This article is part of a series on diagnostics within Women’s Health. We’ll be adding more stories and related content throughout the year. Check out the first story in this series about cervical cancer triage testing here. 

On Jan 28, cervical cancer experts from across the Asia Pacific region and around the world came together for a policy dialogue on Accelerating and Scaling HPV and Cervical Cancer Screening and Testing in the APEC Region. Hosted by the Asia-Pacific Economic Cooperation (APEC), the dialogue explored new strategies for tackling cervical cancer, a disease that caused 351,720 recorded cases in Asia Pacific in 2020, making it the 3rd most common cancer amongst women in the region.

The policy dialogue builds upon years of previous work from the Life Science Innovation Forum (LSIF), an APEC working group, including its 2021 Roadmap to Promote Sustainable Economic Advancement for Women Through Cervical Cancer Prevention & Control 2021-2025 (see this recent piece in the World Economic Forum for an excellent overview of these efforts). As the dialogue indicates, a comprehensive cervical cancer management initiative should include measures to strengthen capabilities for prevention, screening and treatment, as well as public education campaigns to spread awareness of HPV vaccination, self-sampling kits and other tools that can help effectively fight the disease.

For clinical labs, policies to build laboratory capacity, gain access to novel diagnostics, and maintain the workforce necessary to conduct cervical cancer screening will be particularly important. Below are some of the key highlights from the session that may be relevant for lab professionals.

Encouraging greater use of HPV DNA testing

Screening guidelines vary from country to country, but a basic requirement should be to have women screened from their mid-20s every 3 to 5 years with at least a Pap test and/or HPV DNA test where possible, with immediate triage for abnormal results and treatment of precancerous lesions.

Countries are encouraged to move away from cytology-based programmes, but this is not always possible in every setting,  noted Dr Nathalie Broutet, acting unit head at the Department of Sexual Health and Reproductive Cancers at the WHO.

In Malaysia, Dr Zakiah Said of the Malaysian Ministry of Health said that her country has endorsed the use of HPV testing as a primary screening tool. Not all Asian countries, however, have undertaken similar measures, sometimes due to a lack of resources or the lack of coordination within their own countries.

Repurposing PCR infrastructure for cervical cancer efforts

Another challenge is the recent drop in cervical cancer screening rates due to disruption in routine health services caused by the COVID-19 pandemic. Dr Cheng Wen-Fang, Division Head & Attending Physician of the Department of Obstetrics & Gynecology at National Taiwan University Hospital, shared that Taiwan’s 3-year participation rates decreased by ~2%, and that women with abnormal Pap smears are lost to follow up at a 3-4% rate.

This drop has been even more pronounced in other countries. In the United States, for example, healthcare systems observed an initial decline of 80% in routine cervical cancer screening due to COVID-19. Even now at the 2-year mark, screening has slowed down 10% compared to what it was prior to the pandemic, observed Dr Mona Sairaya of the CDC.

On the plus side, the rapid adoption of PCR instruments during the COVID-19 pandemic provides opportunities for improved screening in many countries. Dr Marion Saville, Executive Director at the Australian Centre for the Prevention of Cervical Cancer, expressed hope that countries will be able to leverage PCR infrastructure that was acquired during the pandemic for COVID testing. This infrastructure could be repurposed for cervical cancer screening, as testing volume is a barrier to scaled screening services.

Exploring self-sampling approaches to improve access

To effectively scale cervical cancer testing, self-sampling or self-collection strategies are providing benefits in some countries. In Australia, for example, Dr Saville shared that this approach has proven to be as effective as clinician collected samples [1]. In light of Australia’s vast geography and extreme weather conditions, it has also allowed healthcare systems to extend access to cervical cancer screening, including in rural and First Nation communities where up to 85% of women returned a swab for testing.

In Malaysia, a community-based programme called Project Rose relies on nurses and volunteers to screen women, but even though screening tests have been free there since 1969, many women do not participate in screening activities if they are not unwell. This leaves the 3 year screening rate at less than 25%, but the situation may be improving under a team led by Prof Woo Yin Ling at the University of Malaya, which has successfully screened women with the use of self-sampling within communities [2].

With self-sampling, Prof Woo has demonstrated that those who do not usually go to clinics are happy to perform their own self-screening tests. She sees this as a community programme that complements a government effort and provides a scalable approach for achieving the WHO’s elimination targets more quickly.

Reaching elimination targets by 2030

To reach the 90-70-90 goal for cervical cancer elimination put forth by the World Health Organisation, economies should prioritise implementation research and focus on policies that effectively integrate diagnostic solutions for sustainable screening activities.

“We know more about cervical cancer than almost any other cancer in the world,” said Dr Leslie Mancuso, President and CEO of Jhpiego. “It’s inspiring to see so many working towards the common cause of elimination, a target that’s truly in our reach.”

References:

[1] Arbyn, M., Smith, S., Temin, S., Sultana, F. and Castle, P., 2018. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. BMJ, (363), p.k4823.

[2] Keane, A., Ng, C., Simms, K., Nguyen, D., Woo, Y., Saville, M. and Canfell, K., 2021. The road to cervical cancer elimination in Malaysia: Evaluation of the impact and cost‐effectiveness of human papillomavirus screening with self‐collection and digital registry support. International Journal of Cancer, 149(12), pp.1997-2009.