A game changer for cervical health

Corbett (Te Arawa/Ngāti Pikiao) is the Kaiwhakahaere (Māori Co-ordinator) at the National Cervical Screening Programme based in Hawke’s Bay.

“If you’ve ever known anyone who has developed cervical cancer or been through treatments … it’s such a personal area and so invasive, so when you think we can prevent it, it’s quite exciting.” Although current screening rates are below target, a new screening method – which people can do themselves – is being introduced in July 2023. The new screening test has the potential to reduce barriers to testing and, combined with vaccination, even eliminate cervical cancer.

Cervical cancer screening rates dropping

About 160 people develop cervical cancer in New Zealand each year, and about 50 die.

The NCSP aims to screen 80% of eligible people every three years. In the three years ending March 2022, the screening rate was 67%.

Screening rates for Māori, Pasifika and Asian people are lower than for the general population – around 54% to 57%.

While Asian people have lower screening rates, the incidence and mortality are similar to those for Pākehā. But Māori and Pasifika are more likely to die from cervical cancer than Pākehā are.

Why aren’t people getting screened?

Carmen Rewi-de Joux is a clinical nurse specialist in women’s health with Te Whatu Ora Southern. She said the current way of testing is effective, but it can be a hard sell.

Commonly known as the smear test, the current cervical screening test is where a sample of cells is taken from the cervix and tested to see whether there are pre-cancerous cell changes in the cervix.

For some people with a previous sexual trauma, a negative experience getting tested or perhaps a medical professional’s technique, “hasn’t suited that lady’s needs”, Rewi-de Joux said.

Dr Emily Cavana, a Wellington GP and member of the NCSP Advisory and Action Group alongside Rewi-de Joux and Corbett, agrees the unpleasantness of the test is a barrier. However, other factors also come into play.

Finding childcare, and time off work to go to the medical centre can be a hassle. Meanwhile older people who don’t have a partner may not think they need the test, Dr Cavana said.

Some patients say, “well, I don’t need that test [because] nothing’s going on down there, but you know, that’s not correct”.

Cervical cancers can take many years to develop, she said.

“The point of the screening test is to pick up the changes.”

Some people who are feeling well, and have a busy life, don’t see the point in getting tested either, said Corbett.

“When you’ve got a lot going on in your life, and if you feel healthy, and well … women may make a conscious choice sometimes that they don’t need to,” she said.

Others may think cervical cancer is hereditary, but it’s not. It’s predominantly caused by a virus.

The new screening test for cervical cancer

From July 2023, a new screening tool – the HPV test – will be available.

The HPV test will screen for the presence of human papillomavirus (HPV). Cervical cancer is the most common cancer associated with HPV.

Rather than enduring a smear test, the new screening tool is essentially a long cotton bud that’s used to swab the vagina walls. It doesn’t require a speculum or contact with the cervix.

Rather than the current three-year screening period for participants aged between 25 and 69, once a person has had the HPV test, for those with no virus detected, it shifts to a five-year screening interval. With the new programme, fewer screens will prevent as many, if not more cancers.

Perhaps best of all, people with a cervix can do the test themselves.

A chance to redress inequities in screening

The HPV self-test has the potential to halve the number of under-screened or never-screened Māori.

A 2020 study in Northland with 500 eligible Māori found that those offered the self-test were 2.8 times more likely to be screened than those offered the current screening test.

A Kaupapa Māori study the following year, which included 254 never-screened or under-screened women, found people saw the self-test as empowering.

Many involved in the study said it was preferable to a cervical smear. One woman said it took the whakamā (embarassment or shame) out of the process, while others said it was a better, easier, faster, pain-free and more practical. It was also considered to be more comfortable, private and dignified than the current cervical screening.

“I found the self-test so easy and good,” one study participant said. “Once it was done, I came back to my workplace and encouraged ladies I work with to go and get it done.”

The ability to self-test addressed concerns some Pasifika women had about privacy and confidentiality, a 2022 study found.

One study participant noted the public space of the doctor’s waiting room was a barrier to testing: “If you happen to go in on a Wednesday, then everybody knows that you’re going to see the lady doctor and then they start putting their own spin on it.”

Being able to self-test in private in your own home alleviated these concerns.

This was backed up by a 2021 study which found Pasifika women were six times more likely to agree to self-test at home, compared with taking the self-test at a general practice.

It’s a better test, but there’s still a charge

Cost has consistently been identified as a major barrier to getting a cervical screen.

Although fully funded screening for eligible people was recommended by the Parliamentary Review Committee to the NCSP in 2018, there’s still a charge because of a lack of funding.

The first consultation you have as part of the HPV screening must be with a health care provider, although after the consultation, you can still do the test yourself in private at the clinic, or take it home with you, or opt to have a clinician do it for you.

Yet this means one barrier – cost – is still in place because people will need to pay to see a clinician to do the new test.

Te Whatu Ora (Health New Zealand) said it will continue to provide outreach services for people who experience barriers to cervical screening, and is exploring options to break down cost barriers.

Other cancer screening programmes are free; bowel screening is free for those aged 60 to 74 years, and breast cancer screening is free for those aged 45 to 69.

However, the need to see a clinician to get the self-test may change in the future, Corbett believes. In the future, there could well be HPV self-tests available at selected stores or sports clubs to make it more accessible. However, ensuring that someone doesn’t have symptoms that require more investigation is still important.

Covid 19 lockdowns created a screening backlog

Since the March 2020 lockdown, screening rates for Māori and Pasifika have taken a tumble.

Data from the National Screening Unit shows the screening rate between February 2020 and June 2022 was down 9.1% for Pasifika and 7.5% for Māori.

There’s also a backlog of cervical screen tests to be processed, for those currently registered with the screening programme.

Dr Bryan Betty from the Royal New Zealand College of General Practitioners expressed concerns in April 2022 that there was a backlog of 50,000 smears to be processed because of Covid-19.

The College of GPs wanted to catch up on those smears within six to 12 months.

However, Dr Betty said progress has been slow and the backlog is still about 50,000.

“It’s slowly being chipped away at because there’s a real capacity issue on the system.”

But people who are due their cervical screen should get it done as soon as possible, rather than waiting for the change to the HPV test, Dr Betty said.

There have also been delays with the HPV immunisation programme which is delivered via GPs and schools. Given the lockdowns and low rates of school attendance in many areas, Te Whatu Ora is looking at how uptake can be improved next year.

The vaccine is free for those aged nine to 26 years. It gives highly effective protection against 90% of cervical and other HPV related cancers – but there are a few other types of HPV not covered by the vaccine.

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Questions and answers

1. Is the HPV test better?

Yes, it’s a better test. It will find more pre-cancers and prevent more cases of cervical cancer.

HPV is responsible for more than 99% of cervical cancers, and about 80% of sexually active people will have had an infection of HPV at some stage. While there are many types of HPV, only a few types will lead to abnormal, pre-cancerous cells that could progress to cancer.

The HPV test will identify if the human papillomavirus is present. It will also identify those who may need further testing at an earlier stage than the current test. This makes it a more effective test for identifying the risk of developing abnormal cell changes that may lead to cervical cancer.

The World Health Organization recommends the HPV test as the primary screening tool.

Australia has been offering the HPV test since 2017. It’s been offered in England and Ireland since 2020.

2. Will I need to see a healthcare provider to do the self-test?

Yes.

Carmen Rewi-De Joux of Te Whatu Ora Southern said a consultation is needed because there needs to be a conversation between participants and clinicians about the different form of screening.

Sandra Corbett of NCSP in Hawke’s Bay agrees. There will need to be a transition period so that people can get used to doing the test differently – and for clinicians to get used to the different testing method and to provide education in a clear and culturally appropriate way, she said.

A spokesperson for Te Whatu Ora said there needs to be clinical oversight of the test, getting the results back and any follow-up needed.

3. Can I get the self-test wrong?

Highly unlikely.

Francesca Storey is a Senior Research Fellow and deputy director at the National Centre for Women’s Health Research Aotearoa. She’s been involved in studies where people have been offered the HPV self-test.

She explained that when samples are being tested for HPV, they’re first being checked to ensure there are sufficient vaginal wall cells. Next, they’re analysed to detect DNA of the many types of the virus.

“You just need the tiniest amount of that virus for it to be detected,” she said.

If there’s not enough vaginal cells in the sample, you’ll be contacted by your healthcare provider to re-do the test.

“This vary rarely happens, it’s a super easy test to do yourself,” says Storey.

You can ask your doctor, or nurse to administer the swab for you, if you’d prefer. However, self-collected samples have been proven to be as good at detecting high-risk HPV as clinical collected samples.

4. What happens if you’re positive for HPV?

If you test positive for HPV, you will be contacted for follow-up.

The type of HPV virus detected will determine the next step. If you have one of the less potentially cancer-causing types of HPV, you may be asked to repeat the test in a year, said Storey.

HPV is common and it often clears itself. However, if the virus is still there a year later, more investigation may be needed.

That could involve a speculum exam (like the smear test) to look at the cervix and check the cells, or a colposcopy. The latter procedure is done in a hospital outpatient clinic, where a specialist can inspect the cervix through magnification, and may take a biopsy or remove an area of concern.

“And for those positive for one of the more cancer causing HPC types, it’s important that the person is seen by a specialist for follow-up assessment and possible treatment more quickly,” said Storey.

5. Can I still do the speculum screening test?

Yes, you can choose to have the speculum exam and have the sample taken by a clinician.

6. Do I still need the HPV vaccination?

Yes. The HPV vaccination and HPV test work side by side.

The vaccine is effective in preventing infection for about 90% of the cancers caused by HPV. It doesn’t cover all types of HPV that can cause cancer.

People who have been vaccinated still need to continue with regular cervical screening.

The vaccine is free for those aged nine to 26 years old, and is available via your GP or participating schools.

7. When do I need to go and get the HPV test?

Wait until you’re contacted as part of the National Screening Programme.

If it has been four years or more since you were screened, or you have never been screened for cervical cancer, it’s important to get tested as soon as you can. Don’t wait until the changes in July 2023. Call your local hauora/health practice or call 0800 729 729 for more information.

8. Can cervical cancer be eliminated?

Yes. In 2018, World Health Organization (WHO) director general issued a call for the elimination of cervical cancer.

Elimination can be declared once incidences of cervical cancer are below four per 100,000 women a year. Globally, it’s estimated that more than 600,000 women were diagnosed with cervical cancer, and just over half of those women died in 2020.

In response to the WHO goal, some parts of the world have trials underway involving HPV testing and same day treatment.

“It involves the HPV self-test, point of care analysis onsite, and immediate treatment there and then if needed,” said Storey.

It’s about time New Zealand introduced this step towards cervical cancer elimination, said Storey.