Transitioning to HPV primary screening in Canada

Franco et al state that the 'evidence from over a decade of large­‐scale clinical trials, feasibility studies and real‐world experiences from countries that have adopted primary HPV screening as the primary cervical screening mode overwhelmingly prove that the benefits for shifting to primary HPV screening far outweigh potential or perceived  harms. HPV primary screening has proven to be clinically superior to the Pap test for primary screening without increasing the costs' [1].  
 
As Canada moves forward with provincial and territorial HPV screening pilot studies, strategies for implementing HPV primary screening, new protocols and strategies for laboratory technicians, and health education strategies for both medical professionals and the general public should not become a barrier from transitioning from Pap testing to HPV primary screening [2].

British Columbia and the HPV focal study

Currently, the BC Cancer Agency is currently conducting a study with over 25, 000 women from Metro Vancouver and Greater Victoria to find out if the HPV test can enhance cervical cancer screening for women in British Columbia [3]. In broad terms, this is being done by comparing the Pap test against the HPV test.  Most of the participants are in the final phases of the study and only need to visit their health care provider their final cervical screen visit. The study itself is expected to be completed sometime in late 2016 [4]. However, preliminary FOCAL results consistently show that HPV testing followed by Pap triage (follow-up) leads to a greater detection of precancerous lesions.

A harmonized transition

The main steps to implement HPV primary screening in Canada are known and have been described by Pan-Canadian Cervical Cancer Screening Network (PCCSN).

Laboratory organization and performance

Switching to HPV-based primary screening would have considerable impact on cytology laboratories. Loss of volume, a reorganization of the technical staff, along with the potential reorganization of services would need to be planned for in advance [5]. Incurred costs, the standardization of operating procedures and integrated reporting, and changes in quality assurance will also need to be planned for [6].

Health education: Targeting the general public

Appropriate Information about HPV and HPV testing will need to actively target the general population. Effective public health education strategies would reach out to vulnerable populations who may otherwise be missed by traditional cervical cancer screening methods. Therefore, health education and promotion of cervical cancer screening must take place in a community-based and culturally sensitive context to increase screening amongst those groups [7].

Studies have shown that when appropriate information about HPV and HPV testing are provided, patients readily consent to HPV testing. In a study by Ogilvie et al, it was found that while more than 80 per cent of women intended to be screened for cervical cancer with HPV primary testing. Subsequently, it decreased once they were advised of the extended screening interval (4-5 year intervals) with HPV testing, from 84.2 to 54.2 per cent [8].  Furthermore, when advised HPV testing would not start until the age of 25, women's intentions to be screened remained low at 51.2 per cent [9]. Therefore, HPV testing and the benefitss of switching from the Pap test to primary HPV testing must be effectively communicated.

Health education: Medical professionals

As healthcare professionals and practitioners become the primary vehicles for the first-line delivery of HPV testing, health education strategies will also need to target them as well [10]. Information addressing the specifics of HPV-based screening will have to follow in line with provincial and territorial policy changes that implement or introduce HPV testing for primary screening. And, as with the general public, any confusion about HPV and HPV testing amongst medical professionals will need to be met with updated, current information. Educational training and support should be available to provide medical professionals with effective, sensitive communication skills. For example, in their study, Ogilvie et al says [11]:

HPV testing in screening may require practitioners to inform some women, many of whom have been in monogamous relationships, that they are infected with a highly    prevalent sexually acquired virus. Although the virus may have been acquired many years prior, HPV is different from other STIs owing to its high prevalence and long lifespan. Thus, delivering the news of a positive result will create significant challenges both for practitioners and for patients. Practitioners will need to ensure that they set the appropriate context for HPV infection and effectively manage emotional responses to positive results.

Optimal follow-up strategies

Because the HPV test is more sensitive, it will detect more pre-cancerous lesions than the Pap test, which might lead to an initial increase in the number of women referred  for the colposcopy diagnostic test.  However, what is most important is that the HPV screening test is a much more precise measure of whether women are at risk of cervical 
cancer.  This means that fewer women will undergo unnecessary colposcopies and other  invasive procedures and treatments.  Investigators for BC’s FOCAL study found that cumulative long-term colposcopy rates for the HPV test and Pap test would be similar for women 30 and over [12].

There is, however, a great deal of  interest in identifying follow-up options that can pinpoint, among HPV positive women, those who are most at-risk of developing high grade precancerous legions or cancer, in order to restrict diagnostic follow-up. A proposed idea by experts is to have cytology used as a follow-up test for HPV positive women, and only those with a positive result would go for colposcopy [13].  

References 

[1] Tota, Joseph E. and Franco, Eduardo L et al. Introduction of molecular HPV testing as the primary technology in cervical cancer screening: Acting on evidence to change the current paradigm, December 2015 
[2] ibid. 
[3] "HPV FOCAL Study." HPV FOCAL Study. BC Cancer Agency, 2015. Web. 03 Sept. 2015.
[4] ibid.
[5] Mayrand, Marie-Hélène, Verna Mai, Dr, François Coutlée, James Bentley, Yvonne Taylor, Gina Ogilvie, Patricia Goggin, and Dirk Van Niekerk. HPV Testing for Cervical Cancer Screening. Summary of Evidence. Canadian Partnership Against Cancer, 29 Mar. 2012. Web. 4 Sept. 2015.
[6] McLachin, Meg, MD. Recent Changes to Cervical Cancer Screening in Canada. Rep. no. Powerpoint Presentation. Schulich School of Medicine and Dentistry & London Health Sciences Centre, 17 Apr. 2015. Web. 4 Sept. 2015.
[7] "Cervical Cancer Screening." Canadian Cancer Survivor Network. Canadian Cancer Survivor Network, 12 June 2012. Web. 4 Sept. 2015.
[8] Ogilvie, Gina S., Laurie W. Smith, Dirk J. Van Niekerk, Fareeza Khurshed, Mel Krajden, Mon Saraiya, Vivek Goel, Barbara K. Rimer, Sandra B. Greene, Suzanne Hobbs, Andrew J. Coldman, and Eduardo L. Franco. "Women’s Intentions to Receive Cervical Cancer Screening with Primary Human Papillomavirus Testing." International Journal of Cancer 133 (2013): 2934-943. International Journal of Cancer, 2013. Web. 5 Sept. 2015.
[9] ibid.
[10] Mayrand, Marie-Hélène, Verna Mai, Dr, François Coutlée, James Bentley, Yvonne Taylor, Gina Ogilvie, Patricia Goggin, and Dirk Van Niekerk. HPV Testing for Cervical Cancer Screening. Summary of Evidence. Canadian Partnership Against Cancer, 29 Mar. 2012. Web. 5 Sept. 2015.
[11] Ogilvie, Gina S., Laurie W. Smith, Dirk J. Van Niekerk, Fareeza Khurshed, Mel Krajden, Mon Saraiya, Vivek Goel, Barbara K. Rimer, Sandra B. Greene, Suzanne Hobbs, Andrew J. Coldman, and Eduardo L. Franco. "Women’s Intentions to Receive Cervical Cancer Screening with Primary Human Papillomavirus Testing." International Journal of Cancer 133 (2013): 2934-943. International Journal of Cancer, 2013.

[12] Tota, Joseph E. and Franco, Eduardo L et al. Introduction of molecular HPV testing as the primary technology in cervical cancer screening: Acting on evidence to change the current paradigm, December 2015 
[13] Mayrand, Marie-Hélène, Verna Mai, Dr, François Coutlée, James Bentley, Yvonne Taylor, Gina Ogilvie, Patricia Goggin, and Dirk Van Niekerk. HPV Testing for Cervical Cancer Screening. Summary of Evidence. Canadian Partnership Against Cancer, 29 Mar. 2012. Web. 9 Sept. 2015.