Provinces are moving away from pap smears, but more infrastructure is needed
File photo of someone recieving an HPV vaccine. Image credit: Pan American Health Organization-PAHO via Flickr (CC BY-ND 2.0)
In a year, maybe two, take-home human papillomavirus (HPV) tests will have replaced traditional pap smears in every province, predicts the head of the Society of Obstetricians and Gynaecologists of Canada.
Doctors and nurse practitioners have traditionally used pap smears to screen for cervical cancer in patients, but 95 per cent of cervical cancers are caused by HPV.
A growing number of provinces are now moving away from pap smears in favour of less invasive and more accurate HPV tests.
According to the Canadian Partnership Against Cancer, Quebec, Ontario and Prince Edward Island have formally announced the move to HPV tests as the primary mode of screening.
Dr. Diane Francoeur, CEO of the Society of Obstetricians and Gynaecologists of Canada, says others are close behind.
"I would say it's going to happen probably within one or two years in every province in Canada," Francoeur told CTVNews.ca in a phone interview on Friday. "Everyone is working now on their lab burdens or registry burdens on how to implement it, but everyone is, and every province is, working very hard on that. All provinces want to make it happen."
An HPV test is normally carried out every five years, whereas doctors recommend pap smears every three years, said Canadian Partnership Against Cancer CEO Dr. Craig Earle in a phone interview with CTVNews.ca. An HPV test can start at age 25 and continue up to age 69 while it’s recommended to start pap tests at age 21.
There are more than 200 types of HPV, a sexually transmitted infection. Some types are considered "low-risk," such as those commonly associated with genital warts, and do not cause cervical cancer, Francoeur said.
"What we call the oncological type are the ones that are going to be associated with cervical cancer, and there are many of them," she added.
HPV varieties associated with cervical cancer are symptomless, Francoeur said.
She said while other HPV infections can be cleared, others can linger and cause cells in the cervix to become pre-cancerous and then cancerous, producing a positive result on an HPV test.
One of the benefits to switching to this type of testing is that it can determine whether a high-risk HPV type is present in a cell sample at an earlier point than pap smears, according to an action plan report by the Canadian Partnership Against Cancer.
"This is why it is so important to do the HPV screening, because we kind of cut the line in the progression of getting those pre-cancerous lesion(s) and then getting the real cancer, which is really bad. And we want to avoid that because cervical cancer is a very, very bad disease," Francoeur said.
According to the Canadian Cancer Society, an estimated 1,550 Canadian women will receive a cervical cancer diagnosis in 2023, and an estimated 400 will die from it.
HPV TEST MORE ACCURATE
HPV tests are twice as accurate as pap smear testing, Francoeur said. While pap smears detect pre-cancerous lesions in about 50 to 55 per cent of cases, HPV tests boast an accuracy rate of about 90 per cent, she added.
"But the new HPV testing is so accurate that when it's negative we feel very, very confident, because it's so good that we can do this every five years and that's going to be enough."
According to Francoeur, persistent HPV infection is the cause of 95 per cent of cervical cancers and as a result, a negative HPV test will almost always mean there's no need to screen for cancerous cells.
"If your HPV screening is negative ... you can rest easy because you're not going to have pre-cancer or cancer of the cervix. It's really, really reliable. We call it the predictive negative value, meaning when it's negative, you're good."
When it comes to ease of access, tests can be self-administered, similar to at-home COVID tests, meaning almost anyone with a cervix can take the test anywhere, even if they don't have a family doctor.
Francoeur says the self-administered process involves inserting a swab, similar to a tampon, into the vagina to take a sample and then sending it to a lab for testing. Francoeur says B.C. has rolled out an exploratory study to look at self-testing. The province is also running a pilot program in the more remote northern regions.
On the other coast, P.E.I. has implemented HPV screening in all primary care clinics as the first test used to screen cervical cancer.
Its government is still working on making a province-wide prevention program, Earle said.
"We want to be able to reach every woman or every person with a cervix," Francoeur said.
Lack of access to a family physician is a barrier to screening, Francoeur confirmed, referencing provinces like Ontario and Quebec where women struggle to lock down a primary health-care provider.
"You have to be very, very (worried about having) cervical cancer to go to a walk-in clinic and wait eight hours before you're going to have the screening done," said Francoeur, expanding on how this is a barrier to routine screening.
"Women should be able to go to the drugstore, just like we do with the COVID tests, get your stuff, do it at home and get it done, and we'll see you in five years," she added.
Self-sampling tests also help address issues related to privacy, confidentiality, a lack of comfort with the pap smear, which may be associated with trauma, and increasing access to members of some cultural communities, LGBTQ2S+ individuals, and those who are First Nations, Inuit and Métis, said the action plan report.
"If you live in a remote Indigenous community, you can still be screened and the swab can be sent back in the mail," Earle said.
The action plan report outlined that HPV as primary screenings will help reach Canada's target to eliminate cervical cancer by 2040, in alignment with the World Health Organization's (WHO) call to eliminate cervical cancer.
In a 2023 report, the Canadian Cancer Society said that the incidence of cervical cancer increased by 3.7 per cent.
"We don't know why because we don't have all the details but we know that unfortunately, during COVID, we were late on (HPV) vaccination, and when we got late on screening it's probably some kind of melting pot of all of that together. But nevertheless, these concerns can be prevented by vaccination," Francoeur said.
The switch to HPV will be a big part of reaching the WHO's global call, Earle said.
Francoeur said figuring out how to enforce HPV testing in provinces is the main thing preventing HPV testing from rolling out faster.
"It takes time to get the implementation of the screening because we know how to do the screening. We know how it works. Governments all agree that it needs to be done," Francoeur said.
Earle said pilots are in place to figure out infrastructure around HPV testing. "This does have the potential of you just picking it up in your pharmacy, or they're also looking into whether you go to the local lab in Ontario, the Dynacare labs or even if it's just mailed out to you."
As pap smear tests are done by physicians or health-care providers who navigate the next steps if tests come back abnormal, Earle questioned, "But then if you don't have a family doctor, what happens next if the test is that abnormal?"
"It's great if you're going to get screened, but screening is only good if the abnormal tests then are somehow navigated into the next steps and through an algorithm to make sure that treatment is needed."
Earle also said because the pap test involves a cytotechnologist looking to identify abnormal slides, a HPV test requires machines to analyze a swab and is needed to set up this type of screening.
Earle referenced Australia, a country that has fully switched to HPV tests as its primary cervical cancer screening.
According to the 2022 Cervical Cancer Elimination Progress Report, the WHO's 2030 target goal for screening participation is 70 per cent of women screened using a high-performance test by age 35 and again at age 45. Australia has reached 73.8 per cent of women aged 35 to 39 who have received at least one HPV test by the end of 2021. They note that HPV screening has not been available long enough for women to have two tests by age 45.
With a global goal of 90 per cent of women treated by 2030 after pre-cancer is identified, Australia is ringing in with 85.8 per cent of those who had cervical pre-cancer were treated within six months and 89.1 per cent were treated within 12 months, respectively.