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.