Recommendations for implementing HPV self-testing in Aotearoa
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
editorial
Recommendations
for implementing HPV
self-testing in Aotearoa
Karen Bartholomew, Beverley Lawton, Susan M Sherman,
Collette Bromhead, Jane Grant, Georgina McPherson,
Anna Maxwell, Marion Saville, Sue Crengle, Nina Scott
I Background
n Budget 2021 published earlier this
month, the Government made the wel-
come and long-awaited announcement Cervical cancer is almost entirely
that they will invest “up to $53 million to preventable through screening and HPV
complete the design of and implement a new vaccination. Despite this, there are approx-
human papillomavirus (HPV) test” in 2023.1 imately 150 new diagnoses and 50 deaths
Here we explain HPV self-testing and the from cervical cancer in Aotearoa New
background to this announcement, and we Zealand every year. Although these figures
make evidence-based recommendations as represent a dramatic decrease since the
to how the Government can most equitably National Cervical Screening Programme
and effectively implement rollout of HPV (NCSP) was established in 1990, there are
self-testing. longstanding ethnic and socioeconomic
inequities in cervical cancer incidence and
HPV self-testing mortality, with cancers concentrated in
unscreened and under-screened groups, in
High-risk types of HPV cause more particular Māori and Pacific women and
than 90% of cervical cancers.2 HPV-based other women living in higher deprivation.
screening offers 60% to 70% greater For example, there are more than twice as
protection against the development of many Māori (wāhine Māori, tangata Māori
invasive cervical cancer compared to with a cervix (including tangata trans,
cytology-based screening.3 Many coun- non-binary and intersex)) with diagnoses
tries (eg, Australia, UK, US, Netherlands) and deaths from cervical cancer as for
have now introduced HPV testing as the non-Māori.5 The importance of cervical
primary screening test. Under HPV primary cancer for Māori was highlighted with
screening, the procedure remains the same. Cabinet Minister Kiritapu Allan’s recent
However, an HPV test is conducted on the diagnosis with stage III cervical cancer.
cervical sample rather than cytology. If
The NCSP currently recommends three-
the HPV test is positive, the cells are then
yearly routine cytology screening for
examined using liquid-based cytology.
25–69-year-old people with a cervix (the
Crucially, by moving to HPV primary
start age was recently changed in the
screening, HPV self-testing becomes
NCSP from 20 to 25 years). The current
possible. HPV self-testing, in which the
test requires attendance at a clinic with
participant carries out their own vaginal
a health-professional collected sample of
swab, does not require a speculum, does
cells from their cervix during pelvic exam
not require finding the cervix and can
(requiring insertion of a speculum). The
be done in a clinic or potentially in the
cells are sent for microscopic examination.
privacy of the home. A Cochrane review
Cervical screening attendance in New
found self-testing for HPV using polymerase
Zealand has declined from a high of 76% of
chain reaction (PCR) assays reliably offers
all eligible women in 2009 to 70% in August
equivalent sensitivity to clinician-collected
2020, including the impact of COVID-19,
samples.4
leaving more women at risk of developing
11
NZMJ 21 May 2021, Vol 134 No 1535
ISSN 1175-8716 © NZMA
www.nzma.org.nz/journaleditorial
cervical cancer. Screening figures for Māori, A Northland community-based trial in
Pacific and Asian women are even lower. never- and under-screened women found
In March 2021, the national coverage was a high 51% uptake of self-testing, with
61.4% for Asian, 63.1% for Pacific and 61.2% Māori 2.8 time more likely to self-test than
for Māori, compared to 75.6% for others attend usual care.12 The study found an
(the coverage equity gap between Māori and 11% positivity rate, which is comparable
others (mostly European) is 14.4%).6 to international studies. In a recent urban
There are many explanations why the Auckland-based randomised controlled
present cervical screening programme has trial,13 3,553 Māori, Pacific and Asian women
failed to reach some women. For example, were invited to take part in clinic-based
direct and opportunity costs including HPV self-testing, home-based self-testing or
work or family commitments, the nature a standard smear test. Women were much
and invasiveness of the test, a previous more likely to take part if they were in
negative experience of screening or cancer, the home-based group, particularly Māori
history of sexual violence, embarrassment women (9.8 times more likely to complete a
and shyness or whakamā.7,8 Women mailed screen at home compared to usual
with physical or intellectual disability care). With tailored support more than
and members of the LGBTQI community 90% follow-up of participants with positive
frequently face additional and multiple HPV tests was achieved in this community
barriers.9,10 trial. In a survey alongside the community
trial the most frequently cited reasons for
However, the new HPV self-test is likely to
choosing a self-testing were its simplicity,
overcome many of these barriers, improve
being less embarrassing, not requiring an
the cervical screening programme coverage
appointment with a clinician, not requiring
and reduce the incidence of cervical cancer.
a speculum and that the test is free.8
International research, and our collective
local research, demonstrates HPV self-testing In a small pilot testing different device
is more acceptable and likely to improve types, the feedback from Māori, Pacific and
equitable access compared with current Asian women was positive, underscoring
screening. the need for a flexible programme with
different options and the importance of the
What we have relationship with the health professional,
such as preferring a female and, usually, a
learned from research culturally concordant sample taker.14
into HPV self-testing It was notable that Māori reported the
in Aotearoa? current screening programme as being
disempowering, whereas their involvement
The acceptability of HPV self-testing for with HPV self-testing, by comparison,
never- and under-screened Indigenous was empowering. Similarly in Australia,
populations and minoritised groups has Aboriginal participants perceived self-
been explored internationally, as well as testing as a way of exerting control over
in Aotearoa. Kaupapa Māori hui-based their own health.15 It may be that exploring
research confirmed the acceptability, and promoting messages of empowerment
empowerment, potential for improving might further increase uptake of self-testing
coverage and equity of HPV self-testing, and in Māori and indeed other groups.
showed that the majority of Māori surveyed
were positive about attending follow-up HPV and
healthcare providers
cytology or colposcopy appointments if
required.7 A feasibility study in seven
West Auckland general practices included New Zealand healthcare providers have
co-design of tailored participant materials talked about the importance of delivering
taking a health literacy and ethnic-specific empathetic cervical screening services and
approach. The study demonstrated high wanted an assurance that women would be
acceptability, found women with cervical supported appropriately to have cytology
abnormalities and highlighted the impor- or colposcopy if they had a positive HPV
tance of support to follow-up.11 self-test result. Many supported HPV-pos-
12
NZMJ 21 May 2021, Vol 134 No 1535
ISSN 1175-8716 © NZMA
www.nzma.org.nz/journaleditorial
itive women going straight to colposcopy particularly for those currently under-
and stressed the importance of avoiding served. Support services will need
multiple clinic visits.7 Additionally, in a to be available and culturally safe.
recent survey of New Zealand healthcare Achieving follow-up can be intensive
providers’ knowledge and understanding and has to be adequately resourced
about HPV testing, it was evident that more and performed by skilled staff using a
targeted education is required before the shared decision-making approach.
rollout of HPV primary screening. Many • Rapid review and reconsider-
healthcare providers surveyed agreed they ation of Part 4A of the Health Act
did not feel adequately informed to confi- 1956 (National Cervical Screening
dently respond to patients’ questions about Programme) to remove the current
HPV testing. Ongoing education for sample data-related barriers to equitable
takers is essential to ensure that misinfor- access to screening, and to realign and
mation, stigma associated with the sexually strengthen Māori data governance
transmitted nature of HPV and the widening and sovereignty, including the oppor-
of inequalities are not inadvertent conse- tunity to restore cultural licence for
quences of interactions between health use of data.
professionals and the public.16
• Ensure that the new IT solution is
Recommendations population-based and facilitates
easy access to screening, including
for implementation providing multiple methods for
invitation of eligible women. The IT
We outline key recommendations from
solution must integrate with primary
our collective expertise to the NCSP in the
care systems and be able to capture
Ministry of Health as they develop the
participant preferences for receipt of
HPV self-testing implementation plan for
self-test kits.
Aotearoa New Zealand:
• Review the place of cervical screening
• Centralisation of equity, specifically
in the broader context of women’s
Māori health equity. Universal access
health and reproductive health in
is likely to be pro-equity. However,
general practice, with particular
ensuring access equity requires
emphasis on the importance of
intentional action in planning and
diagnostic investigations for gynaeco-
implementation. Hei Āhuru Mōwai,
logical symptoms.
the national Māori Cancer Lead-
ership Aotearoa group, have outlined • Plan for a facility within the
a number of recommendations on programme for at least an ‘on-re-
HPV self-testing;17 two key recom- quest’ service of mailed self-testing
mendations are Māori governance kits, leveraging knowledge from local
and the need to consider interim research and approaches used in the
measures due to the lead time for National Bowel Screening Programme.
implementation. • Review positive result triage/follow-up
• With universal access, many pathways to ensure that these are
well-screened women will access risk-stratified, women-centred and
self-testing and their needs will not have an equity lens applied. Expected
be the same as those who are under- colposcopy demand from primary
screened. In addition to equity of HPV screening and self-testing needs
access, we recommend a focus on proactive management and additional
equity in follow-up, colposcopy resource. Workforce development
and treatment to ensure equity of needs to consider the wider imple-
outcomes. Building on the recent mentation of the nurse colposcopist
review of current cervical and breast role.
support-to-service models, consider- • Rapid development and implemen-
ation should be given to redirection of tation of an education package for
resources to enable tailored follow-up healthcare providers ahead of the
of people who are HPV positive, implementation start date, as well
13
NZMJ 21 May 2021, Vol 134 No 1535
ISSN 1175-8716 © NZMA
www.nzma.org.nz/journaleditorial
as ongoing updates and continuing
professional education opportunities
Conclusions
in HPV and cervical cancer. There is considerable support across New
Zealand for the introduction of HPV self-
• There needs to be simple, well-de-
testing, with local evidence and expertise
signed resources based on local
available to shape implementation planning.
research that explain how to take a
Hei Āhuru Mōwai have outlined their
self-test, what happens next and when
recommendations in a position paper calling
to see a health professional. Culturally
for the urgent implementation of a national
appropriate health promotion and
‘māu anō he kuhu—do it yourself HPV test’
materials that cater to Māori, Pacific
programme alongside Māori governance.17
and Asian women’s health literacy
Support has also been expressed by the
needs are required.
Royal New Zealand College of General Prac-
• Alongside health professional titioners, Te Rōpū Whakakaupapa Urutā
education and communication, there (National Māori Pandemic Group), the
needs to be a public communica- Royal Australian and New Zealand College
tions strategy, including timelines of Obstetricians and Gynaecologists and
for implementation to manage Smear Your Mea, a community funded and
public expectations and pressure whānau-driven campaign to encourage
on primary care. Consideration of women to attend cervical screening—all of
the empowerment potential of self- whom also backed a recent petition calling
testing in promotional messages is for the introduction of HPV self-testing.18 As
recommended. a collective, we welcome the Government’s
Our two research groups are progressing commitment to and investment in HPV
implementation studies in Northland and testing. Evidence-based implementation
Auckland in upcoming months, to inform strategies are now required to maximise
NCSP implementation planning on a range the potential for this technology to address
of the recommended issues. current inequities.
14
NZMJ 21 May 2021, Vol 134 No 1535
ISSN 1175-8716 © NZMA
www.nzma.org.nz/journaleditorial
Competing interests:
Dr Crengle reports grants from Health Research Council of NZ and personal fees from
WellSouth PHN, outside the submitted work. Dr Saville reports non-financial support from
Roche, other from Roche, non-financial support from Seegene, non-financial support from
Cepheid and non-financial support from Becton Dickinson, outside the submitted work. Dr
Grant reports grants from Health Research Council, grants from Awhina Trust and grants
from A+ Trust, during the conduct of the study. Dr Lawton reports personal fees from Pfizer
Menopause Advisory Board, Australasia and personal fees and other from Seqirus, during
the conduct of the study. Dr Bartholomew reports grants from Health Research Council,
grants from Awhina Trust and grants from A+ Trust, during the conduct of the study, and
that they are Member of the National Screening Advisory Committee (NSAC).
Acknowledgements:
Endorsed by the Hon Dame Silvia Cartwright PCNZM, DBE, QSO,
Sandra Coney QSO and the Cartwright Collective.
Author information:
Karen Bartholomew: Planning Funding and Outcomes,
Waitematā District Health Board; Auckland District Health Board.
Beverley Lawton: Centre for Women’s Health Research
Te Tātai Hauora o Hine, Victoria University.
Susan M Sherman: School of Psychology, Keele University.
Collette Bromhead: School of Health Sciences, Massey University.
Jane Grant: Planning Funding and Outcomes,
Waitematā District Health Board; Auckland District Health Board.
Georgina McPherson: Clinical Lead Colposcopy,
Women’s Health, Waitematā District Health Board.
Anna Maxwell: Planning Funding and Outcomes,
Waitematā District Health Board; Auckland District Health Board.
Marion Saville: Victoria Cytology Service, Melbourne.
Sue Crengle: Department of Preventive and Social Medicine, University of Otago.
Nina Scott: Hei Āhuru Mowai; Funding, Strategy and Equity,
Waikato District Health Board.
Corresponding author:
Karen Bartholomew, Planning Funding and Outcomes,
Waitematā District Health Board; Auckland District Health Board
Karen.Bartholomew@waitematadhb.govt.nz
URL:
www.nzma.org.nz/journal-articles/recommendations-for-implementing-hpv-self-test-
ing-in-aotearoa
REFERENCES
1. Little A, Verrall A (2021). 3;212(2):63-4. underscreened women
Budget delivers improved 3. Ronco G, Dillner J, Elfström by using HPV testing on
cervical and breast cancer K, Tunesi S, Snijders P et self samples: updated
screening. Accessed on al. Efficacy of HPV-based meta-analyses BMJ 2018;
9th May from https:// screening for prevention 363: k4823 http://dx.doi.
www.beehive.govt. of invasive cervical cancer: org/10.1136/bmj.k4823
nz/release/budget-de- follow-up of four European 5. Gurney J, Robson B, Koea J,
livers-improved-cer- randomised controlled Scott N, Stanley J et al. The
vical-and-breast-can- trials. The Lancet. 2014 most commonly diagnosed
cer-screening 8;383(9916):524-32. and most common causes
2. Brotherton J, Budd A, 4. Arbyn M, Smith S, Temin of cancer death for Maori
Saville M. Understanding S, Sultana F, Castle P on New Zealanders. The
the proportion of cervical behalf of the Collaboration New Zealand Medical
cancers attributable to on Self-Sampling and HPV Journal (Online). 2020
HPV. The Medical Jour- Testing. Detecting cervical Sep 4;133(1521):77-6.
nal of Australia. 2020 precancer and reaching 6. Ministry of Health.
15
NZMJ 21 May 2021, Vol 134 No 1535
ISSN 1175-8716 © NZMA
www.nzma.org.nz/journaleditorial
April 2021. NCSP New sionals. 2001 Apr;11(1). medical journal. 2019
Zealand District Health 11. Bromhead C, Sherman S, Jun 21;132(1497):21-31.
Board Coverage Report: Allport T, Crengle S, Grant 15. Butler TL, Anderson K,
period ending 31 March J et al. Human papilloma- Condon JR, Garvey G,
2021. Wellington: Minis- virus (HPV) self-sampling Brotherton JML, Cunning-
try of Health. https:// among never- and ham J, et al. Indigenous
www.nsu.govt.nz/ under-screened Indige- Australian women’s expe-
health-professionals/ nous and other minority riences of participating in
national-cervical-screen- women in Aotearoa New cervical screening. 2020.
ing-programme/ Zealand: A Feasibility PLoS One 15(6):e0234536
cervical-screening-cov- Study (in preparation). 16. Sherman SM, Bartholomew
erage/dhb-quarte-34
12. MacDonald E, Geller S, K, Denison HJ, Patel
7. Adcock A, Cram F, Lawton Sibanda N, Stevenson K, H, Moss EL, Douwes J,
B, Geller S, Hibma M et al. Denmead L, Adcock A et al. Bromhead C. Knowledge,
Acceptability of self-taken Reaching under-screened/ attitudes and awareness of
vaginal HPV sample never-screened indigenous the human papillomavirus
for cervical screening peoples with human among health profes-
among an under-screened papilloma virus self-testing: sionals in New Zealand.
Indigenous population. A community-based cluster PLoS One. 2018 Dec
2019. Aust N Z J Obstet randomised controlled 31;13(12):e0197648.
Gynaecol. 59(2):301–7. trial. 2021. Aust N Z J Obstet 17. Hei Āhuru Mōwai Māori
8. Sherman S, Bartholomew Gynaecol.61(1):135–41. Cancer Leadership
K, Brewer N, Bromhead 13. Brewer N, Bartholomew Aotearoa. Position State-
C, Crengle S et al. Human K, Grant J, Maxwell A, ment on Cervical Cancer
Papillomavirus (HPV) McPherson G, Wihongi Screening and HPV.
self-testing among un- and H, Bromhead C, Scott Wellington. New Zealand.
under-screened Māori, N, Crengle S, Foliaki S, www.heiahurumowai.
Pacific and Asian women: Cunningham C. Acceptabili- org.nz. 2021. Accessed
a preference survey and ty of human papillomavirus on 8th May 2021 from
interviews with clinical (HPV) self-sampling https://4338709a-7b32-46a4-
trial non-responders among never-and under- 8b1a-6ddebf8d035f.filesusr.
(in preparation). screened Indigenous and com/ugd/b7edfc_d4cad-
9. Pearson J, Payne D, other minority women: 309627648c6a04a3e-
Yoshida K, Garrett N. a randomised three- c5bbba3da6.pdf.
Access to and engagement arm community trial in 18. Mackay, T. (2021).
with cervical and breast Aotearoa New Zealand. Prevent Cervical Cancer!
screening services for medRxiv. 2021 Jan 1. Introduce HPV Self-Test-
women with disabilities https://www.medrxiv. ing to Aotearoa – We
in Aotearoa New Zealand. org/content/10.1101/20 Need it NOW. Accessed
Disability and Rehabili- 21.04.11.21255231v1 on 9th May 2021 from
tation. 2020 Sep 14:1-2. 14. Brewer N, Foliaki S, https://our.actionsta-
10. Anderson S, McNair R, Bromhead C, Viliamu-Amu- tion.org.nz/petitions/
Mitchell A. Addressing sia I, Pelefoti-Gibson L, introduce-hpv-self-test-
health inequalities in Jones T, Pearce N, Potter ing-to-aotearoa-new-zea-
Victorian lesbian, gay, JD, Douwes J. Acceptability land-to-prevent-cervi-
bisexual and transgender of human papillomavirus cal-cancer?fbclid=IwAR-
communities. Health self-sampling for cervi- 1HhlNOTCbvQdNjocSM7G-
Promotion Journal of cal-cancer screening in tzZRgeHZ3-NHrD9NRP-
Australia: Official Journal under-screened Māori and FI2q1e3-oNZHpvxbngc
of Australian Association of Pasifika women: a pilot
Health Promotion Profes- study. The New Zealand
16
NZMJ 21 May 2021, Vol 134 No 1535
ISSN 1175-8716 © NZMA
www.nzma.org.nz/journalYou can also read
