Home Screening for Human Papillomavirus Falls Short in Initial Application, Remains Promising

Abstract

In their randomized clinical trial, Winer et al 1 studied the effect of mailed human papillomavirus (HPV) self-screening kits vs usual care reminders on cervical cancer screening among underscreened women (ie, women whose last Papanicolaou test was more than 3.4 years before the intervention) in the Kaiser Permanente health care system. As the authors note, 1 the challenges of increasing cervical cancer screening uptake are daunting, and overcoming those challenges has the potential to drastically reduce morbidity and mortality from cervical cancer. Given the barriers to in-clinic screening, the idea of home HPV testing to increase cancer prevention efforts is appealing. Although the intervention did not lead to a statistically significant increase in the primary outcomes of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) detection (relative risk, 1.49; 95% CI, 0.61-3.64) or treatment (relative risk, 1.70; 95% CI, 0.67-4.32), the intervention increased screening uptake (relative risk, 1.51; 95% CI, 1.43-1.60) and reduced the time to screening uptake (median [interquartile range] time to screening uptake: 37 [22-49] days vs 80 [43-129] days). 1 While the trial is admirable in its design and large sample size, several limitations prevent it from having broad implications for cervical cancer screening at this time.Of 9960 women in the intervention group, only 1206 (12.1%) returned the kit, 1 which may have been due to several factors. First, patients were instructed to undergo clinic-based screening regardless of home HPV screening; thus, motivation to use the kit may have been low. Second, some patients may have been aware that they were not due for screening based on American Society for Colposcopy and Cervical Pathology guidelines. Kits were mailed to patients slightly more than 3 years after their last screening, and patients older than 30 years with previous negative cotesting (ie, normal Papanicolaou cytology and negative HPV testing) would have almost 2 years before their next recommended screening was due. Third, patients may have been wary of home screening given that vaginal HPV testing is not approved by the US Food and Drug Administration for risk stratification in cervical cancer screening. Furthermore, patients may have lacked knowledge regarding the superior sensitivity and negative predictive value of HPV testing. 2 It is understandable given these factors that the effect of this mailed HPV kit on screening uptake was modest, with an increase of only 8.9% (95% CI, 7.8%-10.0%) over usual care. 1 Despite an increase in screening uptake, the primary outcome of detected or treated CIN2+ was not significantly different among those who received the HPV kit than among those who underwent usual care reminders. This may be partly because of low prevalence of dysplasia in this population.The study population had low HPV test positivity (12%) compared with more diverse clinic settings and age ranges, in which high-risk HPV may be as prevalent as 35%. 3 It is especially concerning that slightly less ...

Performance and acceptability of self-collected human papillomavirus testing among women living with HIV

“…For example, one of the largest randomized clinical trials in the US of home HPV testing reported only 12% of participants returned the home HPV test kit, and there was no difference in detection of precancerous lesions compared to usual care ( Winer et al, 2019 ). The poor kit return in this trial might be explained by the patients’ lack of knowledge regarding the superior performance of HPV testing, the requirement to still attend the clinic for usual care, or the awareness that the results could not replace usual care screening methods ( Moss et al, 2019 ).…”