Three years ago, the federal government set a series of targets to improve Americans’ overall health. Among the dozens of goals laid out in the plan, called Healthy People 2030, was a significant increase in the proportion of Americans who kept up to date with cervical cancer screening.
That, in turn, would enable more people to catch cervical cancer early, when it’s most treatable.
New research from the University of Washington and the Kaiser Permanente Washington Health Research Institute (KPWHRI) found that the simplest solution may also be the most effective: mailing test kits directly to patients’ homes. In the study published Nov. 28 in the Journal of the American Medical Association, researchers report that mailing test kits significantly increased cervical cancer screening rates, both in populations overdue for screening and those who had previously kept up to date.
The home test kits detect the presence of the human papillomavirus (HPV), which causes most cervical cancers. And a negative HPV test counts as a negative cervical cancer screening, allowing most people to avoid a clinic visit altogether. Currently, more than half of all cervical cancers diagnosed in the United States are in people who are overdue for screening or have never been screened. The team behind this study believes at-home testing can help close the gap.
“This is an alternative, patient-centered way to get people screened for cervical cancer, because patients tend to prefer testing at home and not having to come into the clinic,” said Rachel Winer, a UW professor of epidemiology who led the research. “This is a strategy that other countries are already using, and there’s overwhelming evidence that an HPV test on a patient-collected sample is similarly accurate to an HPV test on a sample collected by a clinician. So there’s really no reason why this shouldn’t be available in the U.S.”
In partnership with Kaiser Permanente Washington, researchers enrolled more than 31,000 female patients between the ages of 30-64 who were either due or overdue for screening, or whose screening history was unknown. Depending on their screening history, patients were randomly sorted into four groups: One group had HPV test kits mailed directly to participants’ homes, another received information on how to request a test kit, and another received an educational brochure on cervical cancer screening. The fourth group received only a standard reminder that participants were due for screening.
Over the next six months, 62% of people who were due for screening and 36% of people who were overdue were screened for cervical cancer after being directly mailed a kit. Those percentages fell to 48% and 19%, respectively, among patients who received only the educational brochure. Sending information on requesting a kit minimally increased screening.
The results, Winer said, indicate that healthcare systems should prioritize mailing HPV test kits directly to patients to maximize cervical cancer screening participation.
“We just think this should be an option for all patients,” Winer said. “It’s convenient, preferred by most patients and an accurate way to screen for cervical cancer. So why not have it as an option?”
This study builds on previous research conducted by Winer and her colleagues, which found that mailing HPV test kits to under–screened patients increased screening rates, though most people remained untested. That study took place before the cervical cancer screening guidelines were updated to include HPV testing alone, so the test kit did not count as a regular screen.
Self-testing is already an option for other routine screenings, most notably for colorectal cancer. The most recent guidelines encourage home test kits as a primary screening option, suggesting that annual stool samples may be taken in place of a routine colonoscopy, which many patients find uncomfortable. Home test kits are now so commonplace that Saturday Night Live has parodied the ubiquitous TV commercials for one prominent manufacturer.
Colorectal screening rates have risen steadily in recent years.
There are still significant barriers to overcome before HPV self-sampling can become widely available, Winer said. Chief among them is approval by the Food and Drug Administration, which is expected to come in the next few months.
Once HPV self-sampling receives FDA approval for use as a cervical cancer screening tool, healthcare systems that want to implement self-screening need to procure test kits, review their policies and educate both patients and providers. Algorithms used to track patients’ care have to be updated. Health centers serving low-income and marginalized communities may not have the staff or financial resources to distribute test kits. Patients without a primary care physician may slip through the cracks
“HPV self-sampling is a tool certainly designed to increase access and reduce disparities,” Winer said. “But sometimes when a new intervention is introduced, it can further widen disparities if there isn’t attention taken to how to best implement it, or how to specifically make sure that it reaches people who need it the most.”
This research was co-led by Beverly Green, a senior investigator at KPWHRI. Other authors include John Lin, research coordinator in the UW Department of Epidemiology; Melissa Anderson and Kristina Hansen from KPWHRI; Jasmin Tiro and Hongyuan Gao from the University of Chicago; Richard Meenan from the Kaiser Permanente Center for Health Research; Angela Sparks from UnitedHealthcare; and Diana Buist of GRAIL LLC in Menlo Park, Calif. This research was funded by the National Cancer Institute.
