The next big thing in the prevention of cervical cancer has arrived – no Pap smears required.
Cervical cancer is unique: it’s the one cancer that can be almost entirely prevented through a combination of vaccination and screening.
We call vaccination “primary prevention” – it stops you ever getting infected with the human papillomavirus (HPV). We call screening “secondary prevention” – it allows you to prevent the development of cancer even though you may have had infection from HPV, which most of us will have had at some stage, and which we know causes more than 90% of cervical cancers.
The vaccine is optimally given around the age of 12 to 13. It’s ideally given before any chance of coming into contact with HPV through sexual activity. But it’s only been available since 2007, so there are many women around the world who still depend on screening to prevent this cancer.
Screening has meant regular Pap smears for the rest of us. This involves a pelvic exam and a speculum inserted. While nobody looks forward to that process, most women have been able to bring themselves to do it.
In Australia, we’ve had a well-supported screening program for many decades. However, it’s still not reaching everyone. That’s usually because of disadvantage. If you are from a marginalised community, or if you have experienced sexual assault or abuse, or even if you’ve had a bad experience with previous Pap smears, it can be very difficult to get those women to have that exam. This has been a major challenge in getting this lifesaving screening to everyone who needs in this country.
The other big challenge is equity of access and accessibility. All around the world there are countries with very little effective or no cervical screening, and consequently there are very high rates of cancer that are preventable.
Fortunately, the “next big thing” in screening is here, now. We no longer have to look for the cells via Pap smears that tell us that pre cancer is developing, but we can go even earlier than that and look for the human papillomavirus that causes those changes.
The government has just announced that a new method of collecting samples for testing for HPV will be made available broadly across the Australian community. This is a self-collection method. Instead of a doctor doing an internal exam to take a sample of cells from the cervix, the patient will be given a swab which they can use themselves to take a sample from the vagina – and this is as accurate as the sample taken by the healthcare practitioner. It’s super exciting in its potential to screen the people that we’re not reaching.
The program is being rolled out as we speak. It’s currently available in Australia to people who meet criteria that they’re at least 30 years old, and at least two years overdue for screening. Then, from July 1 next year, it will be available to anyone who’s eligible for screening and it will be their choice how the sample is collected.
This is a real breakthrough, giving autonomy and agency to women, who are now in control of how that test is taken. There’ll still be some people who are used to having Pap smears and are comfortable with that process – that doesn’t need to change if that’s what they want. But there’ll be many for whom this makes all the difference between not being screened and being screened. The World Health Organization has called for elimination of this cancer, because we can almost entirely prevent it.
I was so excited to read the meta-analysis in 2018 telling us that we weren’t going to lose any test sensitivity by switching to self-collection. I’ve been working in projects in Australia and Malaysia and in Papua New Guinea and I’m so excited that we can bring screening to people who have not been able to access it. We can now go up into Papua New Guinea and across the Pacific region where the rates of cancer are tragically high – probably higher than have been measured because women are often dying without even a diagnosis or even dignified palliative care. If you think about the health workforce needed to do those internal pelvic exams previously, they are very difficult to scale. And of course, there are cultural barriers. So self-collection gives us that way of scaling up screening, so we can then have the health workers actually look at the cervix from people in whom we detect HPV, while the 90% who have nothing there are taken care of.
It’s a simple swab, but it will make the world of difference.
I originally chose pathology as my medical specialty because back then I naively thought the pathologist had all the answers. Of course, the more you learn, the more uncertainty you understand there is in any science. But I’ve been very lucky to work behind the scenes in the screening programs, knowing we make an incredible difference.
We just don’t know who the people are that benefit from the program. Successful prevention is invisible, and it should be.
Professor Marion Saville AM is executive director of the Australian Centre for the Prevention of Cervical Cancer.