Christine Layton, a family physician in Nanaimo, B.C., used to see anyone in her community who needed a Pap test. Over the past year, however, the worsening crisis in family medicine has made it difficult, if not impossible, for the 30% of patients without a primary care provider to access Pap tests. The demand has become unsustainable.
After seeing 20 patients in a single day for Pap smears, Layton and her OB/gyn colleague Kristi Kyle came up with the idea of holding a “Pap-a-palooza” to offer screening to patients without a family physician. Layton describes it as a “Pap party,” complete with decorations, music and goodie bags.
The first event went viral on social media and was fully booked in less than six hours. Over the course of four Pap-a-paloozas in the past year, they have screened almost 350 patients and found four high-grade precancerous lesions as well as other abnormalities needing follow-up.
Layton recalls one patient saying that “getting into Pap-a-palooza was like Willy Wonka and the Chocolate Factory and getting the golden ticket.”
In 2023, Layton and Kyle will work with two University of British Columbia medical students, Alisha Hussey and Anika Brown, to expand Pap-a-palooza to Vancouver, Prince George, Kelowna and Victoria.
Despite Layton and Kyle’s efforts, there are still many patients who are unable to access cervical cancer screening. A clinician-administered Pap test is currently the only publicly insured option available in Canada. The Pap test looks for cervical cell abnormalities, but other countries like Australia and the UK have switched to testing directly for the Human Papilloma Virus (HPV), the cause of almost all cases of cervical cancer.
Last year, BC Cancer launched a pilot project inviting 67,000 patients to self-collect vaginal swabs at home for HPV, the cause of almost all cases of cervical cancer. According to BC Cancer’s website, the pilot will help “fine-tune patient communications, provider engagement and internal processes” prior to implementing HPV screening across the province.
Says Michelle Halligan, director of the prevention team at the Canadian Partnership Against Cancer (CPAC): “HPV testing is just a better test in so many ways … We upgrade our phones quite regularly when a new one comes out. This is the same thing.”
HPV screening is more accurate than Pap tests, which miss almost half of all abnormalities, meaning testing can be done every five years with HPV screening instead of every three years. It can detect abnormalities earlier and is more effective at preventing advanced cases of disease. It is also more cost-effective, costing $800 less per detected high-grade lesion.
For the 20 per cent of patients who have never had a Pap test or are not up to date, whether because they don’t have a primary-care provider or because they have experienced discrimination within health-care settings, the option to self-collect swabs may remove a significant barrier.
Halligan says HPV screening is a key component of Canada’s plan to eliminate cervical cancer by 2040, along with vaccination and ensuring timely follow-up of abnormal results, adding that most provinces and one territory are planning to implement HPV screening using PCR tests.
While the pandemic led to disruptions in cervical cancer screening programs, Halligan says it also has created an opportunity. “The self-sampling discussion is a real discussion now … People are used to rapid testing now in their homes. The comfort with this has totally shifted, and the need to provide care closer to people’s homes and away from traditional health systems has really shifted, too.
“A lot of provinces and territories didn’t have the equipment that was needed to process these tests. Guess what, there’s a lot of PCR equipment available now.”
Diane Francoeur, CEO of the Society of Obstetricians and Gynecologists of Canada, says the plan to implement HPV screening is good news. “We’re moving in the right direction,” she says. “The only problem – we wish it was done yesterday.”
She acknowledges that the initial cost of setting up and implementing HPV screening is a barrier, and that it takes time to create a structured and systematic screening program. Francoeur and Halligan were not able to provide an estimate of initial implementation costs for different jurisdictions, although Francoeur says the information has been requested. Halligan says that CPAC has contributed $3 million to catalyze HPV primary screening as well as HPV vaccination.
We’re moving in the right direction. The only problem – we wish it was done yesterday.
“It’s amazing how long these things take,” says Amanda Selk, a gynecologist at Women’s College Hospital in Toronto, and President of the Society of Canadian Colposcopists. “But that’s like a lot of medicine, right, to go from evidence to actual implementation.”
Although HPV screening has been available for decades, Selk says it wasn’t until 2013 that the Ontario Cancer Screening Program and Cancer Care Ontario recommended to the Ontario Ministry of Health that HPV testing become the primary screening test for cervical cancer. It took another 4 years before the government agreed to fund HPV screening, “and then it’s taken many, many years to work out the planning.”
Selk says the government has put out a call for bids from the companies providing HPV test systems, and she expects that details will be announced soon although no specific date has been set. The launch of HPV screening is planned for Fall 2024, according to an email response from Ontario Health.
Selk says it’s important for patients and providers to know that Pap tests may still be needed to help triage patients with positive HPV results. She says she thinks that HPV screening could be potentially anxiety-provoking for patients, and that it will be important for physicians to help normalize and destigmatize it.
She notes that many family physicians use the routine Pap test visit as an opportunity for other health counselling and preventative care. “For patients who have no access to any primary care, it would be great that they can get some screening,” she says. “But I think it’s not as good as having a family doctor and having a relationship with them.”
Layton says the benefits of having self-screening available likely outweighs any potential downsides. She adds that optional self-screening may allow her to have more availability in her office to address other issues.
Until then, she and Kyle will keep going with their mission to screen the entire community, much to the appreciation of their patients.
As one social media user put it: “This beats a Tupperware party any day.”
From left to right: Dr. Kristi Kyle, Dr. Trish Caddy, Dr. Christine Layton, Dr. Kelly Hadfield. Photo credit: Nicole Bussian
Second photo: Photo credit Dr. Kelly Hadfield