exam using a speculum. The sample is then examined under the microscope by a pathologist to detect abnormalities. If either HPV testing is positive or a Pap test is abnormal, further workup is recommended.
A key difference for patients is that there are now FDA approved self-collection HPV tests, which allow individuals to collect their own sample in a healthcare setting. These tests are equally or more effective than the clinician-collected HPV test. This provides an option for people who cannot or do not want to undergo a pelvic exam, which is required for a Pap test.
Currently, the self-collected HPV test is still only approved for use in healthcare settings, such as a doctor's office or clinic. Research is ongoing to evaluate at-home testing, but it is not yet FDA-approved. Having the option of at-home HPV testing may make cervical cancer screening more accessible and could mean more people get screened.
What does a positive HPV test result mean? What are the next steps?
A positive HPV test result means that one or more high-risk HPV strains are present in the sample, and that the chance of having CIN3 (or severe precancer lesions) on the cervix is higher. The next steps depend on the subtype of HPV strain detected. Some cases require frequent follow-up, while others may need a colposcopy, an examination of the cervix under a microscope in a clinician's office, as well as possible cervical biopsies.
Why do the guidelines still recommend Pap tests every three years for women aged 21 to 29 instead of HPV testing?
In this age group, HPV infection is very common, and short-lived. The body's natural ability to fight infections (the immune system) is strong and typically clears HPV infection quickly. Since most infections in this age group do not lead to cancer, HPV testing may lead to more frequent and unnecessary procedures. A Pap test alone is the recommended option for this age group.
Could self-collection tests improve screening rates and cervical cancer outcomes?
Yes. We know that even though cervical cancer screenings are available to almost all women at low or no cost, about 20% of eligible women - nearly 14 million - do not get screened regularly. Common barriers include 1) concerns for privacy and discomfort with pelvic exams; 2) lack of awareness about screening options; and 3) logistical challenges, such as difficulty accessing a doctor's office.
The recent FDA approval of self-collection for HPV testing in clinical settings is a major step to reach those who might otherwise go unscreened. It allows individuals to take their own samples privately, without requiring a pelvic exam.
This is a game-changer for those in medically underserved areas, those without insurance, and those for whom a pelvic exam is not feasible or acceptable. Research has shown that under-screened individuals often visit healthcare providers for other medical needs - without specifically seeking out gynecologic care. By including self-collection into healthcare settings, we may be able to increase screening rates and catch potential issues earlier.
While self-collection is currently only available in healthcare settings, the possibility of at-home HPV testing in the future could further expand access. Many meta-analysis and studies have shown that people prefer and are more likely to participate in cervical cancer screening when an at-home option is offered, over coming into a clinician's office for the test.
