Screening significantly reduces the risk of cervical cancer. Nevertheless, one fourth of women in Denmark are not screened as recommended by the Danish Health Authority. Now the Capital Region of Denmark is one of the world’s first screening programmes to introduce self-sampling. This enables women to collect a cervical sample at home rather than visit their doctor for screening. Up to 8 percentage points more women are expected to be screened, and researchers believe that this will save lives. Especially women who think that pelvic examinations are unpleasant choose self-sampling.
Many women need to use considerable time to visit the doctor to be screened for cervical cancer, and many conclude that this takes too long. In Denmark, about one fourth of women are not screened as recommended by the Danish Health Authority – often because of being too busy or because they find pelvic examinations unpleasant. More than 250,000 people die from cervical cancer annually worldwide. Although the Capital Region of Denmark has an effective screening program, it has decided to implement self-sampling on a trial basis, in which women can collect a cervical sample at home and send it to a laboratory. The results of the pilot implementation are now available.
“The very positive numbers show that making self-sampling a permanent option can probably increase the participation rate by up to 8 percentage points. In addition, our study suggests that self-sampling may increase screening participation among all socioeconomic groups, although these groups differed in participation in self-sampling. Participation in self-sampling was also high among women who found standard screening unpleasant or could not book a suitable screening appointment with their doctor. This indicates that busy lives and discomfort are the main reasons why these women initially chose not to undergo standard screening,” explains Susanne Krüger Kjær, Professor and Head of Research, Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center.
Good and easy alternative
The Capital Regional Council took the initiative to implement the new self-sampling method. In 2014 and 2015, invitations were sent to 23,632 women 27–65 years old. None of these women had been screened for at least 4 years. As many as 20% of these women accepted the self-sampling offer, in which they take a sample from their cervix and send it to the laboratory. In addition, a further 10% of the women decided to be screened at their own doctor after being offered self-sampling. In total, 30% of the women contacted were screened.
“Self-sampling is simple. Based on the sample, we can test women for human papillomavirus (HPV), which causes cervical cancer. Women who test positive are called in for follow-up testing by their doctor, so this is an incredibly effective way to get in contact with these women who are in the high-risk group because they have not been screened for a long time,” explains Jesper Bonde, Senior Researcher, Department of Pathology, Hvidovre Hospital, who is responsible for sending out the self-sampling kits.
Previous studies have shown that women participating in screening reduce their risk of developing cervical cancer by at least 80–90%, so these results are good news for the researchers, who have long sought methods to reach the 25% of women who are not screened regularly by their doctor. The accompanying questionnaire about lifestyle and the reasons for not being screened indicated why the self-sampling women had not been screened for several years.
“The survey found several factors. Among other things, the unpleasantness of a pelvic examination was a major reason for not attending standard screening. In addition, many of the women struggle to fit screening into a busy life. Self-sampling is a good and easy alternative in this situation. Further, many women with a high body mass index are not screened by their doctor but participate at the same rate as other women in self-sampling,” says Louise T. Thomsen, co-author and postdoctoral fellow, Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center.
Reaching out to everyone
The study thus indicates that HPV self-sampling may significantly improve the existing screening program. In the process, the researchers have also obtained knowledge about how they might be able to reach even more of the women who do not get screened by their doctor or by self-sampling.
“We have had good experience with such initiatives as disseminating information in several languages. One target group for this is women from other EU countries living in Denmark. The clear conclusion based on this study is that the easier and the less complicated we make screening, the more women participate. In addition to providing information in several languages, we use easy and simple web and app-like registration systems. All these measures increase participation and ultimately save lives,” explains Jesper Bonde.
Although the study is good news, it also indicates that some women are still hard to reach. Previous studies of the standard cervical cancer screening programs have revealed social imbalance in participation. Unfortunately, the sociodemographic characteristics of the women who participate in self-sampling and those who do not are not completely balanced.
“Although the self-sampling initiative increased participation in all socioeconomic groups, some women were still not screened. This especially applied to women with a basic educational level or lower income, women born in non-Western countries and women with severe mental disorders such as schizophrenia. These women probably need more targeted initiatives: for example, in collaboration with mental health services or public health nurses who perform home visits. Ultimately, screening should be made as accessible as possible,” says Susanne Krüger Kjær.
"Determinants for participation in human papillomavirus self-sampling among non-attenders to cervical cancer screening in Denmark” was published in Cancer Epidemiology, Biomarkers & Prevention. The Novo Nordisk Foundation awarded a main author, Susanne Krüger Kjær, Professor and Head of Research, Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, a grant in 2014 for the project Improving Survival of Ovarian Cancer: DNA from Routine Cervical Cytology Samples – the Value in Early Detection of Ovarian Cancer.