ReviewReaching 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
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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