INTRODUCTION
Cervical cancer is the fourth most common cancer in women worldwide, and
the seventh overall, with an estimated 570,000 incident cases per year
with 311,000 women dying from the disease.1,2Approximately nine out of 10 cervical cancer deaths occur in less
developed regions.3,4 Developed countries including
those in North America, Europe, Australia/New Zealand, and Japan have
been effective in reducing cervical cancer incidence and mortality due
to population-based cytologic screening programs.1,5Cytology-based screening, conducted as part of a pelvic examination, is
a method of detecting pre-invasive neoplasia (also known as
pre-cancerous lesions). Detection and treatment of neoplasia at the
pre-invasive stage can prevent lesions from becoming cancerous. Advances
in cytology-based screening, however, have not translated to less
developed regions including countries in Africa, South and Southeast
Asia, and parts of Latin America where cervical cancer is the second
most common cancer.
To address many of the barriers to cervical cancer screening, the World
Health Organization (WHO) recommends low-cost, culturally-acceptable
alternatives to cytology such as Human Papillomavirus (HPV) DNA
testing.6 Persistent HPV infection is associated with
the vast majority of cervical cancer cases.6 Tests for
HPV DNA are easily reproducible and have higher sensitivity for
detecting high-grade cervical intraepithelial neoplasia than cytological
tests.3,4,6-8 A meta-analysis found an overall
sensitivity of 80-95% for HPV testing compared to 60-80% for cytologic
testing, and an overall specificity of 50-70% for HPV testing compared
to 85-95% for cytologic testing.9 Unlike cytologic
testing, HPV testing does not require retesting or multiple visits from
the patient. HPV testing also offers an option for self-sampling where
cytological testing does not.
Due to the physical and psychological discomfort associated with the
pelvic exam necessary for cytologic testing, self-sampling may be an
acceptable alternative. Furthermore, Indian women continue to be
hesitant and shy about undergoing a pelvic exam culturally. The
self-collection method addresses structural issues to resource
constraints, lack of staff, and space to provide screening. A recent
systematic review of 37 self-collection studies from 24 countries found
overall high acceptability.10 A self-sampling option
may be appealing to women that would otherwise not screen.
To address the burden of cervical cancer, the Indian Ministry of Health
implemented a nation-wide cancer-screening program in November 2016.
India with the world’s second largest population, also experiences a
large proportion (27%) of the world’s cervical cancer deaths
annually.4 Each year 96,922 women are diagnosed with
cervical cancer and 60,078 die from the disease.3,11The screening program required mandatory oral, breast, and cervical
cancer screening for people over the age of 30 in 100 selected districts
of India.12 While preliminary data regarding the
overall impact of cancer screening program is not available, three
hospital based studies showed promising results.13-15If the nation-wide screening program is to be successful in the
culturally and economically diverse regions of India, feasibility and
acceptability of different screening methods must be identified and
addressed.
This study was conducted in a community-based setting in rural
communities in the state of Karnataka among asymptomatic women attending
a mobile cervical cancer screening program. The objective was to assess
the feasibility and acceptability of self-sampling for HPV testing as
compared to clinician-collected sample.