Mailed Kits Beat Office Visits for Cervical Cancer Screening
Mailed self-collection kits and a telephone reminder helped increase cervical cancer screening (CCS) rates more than twice as much as telephone reminders for an office visit, according to new data from a randomized clinical trial in a safety-net population. The home kits paired with additional patient contact increased numbers even further.
In a trial that included 2474 people overdue for CCS (94% of them from minority populations), participants randomized to a telephone reminder with a mailed self-collection kit had 41.1% participation compared to those with a phone reminder to come in for an office visit (17.4%). CCS rates were modestly higher (46.6%) when people received contact in addition to the telephone reminder and mailed self-collection kit for testing human papillomavirus (HPV).
Self-collection with additional patient contact was designed to be different from self-collection with a telephone reminder in terms of the dose of patient interactions rather than content, minimizing potential contamination across the self-collection with telephone reminder and self-collection with additional patient contact groups.
The study, led by Jane R. Montealegre, PhD, with the Department of Behavioral Science, The University of Texas MD Anderson Cancer Center in Houston, was conducted from February 20, 2020, to August 31, 2023, and published in JAMA Internal Medicine .
Cervical Cancer Could be Eliminated in the US in 10-20 Years
Estimates show that cervical cancer in the US could see national-level elimination in the next one to two decades if CCS rates hit 90%. However up-to-date screening has declined in recent years and was 75.2% in 2021, with rates notably lower among underserved populations, including women and people with a cervix who are uninsured or publicly insured, live in rural areas, and are from minority populations.
The study researchers noted that the results in this trial, the PRESTIS trial, are consistent with the relative participation rates of previous trials. In a recent meta-analysis of 28 trials, Stefanie Costa and colleagues reported a 2.5-fold higher participation in screening with mailed self-collection vs usual care. 'Notably distinct from previous trials are the large screening proportions attained in the [self-collection (SC) group] (41.1%) and SC with patient navigation (46.6%) groups, as compared to the global estimate of 24% reported in the meta-analysis,' the authors wrote.
In an accompanying editorial, Eve Rittenberg, MD, MA, with the Division of Women's Health, Brigham and Women's Hospital and Harvard Medical School in Boston, and colleagues wrote that home self-collection 'has the potential to meaningfully reduce cervical cancer burden, especially among underserved populations.'
They pointed out that self-collection has previously been studied in a clinical setting, where women can collect a sample privately without undergoing an invasive Pap smear and that 'self-collected HPV samples have similar specificity and sensitivity to clinician-collected samples.' But it hasn't been known whether the tests need to be performed in a clinic.
Home Screening May Further Eliminate Barriers
Montealegre's team shows that 'home self-collection demonstrates that people can adequately obtain usable samples in the privacy of their homes, as only 6% of samples were deemed inadequate for evaluation,' the editorialists wrote. Home-based screening, they explained, may further eliminate screening barriers for underserved populations with lower costs and fewer logistical hurdles. Additionally, screening via pelvic exam can be uncomfortable and may be culturally unacceptable for some. Pelvic exam-based screening may be particularly distressing to those who have experienced sexual trauma, they wrote.
They pointed out that options for CCS are growing with the approval last month by the FDA of a home HPV self-collection kit, which will be available for clinical use within months. Self-collection of HPV samples is included in the World Health Organization's global strategy to eliminate cervical cancer by 2030, and the draft US Preventive Services Task Force CCS guidance now includes self-collection as an option.
Future research should help determine whether more home self-collected HPV screening leads to higher rates of treating precancerous lesions and eventually lower cervical cancer rates, the editorialists wrote.
They also noted that efforts to increase CCS rates should be accompanied by efforts to increase HPV vaccination rates.
The research was funded through grants from the National Institute on Minority Health and Health Disparities and the National Cancer Institute through an MD Anderson Cancer Center Support Grant, the Dan L Duncan Comprehensive Cancer Center Support Grant, and the Hollings Cancer Center Support Grant. The authors reported having no relevant financial relationships. An editorialist, Cary Gross, MD, reported receiving grants from Johnson & Johnson and the National Comprehensive Cancer Network (with funding provided by AstraZeneca) outside the submitted work. No other disclosures were reported.
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