Self-collection of a vaginal sample for human papillomavirus (HPV) testing is now an option for every cervical screening encounter.
Available to all, it particularly aims to support and engage under-screened patients such as such as Aboriginal and Torres Strait Islanders, the culturally and linguistically diverse, disabled, gender diverse and sexually diverse people.
In Australia, the participation rate in cervical screening prior to introducing self-collected specimens was 46.3 per cent. However, 70 per cent of all cervical cancers occur in people who have never screened or are lapsed screeners. A 2021 review by the Australian Government’s Medical Services Advisory Committee found that people offered HPV testing using self-collected vaginal samples instead of a physician-collected swab may be more than twice as likely to participate.
Nevertheless, some GPs still have some concerns about self-collection. Below we have outlined some of the most common barriers health professionals have to providing self-collection to all patients.
I’m concerned that self-collected vaginal HPV testing is not as accurate as a cervical sample.
Evidence shows that HPV PCR tests performed on self-collected vaginal samples are as accurate as those performed on cervical samples obtained by a clinician.
Will tests be sent to patients like bowel screening kits – potentially missing other screening opportunities?
By definition, a screening test is for asymptomatic patients. Clinician-collected and self-collected cervical screening options are still accessed through a health care provider. Access through a clinician ensures patients can still receive an examination or further investigations if they need them. For example, patients with abnormal bleeding will still need an examination and an endocervical sample for liquid based cytology (LBC).
When is it appropriate to offer self-collected tests – is it just for the under screened?
Self-collection is appropriate for any screening samples. It can also be done as the 12-month follow-up test for previously detected non-16/18. However, there is a high likelihood of that test being positive and an LBC then required. Self-collection is not appropriate if the participant requires a co-test (HPV + LBC) or if they have symptoms that could be cervical cancer – postcoital, intermenstrual or post-menopausal vaginal bleeding, or unexplained persistent unusual vaginal discharge.
What if non-16/18 HPV is detected on a self-collected test?
If a self-collected sample does detect non-16/18 HPV, the patient will need to return to collect a cervical sample for reflex liquid-based cytology via speculum examination. (Patients with HPV 16 or 18 are referred directly to colposcopy.) Patients need to be counselled about the chance of needing a return visit when discussing the pros and cons of self-collected testing.
According to the Australian Centre for the Prevention of Cervical Cancer, the age-related rate of HPV incidence, and hence likelihood of a return test, is currently:
For more information, see Cervical Screening: Supporting your patients to make the choice.
I’m concerned about missing the opportunity for an incidental finding, such as a vulval melanoma.
Vulval melanomas are rare. In comparison, cervical cancer made up 1.3 per cent of all cancers diagnosed in females and people with a cervix in Australia in 2022. Increasing the participation rate of screening will contribute to reducing the cervical cancer rate.
Will I miss something if I don’t do a pelvic examination?
There is no evidence to support the use of pelvic examination as routine practice for asymptomatic patients. For HPV-positive patients, the cervix will be visualised during a follow up appointment for cytology or colposcopy.
How do I explain self-collection to patients?
We all have scripting that we have tried and tested over time to explain concepts to and educate our patients. Here are some examples for self-collected cervical screening:
- “The last time you had a cervical screen you and I went to a lot of effort to collect a sample of cervical cells, but once it was HPV-negative the lab discarded those cells. With new HPV PCR testing taking the sample yourself from the vagina is just as accurate”.
- Showing a demo swab can help demystify the process: “It’s like a vaginal RAT test”.
- “HPV testing is more accurate than the old-fashioned pap test and it detects problems earlier.”
- “Self-collection is easy to do and highly accurate. You insert he swab into the vagina and rotate it for at least 10 seconds to collect an adequate number of vaginal cells. The sample does not need to be taken from the cervix. It only needs to be inserted about the length of your index finger.”
Some extra practical tips
- Encourage self-collection to be done in-clinic wherever possible. This ensures the test is completed. Offer a private space, such as a bathroom.
- Participants who may have difficulty, or are not confident, collecting a vaginal sample themselves may be assisted to do so by the health care provider. The health care provider may collect the sample on their behalf using a self-collection swab without using a speculum.
- A self-collected test can be used as the final exit test for those aged 70-75.
- A self-collected test is a time saver for clinicians. We can use the saved time for other screening opportunities.
Complete a Quality Improvement activity on this topic:
More information
- Health Provider Tool Kit
- Australian Centre for the Prevention of Cervical Cancer (ACPCC)
- Information on the National Cervical Screening Program
- Cancer Council of Australia Clinical Guidelines
- National Screening Program Policy
- Resources for patients:
- ACPCC – supporting your patients to make the choice
- ACPCC – FAQ’s
- ACPCC – Program Quick Reference Guide
- National experience in the first two years of primary human papillomavirus (HPV) cervical screening in an HPV vaccinated population in Australia: observational study
HealthPathways Melbourne
Visit HealthPathways Melbourne for clinical guidance at the point of care for:
Are you a GP or health professional in our region who doesn’t have access to HealthPathways Melbourne? Request access online or contact info@healthpathwaysmelbourne.org.au
