Cervical cancer screening: Sharing best practices and addressing common challenges in cervical cancer screening programs

Abstract

There is a concerning trend of declining or stagnated cervical cancer screening participation in some high-income countries, which disproportionately affects women from disadvantaged communities.^{1, 2} For example, in the United Kingdom, screening participation declined from 78.6% in 2011 to 70.2% in 2021, and in the Netherlands, from 66.2% in 2011 to 45.7% in 2022.^{3, 4} This is important as strategies for eliminating cervical cancer, which include high uptake of vaccination, continue to require screening to be deployed for several decades for both unvaccinated and vaccinated individuals.

The reasons behind this suboptimal screening participation are multifaceted, encompassing issues such as lack of awareness, cultural beliefs, geographical and financial barriers, and limited access to healthcare. For younger screen-eligible cohorts, HPV vaccination may also create a sense of security that may detract from screening participation. Urgent action is imperative to reverse this trend and prevent needless deaths from this largely preventable disease.

Recognizing the urgency, the “Advancing Cervical CancEr ScreeningS” (ACCESS) International Consensus Group was established in 2023 as a coalition of leading clinicians, researchers, patient, and women's advocates to advance women's health by increasing participation in cervical cancer screening.

The session provoked discussion around best practices and common challenges within cervical cancer screening programs.

Offering self-sampling only to under-screened women has the potential to increase screening participation.^{6, 7} However, during the roundtable discussion, experts discussed the impact of self-sampling and cautioned against viewing it as a panacea for addressing low participation rates. Real-world experience was shared from countries with relatively high but declining participation rates, where self-sampling has already been introduced but has so far not resulted in substantial increases in uptake among under-screened individuals. One expert predicted that, in the best-case scenario, around 20% of the population would use self-sampling if available.

Further, in the largest population-based real-world study to date,⁸ a large number of individuals who regularly participated in screening switched from provider-collected to self-sampling. This was viewed as concerning given test performance: relative CIN2+ detection with self-sampling was estimated as low as 76% in comparison to clinician-collected samples in the same study.⁸ This would mean that almost one in four women with cervical lesions could potentially be missed when using self-sampling in screening programs.

The speakers emphasized that follow-up after a positive test result has proven particularly difficult in cases of women using self-sampling. Self-sampling was associated with a fourfold higher risk of loss to follow-up compared to women who were screened by their general practitioner, resulting in missed CIN2+/3+ lesions, potentially reducing overall screening program effectiveness.⁹

Some experts present argued that, regardless of the challenges identified, women should be offered a choice of screening modality, including information on the advantages and disadvantages of self and provider-collected screening options.

A second important outcome from the meeting was the sharing of country-level initiatives that have been successful in addressing screening participation among under-screened populations. An example mentioned was an equity-driven project in Ireland focusing on women over 60, which yielded promising results, achieving a 24.9% screening participation rate in this age range through a multidisciplinary approach combining bespoke invitation letters and tailored communication for both women and healthcare professionals.¹⁰

A number of experts spoke about the importance of providing adequate financial incentives for healthcare professionals charged with providing screening, in particular general practitioners and practice nurses. Given the significant pressures on healthcare professionals, the lack of appropriate compensation was seen as a key factor in providers' coverage targets being missed or their limited engagement in trying to increase participation among eligible patients. Some countries have deployed dedicated education teams to educate sample-takers. The adoption of new educational platforms such as webinars and e-learning modules, coupled with the establishment of standardized education protocols, were also cited as key tools.

Finally, experts highlighted the role of robust IT infrastructure and data management systems. Addressing challenges stemming from data privacy regulations (e.g., the General Data Protection Regulation in the EU) and access to population-based data, test results, and distribution of screening invitations, is paramount to ensure the effectiveness of screening programs. In the Netherlands, general practitioners are not able to access self-sampling test results due to personal data privacy laws, which may lead to a higher risk of loss to follow-up after a positive self-test result.

It was clear from the roundtable discussion that there is no silver bullet to address the challenges in screening participation. Holistic approaches addressing all factors that contribute to sub-optimal participation are needed. The meeting highlighted the significant benefits of sharing best practices and innovative approaches through international dialogue and collaboration among stakeholders, including policymakers, screening program managers, healthcare professionals, patient advocacy groups, and representatives of under-screened populations. Such cooperation is essential to advance towards cervical cancer elimination.

Philippe Descamps: Writing – original draft; writing – review and editing; project administration; supervision; conceptualization; methodology. Francesc Xavier Bosch Jose: Writing – review and editing. Joseph Monsonego: Writing – review and editing. Ody Neisingh: Writing – review and editing. Lananh Nguyen: Writing – review and editing. Mairead O'Connor: Writing – review and editing.

The work of the ACCESS Consensus Group is supported by Hologic. Hologic has no editorial control over the content produced by the group. Philippe Descamps, Francesc Xavier Bosch Jose, Joseph Monsonego, Ody Neisingh, and Lananh Nguyen reported financial compensation from Hologic for their activities as members of the ACCESS Consensus Group. Mairead O'Connor reported reimbursement for travel, speaking time, and accommodation from the ACCESS Consensus Group (paid by Hologic) for a roundtable discussion event at the European Parliament in January 2024.