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At-home HPV testing for cervical cancer screening could prevent further harm caused by suspension of NHS services during the pandemic

Professor Gordon Wishart, Chief Medical Officer at Check4Cancer discusses how at-home HPV testing for cervical cancer screening could prevent further harm caused by suspension of NHS services during the pandemic. 

  •  At-home HPV testing is a safe and effective way to perform cervical screening that will reduce the number of smear test appointments that are needed, GP & hospital visits and invasive procedures by 90%.

  • At-home HPV testing should be accelerated by NHS England to cope with the increasing waiting lists of women due for cervical cancer screening, and lessen the impact of falling attendance rates for cervical screening.

  • CRUK reports 200,000 people not being screened every week for breast, bowel and cervical cancer resulting in 400 people with cancer going undiagnosed.

  • Delays in cancer diagnosis can lead to increased cancer deaths, estimated to be 18,000 excess deaths in first 12 months of response to COVID-19 pandemic.

  • Around 857,000 women will miss their cervical screening appointment if screening is suspended for 12 weeks.

10th June 2020

Since the beginning of the COVID-19 lockdown period, screening services for breast, bowel and cervical cancer have been formally paused in Scotland, Wales & Northern Ireland, and informally paused in England. With the lockdown period likely to persist to some extent for most of 2020, this will delay the diagnosis of these three cancers and lead to an increased number of deaths. Around 10 million men and women are screened annually in England for breast, bowel and cervical cancer.

Excess cancer deaths due to COVID-19 emergency response

My previous reports, published in eCancer on 9th and 20th April 20201,2, were some of the first to raise concern that the lockdown was contributing to delays in cancer diagnosis and treatment that would result in increased cancer deaths. On 21st April, Cancer Research UK estimated that 2,700 patients every week were not being diagnosed during the lockdown, with 2,300 as a result of patients not being referred for investigation of urgent symptoms, and another 400 patients who are not being diagnosed due to suspension of 200,000 appointments every week, for breast, bowel and cervical cancer screening.

A report by UK cancer specialists3 has estimated there will be as many as 18,000 excess deaths from cancer during the first year of the UK response to the COVID-19 pandemic due to significant reduction in GP referrals, delays in diagnosis and cancellation of cancer treatments such as chemotherapy.

Suspension of cancer screening services will cause delays and further harm

In 2018-2019, 3.43 million women accepted the invitation for cervical screening, a 70% uptake for women ages 25-49 and a 76% uptake for women aged 50-64. Therefore, a 12-week suspension of cervical cancer screening services will cause a delay in testing for around 857,000 women who will then need to be tested when the suspension is lifted. In addition, a number of women whose investigations for an abnormal screening test were cancelled during the 12-week suspension, will also have to be tested. Trying to re-launch the NHS cancer screening programmes, while dealing with the delays caused by the screening suspension, will put a massive strain on NHS cancer resources that were already failing before the coronavirus pandemic.

I have previously referenced substantial evidence from Cancer Research UK2 that highlights that the NHS is not well prepared to deal with a significant backlog of cancer patients for diagnosis or treatment, with poor survival rates, a shortage of cancer specialists and many months of failed cancer targets. The longer the lockdown restrictions stay in place, the worse this will become and therefore a solution is required now rather than watching the waiting lists grow and grow. Furthermore, the nurses and doctors who perform cervical smears or procedures to look for changes to the cervix, will have to use significant PPE protection to undertake these safely, leading to fewer being performed on each operating list thereby increasing the time taken to reduce waiting lists.

Why not introduce at-home testing for HPV cervical screening?

The NHS now initially screens women for the human papillomavirus (HPV), the cause of 99.8% of all cervical cancer, and only examines the cervical cells for any abnormalities if HPV is detected. It is now possible for women to perform an at-home HPV test using a simple cervical swab and, a Scottish study published in the BMJ in 20164 reported that HPV testing on self-samples was as effective as clinician samples at detecting early cancerous change and, justifies consideration for primary screening. A review of 81 studies published in 2018 also concluded that self-sampling was as effective as clinician sampling, and a more effective way to reach under-screened women5. At Check4Cancer, we have five years’ experience of using an at-home HPV test for cervical screening and can report that it has been extremely well accepted, with high patient satisfaction, with 9% of women having a positive HPV result following the at-home test.

The Dutch cancer screening programme has used primary HPV testing since January 2017 and, participants have the option to request a self-sample collection. In a recent review of more than 450,000 patients6, more than 36,000 used the self-sampling option and the overall rate of HPV-positivity was 9% which concurs with our own data for Check4Cancer’s HPVCheck. Despite the HPV test being accurate, actual analysis of the cells for cancerous changes in self-sample material is unreliable, and therefore women who were HPV positive on self-sampling were invited to have smear test by their GP. Overall 3% of all patients were finally referred to a gynaecologist for further investigation and/or treatment.

The NHS can and should adopt at-home testing for HPV

In the current NHS cervical screening programme, a cervical smear is taken by a clinician then tested for HPV and if positive, the cells are examined to look for early cancerous change. This is a two-step process based on a single sample collection, but all women require a traditional smear test. With an at-home HPV test, approximately 10% will test positive for HPV and proceed to a traditional smear test. This is also a two-step process, but 90% of women avoid an appointment to have a smear test. Under current restrictions, this would allow 90% of women to avoid visiting their GP or hospital, and significantly reduce the number of invasive procedures carried out by clinicians wearing full PPE protection and the expense that would be incurred.

Many doctors and patients have become increasinly concerned that the management of COVID-19 patients has been over-prioritised to the detriment of many other serious and time-critical conditions, and that the imbalance now needs to be redressed. In response to the COVID-19 pandemic, the UK government has shown that laboratory resource can be upscaled in a short space of time, and that home-testing for coronavirus is possible, so why not introduce the same approach for cervical screening? Furthermore, the NHS bowel cancer screening programme already functions well with home testing and onward referral for those with a positive test, so why not adopt the same approach for cervical screening? Current suspension of the bowel screening programme is almost certainly due to lack of safe colonoscopy facilities for patients with an abnormal screening test, but I have argued for the last nine weeks that the NHS should use the COVID-free private sector to maintain access for cancer diagnosis2.

It is clear that NHS England is already thinking about self-sampling, as I was contacted in early April 2020 by the project manager of their cervical screening self-sampling team to discuss Check4Cancer’s clinical service and experience with at-home HPV testing. NHS England has shown many times during the coronavirus pandemic that it can make quick decisions based on scientific evidence, so I would therefore encourage NHS England to review the science and consider early adoption of self-sampling to help manage the backlog of women who will become increasingly concerned about the delay to their screening appointment. In my opinion it ticks all the boxes during the current restrictions – it can be safely performed at home, it avoids an invasive procedure (cervical smear) for 90% of women and only a small number of patients will need to attend secondary care for further investigation and/or treatment.

References: 

  1. Cancer Treatment delays could increase death rates due to impact of Covid-19 pandemic on UK hospital capacity, ecancer, 14th April 2020. https://ecancer.org/en/news/17643-cancer-treatment-delays-could-increase-death-rates-due-to-impact-of-covid-19-pandemic-on-uk-hospital-capacity.
  1. Wishart GC. Failure to fully integrate NHS and private hospitals during the COVID-19 pandemic will increase cancer death rates, ecancer, 20th April 2020. https://ecancer.org/en/news/17677-failure-to-fully-integrate-nhs-and-private-hospitals-during-the-covid-19-pandemic-will-increase-cancer-death-rates
  2. Lai AG, Pasea L, Banerjee A et al. Estimating excess mortality in people with cancer and multimorbidity in the COVID-10 emergency. April 2020. https://www.researchgate.net/publication/340984562_Estimating_excess_mortality_in_people_with_cancer_and_multimorbidity_in_the_COVID-19_emergency?channel=doi&linkId=5ea8b957a6fdcc7050976a3e&showFulltext=true
  3. Stanczuk G, Baxter G, Currie H et al. Clinical validation of hrHPV testing on vaginal and urine samples in primary cervical screening (cross sectional results from the Papillomavirus Dumfries and Galloway – PaVD&G study). BMJ Open 2016; 6: e010660.https://bmjopen.bmj.com/content/6/4/e010660?int_source=trendmd&int_medium=cpc&int_campaign=usage-042019
  1. Arbyn M, Smith SB, Temin S et al. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. BMJ 2018; 363: k4823. https://www.bmj.com/content/363/bmj.k4823
  2. Aitken CA, van Agt HME, Siebers AG. Introduction to primary screening using high-risk HPV DNA detection in the Dutch cervical cancer screening programme: a population-based cohort study. https://bmcmedicine.biomedcentral.com/track/pdf/10.1186/s12916-019-1460-0

 

 

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