ReviewReaching women who do not participate in the regular cervical cancer screening programme by offering self-sampling kits: A systematic review and meta-analysis of randomised trials
Introduction
Well organised screening programmes have reduced the incidence and mortality of cervical cancer substantially in many industrialised countries [1], [2], [3], [4]. However, screening coverage is not always optimal [5], [6], [7], [8], [9], [10]. In the context of organised screening, women who are never screened or under-screened have an increased risk of invasive cervical cancer [11], [12], [13].
Several reasons have been identified as to why women do not attend cervical cancer screening. Barriers for participation in cytological screening do not only include practical (i.e. transport to the clinic, inconvenient clinic hours), economical and educational factors, but also personal-level factors, such as embarrassment and fear of pain [14].
With the introduction of testing for high-risk HPV (hrHPV) as a primary screening test in cervical cancer prevention [15], [16], [17], [18], samples taken by the woman herself (self-samples) have gained broad attention due to its potential to increase screening attendance. Furthermore, it has been shown that the accuracy of hrHPV DNA testing on a self-sample is similar to that of a sample collected by a clinician, if validated PCR tests are used [19], [20].
In most studies, the acceptability, preferences and attitudes of women towards self-sampling are positive, yet some negative findings have been published [21], [22]. Data from a recent review [23] and a meta-analysis [24] indicate that, overall, offering self-sampling can be superior to a reminder invitation for cytology in attracting women who never or irregularly participated in the cervical cancer screening programme. However, heterogeneity among studies is considerable. Given that the participation rate is a fundamental factor determining the (cost-)effectiveness of self-sampling, careful consideration of elements that may influence its success is essential. In this study, an updated review and meta-analysis is performed, including studies published until 2015. The relative participation and participation difference of the self-sampling arm compared to the control arm are calculated in a per-protocol and intention-to-treat analysis. Furthermore, a systematic evaluation of the heterogeneity across studies is performed, by comparing the effect of different methods to invite women for self-sampling.
Section snippets
Materials & methods
This systematic review and meta-analysis evaluates whether offering a kit for self-sampling (at home) could increase screening attendance, compared to sending reminder letters for a Pap smear or HPV test on a sample collected by a clinician (at the clinic).
The literature search was performed using electronic bibliographic databases Medline (PubMed), EMBASE, and CENTRAL. A general search string was constructed and included substrings on four topics, combined by an AND-operator (1: cervical
Literature retrieval and study characteristics of included studies
The literature search and the selection of eligible studies are presented in the PRISMA flow chart (Fig. S1, supplementary online material) [31], [32]. The last search was performed on February 12th, 2015. A total of 16 studies were included in our meta-analysis [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48]. Population and study characteristics of these studies (inclusion criteria, scenarios of invitation, sample size and age) are presented in
Discussion
Vaginal self-sampling by the woman herself, has the potential to overcome practical and personal barriers that may withhold some women from participating in regular cervical cancer screening.
In this meta-analysis, data from 16 randomised studies were pooled. Although inter-study heterogeneity was observed, overall, women offered self-sampling were more likely to participate compared to women invited for a clinician-collected sample at the clinic. When women received a self-sampling kit directly
Funding sources
This study was funded by the seventh Framework Program of DG Research of the European Commission (CoheaHr Project [603019], the Joint Action CANCON which has received funding from the European Union in the framework of the Health Programme [2008-13]), the International Agency for Research on Cancer (IARC, Lyon, France), the European Federation for Colposcopy (Birmingham, UK), and the German Guideline Program in Oncology (German Cancer Aid project # 110163).
Role of funding source
Funds were paid to the Scientific Institute of Public Health. None of the funding agencies had an influence on the scientific process.
Conflict of interest statement
The Scientific Institute of Public Health received scientific research funds as explained in Funding Sources. None of the funding agencies had an influence on the scientific process of the work.
Acknowledgements
The authors want to thank P. Giorgi Rossi and K. Haguenoer for kindly providing additional data.
References (53)
- et al.
Trends of cervical cancer mortality in the member states of the European Union
Eur J Cancer
(2009) - et al.
Cervical cancer screening policies and coverage in Europe
Eur J Cancer
(2009) - et al.
Process of care failures in invasive cervical cancer: Systematic review and meta-analysis
Prev Med
(2007) - et al.
Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials
Lancet
(2014) - et al.
Evidence regarding HPV testing in secondary prevention of cervical cancer
Vaccine
(2012) - et al.
Accuracy of human papillomavirus testing on self-collected versus clinician-collected samples: a meta-analysis
Lancet Oncol
(2014) - et al.
Self-collected samples for testing of oncogenic human papillomavirus: a systematic review
J Obstet Gynaecol Can
(2007) - et al.
Meta-analysis in clinical trials
Controlled Clin Trials
(1986) - et al.
Self-collection of vaginal specimens for human papillomavirus testing in cervical cancer prevention (MARCH): a community-based randomised controlled trial
Lancet
(2011) - et al.
Sancho-Garnier H. L’auto-prélèvement vaginal à domicile pour recherche de papilloma virus à haut risque. Une solution de remplacement pour les femmes ne participant pas au dépistage cytologique des cancers du col de l’utérus. Campagne expérimentale du département des Bouches-du-Rhône
Bull Cancer
(2011)
Comparison of use of vaginal HPV self-sampling and offering flexible appointments as strategies to reach long-term non-attending women in organized cervical screening
J Clin Virol
Effect of self-collection of HPV DNA offered by community health workers at home visits on uptake of screening for cervical cancer (the EMA study): a population-based cluster-randomised trial
Lancet Glob Health
Comparative community outreach to increase cervical cancer screening in the Mississippi Delta
Prev Med
The development and evaluation of a community based model for cervical cancer screening based on self-sampling
Gynecol Oncol
50 years of screening in the Nordic countries: quantifying the effects on cervical cancer incidence
Br J Cancer
Andersson TM-L, Lambert PC, Kemetli L, Silfverdal L, Strander B, Ryd W, Dillner J, Tornberg S, Sparen P. Screening and cervical cancer cure: population based cohort study
BMJ
Attendance at cervical cancer screening and use of diagnostic and therapeutic procedures on the uterine cervix assessed from individual health insurance data (Belgium, 2002–2006)
PLoS ONE
Cervical cancer screening in Germany: group-specific participation rates in the state of Niedersachsen (Lower Saxony). A study with health insurance data
Arch Gynecol Obstet
Sociodemographic factors associated with cervical cancer screening coverage and follow-up of high grade abnormal results in a population-based cohort
Gynecol Oncol
A fall-off in cervical screening coverage of younger women in developed countries
J Med Screen
Coverage of cervical cancer screening in 57 countries: low average levels and large inequalities
PLoS Med
Screening-preventable cervical cancer risks: evidence from a nationwide audit in Sweden
J Natl Cancer Inst
Reasons for cervical cancer despite extensive screening
J Med Screen
Exploring women’s knowledge, experiences and perceptions of cervical cancer screening in an area of social deprivation
Eur J Cancer Care (Engl)
American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer
CA Cancer J Clin
Cited by (221)
The impact of alternate HPV vaccination and cervical screening strategies in Japan: a cost-effectiveness analysis
2024, The Lancet Regional Health - Western PacificComparison of diagnostic accuracy and acceptability of self-sampling devices for human Papillomavirus detection: A systematic review
2024, Preventive Medicine Reports'I'm a bit of a champion for it actually': Qualitative insights into practitioner-supported self-collection cervical screening among early adopting Victorian practitioners in Australia
2023, Primary Health Care Research and Development