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19th July 2024
Do-it-yourself (DIY) human papillomavirus (HPV) tests could be a ‘game changer’, enabling a million more women in England to participate in cervical screening over the next three years, a new study has suggested.
Researchers from King’s College London (KCL) concluded that offering self-sampling kits to women who were at least six months overdue for cervical screening could result in 400,000 more women being screened for cervical cancer each year.
Supported by Cancer Research UK, the YouScreen trial is the largest self-sampling trial conducted for cervical cancer. It offers women the chance to screen themselves at their GP surgery or in the privacy of their own home.
The trial’s results, published in the journal eClinicalMedicine, highlight a simple and effective way to increase the number of people taking cervical smear tests.
Cervical cancer is highly preventable by screening and treating pre-cancer. However, cervical screening participation has been falling in England for over two decades and women who do not regularly attend screening appointments are at the highest risk of developing cervical cancer. Almost a third of eligible women are not being routinely screened; in some parts of London, this is as high as 50%.
Self-sampling has been shown in previous studies to be as effective in detecting HPV as smear tests taken by healthcare staff and can remove some barriers for women who would like to be tested but are put off by the standard cervical smear process.
In partnership with the NHS Cervical Screening Programme, the researchers tested the DIY kits across 133 GP surgeries in North Central and North East London, offering over 27,000 unscreened and under-screened women HPV self-sampling kits between January and November 2021.
People in the trial used a vaginal swab to take their sample either at home or at their GP practice. Samples taken at home could be posted for free directly to the laboratory for testing. If HPV was detected in any samples, a follow-up test was required.
The self-sampling intervention resulted in a 22% increase in non-attenders screened per month, with over 8,000 people using and returning the kits for testing. The women who tested were all between 25 and 64 years of age, with 64% being from ethnic minority groups and 60% from deprived populations. Women were more likely to use the self-sampling kits when they were offered at their GP practice. Some 56% of women self-sampled at their GP surgery, compared to 13% when the kit was sent directly to their home.
Lead investigator Dr Anita Lim, a senior epidemiologist at KCL, said: ‘Self-sampling has been hailed as a game-changer for cervical screening, and we now have evidence in a UK population to show that it is.’
She added: ‘It is crucial that we make cervical screening easier by introducing innovations like self-sampling, alongside the current cervical screening programme, to help protect more people from this highly preventable cancer. Self-sampling can do this by offering people choice and convenience.’
The trial showed that the DIY test is popular with both women and GP practices, and the self-sampling kits enabled screening for a wider population.
Dr Lim added: ‘It’s encouraging that we received self-samples from groups that have been historically underserved, including people from deprived and ethnic minority backgrounds, LGBTQI+, people with learning disabilities and victims of sexual violence.’
Miss Alexandra Lawrence, from the North East London Cancer Alliance and consultant gynaecological oncologist at St Bartholomew’s and the Royal London Hospital, said: ‘Self sampling was hugely popular with women and in primary care during the YouScreen study. Introducing this option will help to address the low uptake of cervical screening in our area of London. Early detection is so important for all cancers and cervical screening enables HPV-related changes on the cervix to be treated before cancer even develops.‘
The NHS is now set to work with the UK National Screening Committee to consider the feasibility of rolling this out more widely across England.
This comes as the latest figures show that of the 11 million 25-49-year-olds eligible for cervical screening, only 65.8% took up invitation and were screened within the recommended time as of December 2023. This rose to 74.1% of those aged between 50 and 64.
Steve Russell, chief delivery officer and national director for vaccinations and screening for NHS England, said: ‘We have set an ambitious target of eliminating cervical cancer within the next two decades – one of the few countries in the world who have committed to this – and we are doing everything we can to achieve our ambition by making it as easy as possible to make appointments, and continuing to send invites and reminders to all eligible women.‘
Evidence has suggested that cancer screening for breast, colorectal and cervical cancers significantly reduced across the world during the Covid-19 pandemic.
But even in 2019, a UK study found that only a third of women take up all offered cancer screenings.
Image credit: YouScreen
A version of this article was originally published by our sister publication Nursing in Practice.
24th November 2023
Vaccination against human papillomavirus (HPV) appears to have changed the mix of HPV strains in circulation, say researchers who have spotted the ‘strain replacement’ for the first time.
An analysis of data from 60,000 young women in Finland who took part in a trial of the HPV vaccine where different cities adopted different approaches also found a decrease in more strains of the virus where girls and boys were both vaccinated.
Four years after vaccination, they found that the vaccine had markedly depleted targeted cancer-causing HPV types in the girls-only vaccine groups as well as the communities where boys and girls had been immunised.
Where boys and girls were vaccinated, there was also an increase of HPV types with lower cancer risks filling the gap left by the cancer-causing vaccine targeted strains around four to eight years after the vaccine was given.
The findings raise questions over potential changes to cervical cancer screening programmes in the future but UK experts said it was too soon to come to any conclusion.
Writing in the journal Cell Host and Microbe, the team said the diversity of strains found were similar to communities where no vaccination had been done, only without the cancer-causing strains targeted by the vaccine.
Study leader Dr Ville Pimenoff, an evolutionary biologist from the Karolinska Institute, Sweden, and University of Oulu, Finland said: ‘HPV vaccine is effective to clear most cancer-causing HPVs, and what we have observed here is the subsequent new equilibrium of untargeted HPV types interacting with the host communities.’
He added: ‘Importantly, the increase of vaccine-untargeted low-cancer-risk HPVs do not increase the risk of cancer.’
The researchers suggested that the findings could lead to the redesign of HPV screening approaches for cervical cancer prevention, which include testing for HPVs with lower cancer risks.
With the increase of low-cancer-risk HPV types in the vaccinated population, ‘current screening is likely to result in over-diagnosing individuals who are not at risk, he added. ‘That would be a huge burden for the healthcare system.’
Professor Anne Mackie, director of the UK National Screening Committee said the study was very welcome but more research was needed and the committee has commissioned a modelling study to help understand the likely impact of potential alternative screening strategies on the vaccinated cohort in the future.
She said: ‘The routine offer of HPV vaccination for girls started in 2008 and has successfully reduced the risk of infection in younger age groups.
‘However, most women in the eligible age range for screening (25 to 64) have not received the vaccine and may have been exposed to infection previously.
‘A high-quality cervical screening programme will continue to prevent cases of cervical cancer in this non-vaccinated population over the coming decades.’
Professor Stephen Duffy, professor of cancer screening at Queen Mary University of London said a major finding from the research was that immunising both boys and girls is the best policy.
‘While we should not rush to change screening policy as a result of one study, it would be prudent to check if these results are replicated elsewhere, and to consider the implications for which populations we screen and how we screen them.’
This comes as NHS England announced plans to eliminate cervical cancer by 2040 through increasing uptake of the HPV vaccine and cervical screening.
As part of a new vaccination drive, NHS England will support health and care professionals to identify patients in most need of the HPV vaccine via ‘targeted outreach’ and offering jabs in convenient local places such as libraries and community centres.
The NHS App will undergo expansion so that people can view their full vaccine record and book appointments in a ‘new dedicated space’ – currently only Covid and flu vaccination status is visible, but this will be increased to all 15 routine vaccine-preventable diseases, including HPV.
The NHS will also look to boost cervical screening by trialling ‘self-sampling’ to see if it could become part of national screening.
Last year, over five million people aged 25 to 64 were invited for screening, which NHS England said is ‘more…than ever before’.
NHSE’s national director for vaccinations and screening Steve Russell said vaccination and screening are ‘some of the most powerful tools’ for preventing disease.
‘We have learnt invaluable lessons from the pandemic, with our hugely successful Covid-19 vaccine programme saving thousands of lives, and our vision for the future of vaccination draws on those learnings, with plans to educate millions more people on the importance of vaccination, while making it easier than ever before to access vaccines online,’ he added.
NHS Providers’ director of policy and strategy Miriam Deakin said they ‘welcome’ the pledge and ‘innovative strategies’ that demonstrate a ‘forward-thinking approach to healthcare’.
She said: ‘These measures not only aim to improve accessibility but also ensure that health services are more responsive to the needs of diverse communities.
‘Ensuring healthcare staff have the resources and training needed to effectively implement these plans is crucial for success.
‘A focus on education and increasing public awareness about the importance of HPV vaccination and regular cervical screening is also vital.’
According to the World Health Organization, cervical cancer is considered to be eliminated when its incidence rate is lower than four per 100,000 women.
Versions of this story were originally published by our sister publication Pulse.
9th November 2023
A short course of induction chemotherapy (IC) ahead of standard treatment with chemotherapy and radiation reduces the rate of relapse and death in women with locally advanced cervical cancer, according to preliminary study findings presented at the European Society for Medical Oncology (ESMO) Congress 2023.
The INTERLACE phase 3 trial enrolled 500 women with squamous, adeno or adenosquamous carcinoma stages IB1/2 to IVA from hospitals in the UK, Mexico, India, Italy, and Brazil over 10 years.
The median patient age was 46 years, overall most women (77%) had stage II cancer, and more than half (57%) were lymph node negative, researchers reported in an abstract simultaneously published in the Annals of Oncology.
Patients were randomised to receive standard chemoradiation (CRT), consisting of external radiation with weekly cisplatin and brachytherapy, or an initial six-week course of IC with carboplatin AUC2 and paclitaxel 80mg/m2 followed by standard CRT.
Researchers found women who received IC followed by CRT had five-year progression-free survival rates of 73% compared to 64% in the women who had received CRT alone.
The corresponding five-year overall survival rates were 80% for the IC and CRT group versus 72% for the standard care group.
Given these results, the study authors said IC with CRT should be considered a new standard of care, adding that carboplatin and paclitaxel were cheap, accessible and already approved for patient use.
Lead investigator Dr Mary McCormack, honorary lecturer at UCL Cancer Institute and consultant clinical oncologist at University College London Hospitals, said the trial showed this short course of additional chemotherapy could reduce the risk of the cancer returning or death by 35%.
‘This is the biggest improvement in outcome in this disease in over 20 years,’ she added.
The median overall treatment time for CRT was 45 days in both arms, the researchers reported, with a median interval of seven days between IC and CRT.
They added that 92% of IC patients had five or six cycles of carboplatin and paclitaxel.
Of the IC and CRT group, 84% had four or five cycles of cisplatin while the figure was 89% in the CRT alone group.
Grade ≥3 adverse events were seen in 59% of patients in the IC and CRT group compared with 48% of patients in the CRT alone group.
Commenting on the findings, Professor Ana Oaknin, head of the gynecologic tumors unit at the Vall d´Hebron University Hospital, Barcelona, Spain, called the results encouraging, given the high unmet need for new treatments for advanced cervical cancer.
‘However, it is important to consider the population recruited and the large proportion of patients who had node-negative disease, as we know that positive lymph nodes are indicative of a high risk of relapse,’ she added.
‘Further analysis, in terms of nodal status, would be useful in determining the suitability of the induction chemotherapy approach for different relapse risk groups.’
Professor Oaknin, who was not involved in the research, said ongoing, planned trials might provide information on other ways to improve outcomes beyond CRT alone in high-risk locally advanced cervical cancer.
These included the phase 2 ATOMICC trial investigating anti-PD1 therapy with dostarlimab and the phase 3 e-VOLVE Cervical Study trial assessing the use of the monovalent bispecific human IgG1 monoclonal antibody volrustomig.
11th July 2022
Cancer screening for breast, colorectal and cervical cancers was significantly reduced during the period of the pandemic compared to pre-pandemic levels according to the results of a systematic review by a group of Italian and US researchers.
According to GLOBOCAN in 2020 there were an estimated 19.3 million new cancer cases and almost 10.0 million cancer deaths and that cancer screening has contributed to a decrease in both cancer morbidity and mortality. As a result, any reduction in screening could potentially lead to a surge in cases. In fact, modelling studies have already indicated a possibly large increase in cases due to the pandemic.
Moreover, in a UK-based modelling study, the authors estimated that as a consequence of the pandemic, there would be a 7·9-9·6% increase in the number of deaths due to breast cancer up to year 5 after diagnosis and for colorectal cancer a 15·3 – 16·6% increase in additional deaths.
However, because of differences in the start date and duration of lockdown measures across the world, for the present study, the researchers wanted to examine how this variation impacted on screening. They focused on breast, colorectal and cervical cancer screening since the beginning of the pandemic and made a comparison with pre-pandemic levels.
The team searched all the major databases for observational studies and articles that reported data from cancer registries and which compared the level of screening tests performed before and during the pandemic and in different areas of the world.
Cancer screening reductions during the pandemic
A total of 39 articles were identified and included in the analysis with 21 related to breast, 22 colorectal and 11 for cervical cancers.
For the period between January and October 2020, there was an overall 46.7% (95% CI -55.5% to -37.8%) decrease in breast cancer screening in comparison the pre-pandemic level.
For colorectal cancer, the overall reduction was 44.9% (95% CI -53.8% to -36.1%) and this included a 52.5% reduction in colonoscopy, a 37.8% decrease in faecal occult blood testing and a 37.8% decrease in immuno-chemical testing.
With cervical cancer, the overall reduction was -51.8% (95% CI -64.7% to -38.9%).
Commenting on their findings, the authors noted that these reductions in screening occurred across the world but that there were some obvious differences. For example, Europe saw the largest reduction in mammography compared to North America. although the decrease for both colorectal and cervical cancer screening was similar in both areas.
The authors suggested that the most likely explanation for the reduced screening was the ‘stay at home’ order introduced during the early stages of the pandemic.
They concluded that there was a large reduction in cancer screening as a consequence of the COVID-19 pandemic and which could be associated with an increased number of deaths and called for further work to investigate the relationship between cancer diagnosis and treatment during the pandemic.
Citation
Teglia F et al. Global Association of COVID-19 Pandemic Measures With Cancer Screening: A Systematic Review and Meta-analysis JAMA Oncol 2022
17th September 2019
In England, women are invited for screening for three types of cancer concurrently in their sixties; for the last cervical screen before they exit the programme, for breast screening every three years, and for bowel screening every two years.
This means that an average woman aged 60 can expect to receive five or six cancer screening invitations by the time she turns 65. In England, cancer screening is provided by the NHS free of charge.
In a study published in the Journal of Medical Screening, researchers categorised a sample of just over three thousand eligible women in their sixties according to the last screening round. They looked into women’s participation in all three programmes.
Results showed that:
They also found that general practices with a higher proportion of unemployed patients and a higher number of smokers had a lower rate of take-up of all three screening programmes. Conversely, take-up was more frequent among practices in areas of less deprivation, with a higher proportion of women with caring duties, those with long-term health conditions, and those with a high level of patient satisfaction with the practice itself.
“To lower the chances of dying from certain cancers, it is important for the population to attend all offered screening programmes,” said lead author Dr Matejka Rebolj from King’s College London.
“We know from the official statistics that the majority of women are up to date with breast screening, but this drops to just over 50% when it comes to bowel screening. It is worrying that only a third of women are up to date with all offered cancer screenings and that 10% remained completely unscreened in the last round. Indeed, similar patterns have been reported from other countries too.
“It is crucial for us to look at the take-up rates in certain areas and in certain practices and address women’s preferences for future screening programmes. We need to understand and target specifically those women who obtain some screening, but decide not to take up all the life-saving screening that is offered to them by the NHS. It is important that policy makers now look at these findings to inform what can be done in the future to reduce the significant number of deaths in the over 60-year olds.”
Senior author Professor Stephen Duffy from Queen Mary University of London said: “These results demonstrate the inequalities in cancer screening participation, with the lowest levels of participation in the areas of highest deprivation.
“Since most women had at least one form of screening, we know that there isn’t an objection to screening as a whole. However, individuals find some screening procedures less acceptable than others, so the key to improving participation is making the screening experience better.
“We’ve seen this work with a new and less burdensome test in bowel cancer screening, which was considerably more acceptable and resulted in a substantial increase in uptake. Most encouragingly, the greatest improvements in uptake were seen in those who previously had the lowest participation levels.”
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