The equalizing potential of a HPV-based self-collection cervical cancer screening program in Québec
By Parker Tope
Cervical cancer, when caught in its initial precancerous stage, is curable (via treatment of cervical dysplasia) and, due to the identification of human papillomavirus (HPV) as the cause of nearly all cases, preventable (via HPV vaccination). Despite this, it remains the fourth most common cancer among women globally. To meet the World Health Organization’s goal of cervical cancer elimination, resources have been directed towards low-middle-income countries in the global south, where cervical cancer burden is the highest. Yet, the very need for dichotomized prioritization between the global north and south as well as between high-income and low-middle-income countries unmasks the very crux of cervical cancer elimination; cervical cancer is a disease of inequity, as it exposes the discriminatory underpinnings that are at the foundation of historically colonializing nations. If we focus efforts towards global regions most afflicted by cervical cancer, it is our responsibility to do so locally as well. In Québec, this entails addressing the disparity in the cervical cancer burden between Indigenous and non-Indigenous women. Right now, cervical cancer screening based on HPV testing of self-collected samples (referred to as HPV self-sampling) is an essential next step in bridging this gap.
Québec is one of three Canadian provinces without an organized cervical cancer screening program. Organized programs, compared to opportunistic ones, provide centralized registries for recall mechanisms, or reminders for routine screening, that ensure the highest possible coverage of all women of screening age. Further, no province offers HPV testing as the primary screening method; cytology-based tests (i.e., Pap tests) are standard-of-care in Canada. However, they only have a 55% probability of detecting cervical cancer among those who have the disease, whereas HPV tests have a 95% probability of doing so. This 40% detection gap between tests leaves a multitude of women who are screened unaware that they are actually at risk of developing cervical cancer. HPV testing of self-samples, which can be collected by women at home, are equally as accurate as clinician-collected samples. Low participation in regular screening could be mitigated by HPV self-sampling; offering self-collection in lieu of a Pap test or clinician-collected sample for HPV testing has been shown to increase women’s participation in screening programs, especially among those in under-served communities.
Historically, Indigenous women of Canada have been 2-20 times more likely than non-Indigenous women to be diagnosed with cervical cancer. Of those who develop cervical cancer, the rate of death has been 4 times greater among Indigenous women. Simply put, cervical cancers arising in Indigenous women have consistently not been caught early enough and treated soon enough. This inequity stresses the urgent need for improved screening programs across Indigenous communities. Physical barriers to Pap testing, such as living remotely or lack of transportation, contribute to underscreening of Indigenous women. However, further psychological barriers including unreliability on colonially-constructed healthcare systems, lack of culturally appropriate services, mistrust, and fear – stemming from a far too recent history of mistreatment of Indigenous women in reproductive health settings – strongly discourage them from consenting to Pap tests. A self-collection screening program in Québec could eliminate these obstacles by providing a choice to women who might feel safer collecting their samples in a private setting, thus eliminating the potential for trauma.
A foreseen concern in the implementation of a HPV self-sampling screening program is the possibility that some women who receive a positive self-collected HPV result would be less likely to present to clinics for follow-up. One way of safeguarding against this is to integrate the infrastructure to roll out a self-collection program within Indigenous communities. Organized follow-up of women who receive a positive HPV result facilitated by a community-based testing centre could offer women a culturally safe option for continued care. The consequences of positive initial and follow-up screening tests, especially for gynecologic cancers, require emotionally demanding decision-making and invasive next steps. Self-collection screening programs administered by Indigenous health authorities, aligned with Indigenous leadership, would promote ongoing discussion among and support from women’s families, their Elders, and their communities, in a fully participatory fashion. Involving the voices of Indigenous leadership in the development of self-collection screening programs would create a sustainable groundwork for empowering women by placing their reproductive health in their own hands and fostering an Indigenous-lead and trusted healthcare environment.
Developing, piloting, and rolling out any health program takes time. To respectfully target populations in need and, in the case of Indigenous communites, with significant mistrust of the healthcare system, designing a self-collection screening program would require looking to other provinces as models for unification between provincial policy makers and Indigenous health authorities in cancer care. In December 2021, BC Cancer launched a pilot program for at-home self-collection cervical screening targeting low-access communities. With other provinces already planning and rolling out cervical cancer screening programs that address their local needs, Québec is duty-bound to modernize its cervical cancer screening approach to become not only an organized and effective one, but also one that responds to the health inequities deeply rooted within the provincial health system. In committing to a self-collection cervical cancer screening program, Québec’s public health institution would be taking a necessary step in breaking the cycle of oppression sustained by the current provincial health system.
Acknowledgments:
We want to thank Dr. Ananya Tina Banerjee for encouraging her students to write and sharing this opinion article with us.
About the Author:
Parker Tope, a MScPH candidate at McGill University, obtained her BSc in Microbiology and Immunology with a Minor in Hispanic Studies from McGill University. She works as a Research Assistant for the Division of Cancer Epidemiology and Department of Oncology at McGill and as an Assistant Editor for Preventive Medicine and Preventive Medicine Reports. Her current research focuses on lag-times to cancer care and the effect of socioeconomic and demographic factors on cancer incidence and mortality within the context of the COVID-19 pandemic.