Opinion

Scrap the Pap

Traditional Pap testing must go.

Canada must switch to oncogenic primary human papillomavirus (HPV) screening – and we need to do it now to save hundreds of lives and prevent thousands of cases of cervical cancer.

HPV primary screening looks for the presence of high-risk HPV types in cervical cells. The Pap test, on the other hand, screens for cervical changes that may result from HPV infection – but it doesn’t screen specifically for HPV. This matters because HPV causes almost all cases of cervical cancer and can be detected even before the cellular changes that can be picked up on the Pap test.

The World Health Organization has set a goal to eliminate cervical cancer worldwide this century, and the Canadian government has committed to achieving this by 2040. It will take a combination of immunization and screening, as well as timely and appropriate follow-up, to reach that goal. The Action Plan for the Elimination of Cervical Cancer in Canada, 2020-2030, outlines the priorities, targets, actions and key implementation partners needed to get us there. It was developed by the Canadian Partnership Against Cancer with a broad group of partners, experts and stakeholders, including the Public Health Agency of Canada as well as First Nations, Inuit and Métis organizations and patients.

There’s no question that ramping up vaccination rates is crucial. However, unless we quickly change the way we’re screening for HPV, we will not reach our elimination target by 2040.

Right now, the status quo for cervical cancer screening is a Pap test every two to three years. Replacing this with oncogenic HPV primary screening will modernize cervical cancer screening to the benefit of individuals and the cancer-care system. It must be done only once every five years, it’s more cost-effective, and it prevents more cancers than the Pap test.

It also supports equity. Cervical cancer can only be eliminated if everyone in Canada has equitable access to the highest quality prevention and care. Oncogenic HPV screening enables self-sampling, which can be done at home so that more people in more locations, including rural and remote communities, can access screening. This allows for better access to safe screening for people without care providers, those who face cultural stigma around Pap testing, and those with a history of trauma or who mistrust health-care institutions. Oncogenic HPV screening can help break down these barriers that prevent real equity of access and outcomes in cervical cancer.

Many screening programs were paused, and participation rates fell during the pandemic. As we actively work to restore cervical cancer screening programs and continue screening recovery post-pandemic, we can transform them and boost screening participation rates in the process. And because HPV screening can be done at home, it can continue during future pandemics or disruptions and alleviate pressures on overburdened primary care clinics and providers.

We need to make this shift soon. Moving to oncogenic HPV testing will have the greatest impact on achieving Canada’s targets for the elimination of cervical cancer. By 2030, we need to ensure that at least 90 per cent of eligible individuals have been screened with an HPV test. If we can achieve that, an estimated 6,800 cancer cases can be avoided, and 1,750 lives saved through early detection of HPV and early-stage cervical cancer. The fact is, the longer we put off switching, the longer we put off the benefits – needlessly putting people at risk.

Canada must switch to oncogenic HPV screening now to prevent thousands of cases of cervical cancer.

So, what will it take to get us there?

We need organized screening programs everywhere – programs that ensure people are screened at the right time, with the appropriate test, and get the follow-up they need. Currently there are no organized cervical cancer screening programs in Quebec, Prince Edward Island, Yukon, Northwest Territories or Nunavut, so work will be required to partner with these jurisdictions and build the infrastructure.

We should also look at training and technology. In some cases, there may be a need to re-train cytotechnologists because HPV testing uses different technology for analysis than Pap testing. However, in many places the technology used for analyzing HPV tests is similar to that used for genotyping COVID-19 tests, so it is possible that investments recently made there could be used for HPV testing post-pandemic. While Health Canada has approved some devices that can be used for HPV self-sampling, each jurisdiction must still validate and make reimbursement decisions about their use.

At the same time, we need primary care providers to understand and champion HPV testing. And we must be cognizant of how we talk about HPV screening with individuals to avoid any sense of blame and shame associated with HPV as a sexually transmitted infection. The fact is, HPV primary screening should simply become a routine test for all eligible people, every five years.

Globally, a number of other countries, including Australia and the United Kingdom, have already moved to HPV screening. Australia began in 2017. It has also been using the self-sampling HPV test at medical centres. Overall, Australia expects that the HPV test will protect up to one-third more women than the Pap test did. The U.K. switched in 2019, and during the pandemic it also rolled out a pilot test of home-based HPV screening for people in certain regions who were at least 15 months overdue for a check.

In Canada, a number of provinces are beginning to make the move. Ontario, for instance, has taken steps to adopt HPV screening and will be one of the first to do so along with British Columbia. The Canadian Partnership Against Cancer is providing $1.4 million to support implementation of HPV primary screening – including self-sampling in some cases – in six other provinces: Saskatchewan, Manitoba, New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland and Labrador. And Quebec is planning for the transition to HPV screening.

In total, nine out of 13 jurisdictions in Canada are actively planning implementation of HPV primary screening so far. This is a positive sign and an important indicator that these investments are driving meaningful change.

What we need now is full commitment from all jurisdictions to make the switch and to do it as quickly as possible so we can reach our elimination target on time. Preventing cancer, including cervical cancer, and identifying it early and accurately are essential to saving lives and are key priorities of the Canadian Strategy for Cancer Control 2019-2029.

We are poised to eliminate cervical cancer by 2040. By finding HPV and early-stage cervical cancer through oncogenic primary HPV screening, we can prevent many cases from developing in the next few years. It’s a system-level change that can make a rapid difference.

It’s time to scrap the Pap.

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4 Comments
  • Anne-Marie Tynan says:

    This was a really interesting and well-written article. I didn’t know that there might be a better screening test than the Pap test I have been getting for years. I hope Ontario gets things rolling with the HPV test sooner rather than later.

  • Mo Geer says:

    Excellent article.

  • Madeline O'Connor says:

    I have been a primary care physician for 11 years and I was thrilled when Ontario began to provide Oncogenic HPV screening. Unfortunately, this was (and still is) available only to patients who agree to pay a substantial fee. I am hoping this service becomes available without charge throughout Canada so that women, and their physicians, can get an accurate idea of the patient’s cancer risk.

    • Dr. Abba Ali Tijjani. says:

      It is very important that this screening modality came up. In Sub-Saharan Africa where, upto 70% of cases of cervical cancer occur partly due to cultural barriers that prevent women from undergoing the conventional Pap smear testing. The home based oncogenic HPV screening would go a long way in overcoming these barriers and would be an acceptable and effective screening modality for cervical which, in the long run results in elimination of cervical cancer in this part of world.

Author

Heather Bryant

Contributor

Dr. Heather Bryant is Expert Advisor, Cancer Control at the Canadian Partnership Against Cancer. She is a cancer control leader whose expertise spans the continuum – prevention and screening to diagnosis and clinical care.

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