Elsevier

European Journal of Cancer

Volume 51, Issue 16, November 2015, Pages 2375-2385
European Journal of Cancer

Review
Reaching women who do not participate in the regular cervical cancer screening programme by offering self-sampling kits: A systematic review and meta-analysis of randomised trials

https://doi.org/10.1016/j.ejca.2015.07.006Get rights and content

Abstract

Introduction

Population coverage for cervical cancer screening is an important determinant explaining differences in the incidence of cervical cancer between countries. Offering devices for self-sampling has the potential to increase participation of hard-to-reach women.

Methods

A systematic review and meta-analysis were performed to evaluate the participation after an invitation including a self-sampling device (self-sampling arm) versus an invitation to have a sample taken by a health professional (control arm), sent to under-screened women.

Results

Sixteen randomised studies were found eligible. In an intention-to-treat analysis, the pooled participation in the self-sampling arm was 23.6% (95% confidence interval (CI) = 20.2–27.3%), when self-sampling kits were sent by mail to all women, versus 10.3% (95% CI = 6.2–15.2%) in the control arm (participation difference: 12.6% [95% CI = 9.3–15.9]). When women had to opt-in to receive the self-sampling device, as used in three studies, the pooled participation was not higher in the self-sampling compared to the control arm (participation difference: 0.2% [95% CI = −4.5–4.9%]).

Conclusion

An increased participation was observed in the self-sampling arm compared to the control arm, if self-sampling kits were sent directly to women at their home address. However, the size of the effect varied substantially among studies. Since participation was similar in both arms when women had to opt-in, future studies are warranted to discern opt-in scenarios that are most acceptable to women.

Introduction

Well organised screening programmes have reduced the incidence and mortality of cervical cancer substantially in many industrialised countries [1], [2], [3], [4]. However, screening coverage is not always optimal [5], [6], [7], [8], [9], [10]. In the context of organised screening, women who are never screened or under-screened have an increased risk of invasive cervical cancer [11], [12], [13].

Several reasons have been identified as to why women do not attend cervical cancer screening. Barriers for participation in cytological screening do not only include practical (i.e. transport to the clinic, inconvenient clinic hours), economical and educational factors, but also personal-level factors, such as embarrassment and fear of pain [14].

With the introduction of testing for high-risk HPV (hrHPV) as a primary screening test in cervical cancer prevention [15], [16], [17], [18], samples taken by the woman herself (self-samples) have gained broad attention due to its potential to increase screening attendance. Furthermore, it has been shown that the accuracy of hrHPV DNA testing on a self-sample is similar to that of a sample collected by a clinician, if validated PCR tests are used [19], [20].

In most studies, the acceptability, preferences and attitudes of women towards self-sampling are positive, yet some negative findings have been published [21], [22]. Data from a recent review [23] and a meta-analysis [24] indicate that, overall, offering self-sampling can be superior to a reminder invitation for cytology in attracting women who never or irregularly participated in the cervical cancer screening programme. However, heterogeneity among studies is considerable. Given that the participation rate is a fundamental factor determining the (cost-)effectiveness of self-sampling, careful consideration of elements that may influence its success is essential. In this study, an updated review and meta-analysis is performed, including studies published until 2015. The relative participation and participation difference of the self-sampling arm compared to the control arm are calculated in a per-protocol and intention-to-treat analysis. Furthermore, a systematic evaluation of the heterogeneity across studies is performed, by comparing the effect of different methods to invite women for self-sampling.

Section snippets

Materials & methods

This systematic review and meta-analysis evaluates whether offering a kit for self-sampling (at home) could increase screening attendance, compared to sending reminder letters for a Pap smear or HPV test on a sample collected by a clinician (at the clinic).

The literature search was performed using electronic bibliographic databases Medline (PubMed), EMBASE, and CENTRAL. A general search string was constructed and included substrings on four topics, combined by an AND-operator (1: cervical

Literature retrieval and study characteristics of included studies

The literature search and the selection of eligible studies are presented in the PRISMA flow chart (Fig. S1, supplementary online material) [31], [32]. The last search was performed on February 12th, 2015. A total of 16 studies were included in our meta-analysis [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48]. Population and study characteristics of these studies (inclusion criteria, scenarios of invitation, sample size and age) are presented in

Discussion

Vaginal self-sampling by the woman herself, has the potential to overcome practical and personal barriers that may withhold some women from participating in regular cervical cancer screening.

In this meta-analysis, data from 16 randomised studies were pooled. Although inter-study heterogeneity was observed, overall, women offered self-sampling were more likely to participate compared to women invited for a clinician-collected sample at the clinic. When women received a self-sampling kit directly

Funding sources

This study was funded by the seventh Framework Program of DG Research of the European Commission (CoheaHr Project [603019], the Joint Action CANCON which has received funding from the European Union in the framework of the Health Programme [2008-13]), the International Agency for Research on Cancer (IARC, Lyon, France), the European Federation for Colposcopy (Birmingham, UK), and the German Guideline Program in Oncology (German Cancer Aid project # 110163).

Role of funding source

Funds were paid to the Scientific Institute of Public Health. None of the funding agencies had an influence on the scientific process.

Conflict of interest statement

The Scientific Institute of Public Health received scientific research funds as explained in Funding Sources. None of the funding agencies had an influence on the scientific process of the work.

Acknowledgements

The authors want to thank P. Giorgi Rossi and K. Haguenoer for kindly providing additional data.

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