Two analyses detail preferred cervical cancer (CC) screening strategies, with one concluding that most US women would choose in-clinic testing over at-home sample collection, and the other suggesting that the cost-effectiveness and risk-benefit tradeoffs of adapting CC screening strategies by age at human papillomavirus (HPV) vaccination favor less-frequent screening and longer intervals between tests rather than the current five-year recommendations in Norway.

61% preferred in-clinic specimen collection

For the first study, published late last week in JAMA Network Open, researchers from the University of Texas Health Science Center at Houston (UTHealth) parsed data from the 2024 Health Interview National Trends Survey, a nationally representative survey of US adults from March to September of that year. 

Participants were 2,300 women aged 21 to 65 years (average, 45.5 years) eligible for CC screening per the US Preventive Services Task Force guidelines. 

“While home-based self-sampling for cervical cancer screening is an evidence-based strategy proven to increase screening access and uptake, it is not currently recommended in the US despite recent Food and Drug Administration approval of the first at-home self-sampling device,” the authors wrote.

Of all women, 20.4% preferred home-based self-sampling, while 60.8% preferred clinic-based testing, and 18.8% were unsure. Relative to their White peers, Black women had a lower likelihood of preferring at-home self-sampling (adjusted OR [aOR], 0.45]). Women who reported experiencing prejudice or discrimination when receiving medical care had a higher probability of preferring at-home sample collection (aOR, 1.94).

In this cross-sectional study, marginalized populations, individuals with low income, and individuals who do not trust the health care system were more likely to prefer at-home self-sampling for cervical cancer screening or not know which option to choose.

The most common reasons given for favoring at-home self-sampling were privacy (54.9%), time constraints (35.1%), and fear of embarrassment (33.4%).

“In this cross-sectional study, marginalized populations, individuals with low income, and individuals who do not trust the health care system were more likely to prefer at-home self-sampling for cervical cancer screening or not know which option to choose,” the researchers wrote.

The findings suggest incorporating at-home sample collection into US guidelines as an alternative to clinic-based testing would improve cervical cancer uptake. The researchers also called for enhanced women’s education and empowerment and the development of tailored interventions focusing on high-risk groups to raise awareness and self-confidence in performing self-sampling.

In a UT M.D. Anderson Cancer Center news release, senior author Sanjay Shete, PhD, said, “Home-based self-sampling has the potential to remove many of the barriers women face when it comes to cervical cancer screening. By expanding screening options and pairing them with targeted education, we can empower more women to participate in screening in a way that fits their lives.”

Targeted approach may be effective, less costly

The second study, published last week in the Annals of Internal Medicine, aimed to evaluate the cost-effectiveness and risk-benefit tradeoffs of adapting CC screening strategies by age at HPV vaccination.

A team of University of Oslo–led scientists conducted an individual-based mathematical modeling study of three CC screening strategies and health and economic outcomes among seven age-groups of Norwegian women vaccinated against HPV at ages 12 to 30 years. 

The researchers assumed that participants were fully vaccinated either with 2vHPV against HPV-16 and HPV-18 infections, with cross-protection against types 31, 33, and 45, or with 9vHPV against high-risk infections with HPV type 16, 18, 31, 33, 45, 52, or 58. Under their scenario, 2vHPV was 100% effective against HPV-16 and HPV-18, with respective cross-protection of 93.8%, 79.1%, and 82.6% for HPV types 31, 33, and 45.

For all age-groups, regardless of the assumed age at vaccination, the optimal (cost-effective) strategy for each age-group was extending screening intervals beyond the five years recommended in current guidelines. But for women vaccinated with either vaccine type, the age to start screening and the interval between tests of the preferred screening strategy varied by age- group.

Policymakers should consider changing screening guidelines because of the expected vaccine-derived protection against CC.

For women vaccinated at age 25 to 30 years with either vaccine type, the number of lifetime screening tests could drop from nine (current recommendation) to five, which entailed screening at 10-year intervals starting at age 25. For women vaccinated at ages 12 to 24 years, the preferred strategies further reduced lifetime screening tests to two or three by delaying the start date of screening and lengthening the time between screenings. 

For example, at a cost-effectiveness threshold of $55,000 per quality-adjusted life-year (QALY) gained, the preferred strategy for women vaccinated with either vaccine at age 22 to 24 involved screening at ages 25, 40, and 55 years (incremental cost-effectiveness ratios [ICER], $48,150 for women vaccinated with 2vHPV and $51,460 for 9vHPV recipients). 

For the group vaccinated at age 19 to 21 years, screening at ages 25, 45, and 65 years was the preferred strategy, which was also preferred for those vaccinated at age 16 to 18 years if vaccinated with 2vHPV. But a slightly less-intensive strategy of screening twice at ages 25 and 50 was preferred for 9vHPV recipients. Screening twice per lifetime at ages 35 and 60 years was optimal for women vaccinated at 12 to 15 years with either vaccine. 

“These preferred strategies with fewer lifetime screening tests were associated with considerable cost reductions compared with the current guideline-recommended screening (every 5 years starting at age 25 years),” the authors wrote. “For example, for women vaccinated with 2vHPV at age 13 to 15 years, the total cost per woman was reduced by 21% to 76% for the cost-efficient strategies.”

“Policymakers should consider changing screening guidelines because of the expected vaccine-derived protection against CC,” they concluded. “Successful implementation requires sustained screening participation among eligible women as the frequency of CC screening decreases.”

Feasibility of preferred strategy in US

In the editorial accompanying the second study, Nicolas Wentzensen, MD, PhD, and Didem Egemen, PhD, both of the National Cancer Institute in Maryland, said the findings show that CC screening can be safely reduced in vaccinated cohorts, preventing unnecessary screening, diagnostic procedures, and treatment without negatively affecting CC prevention.

But implementing screening based on age at HPV vaccination requires reliable individual-level data on vaccination and an organized screening program that can issue individual screening invitations. Such an approach may be confusing for patients and providers, they said, and although potentially feasible, would be very difficult to implement in other settings.

“For example, in the United States, neither vaccination registries nor organized screening exists, putting an unrealistic burden on participants to remember their age at vaccination and on providers to follow complex recommendations modified by many individual factors,” they wrote.

In addition, in settings in which screening participants’ vaccination status or age at vaccination can’t be determined, risk-adapted management strategies based on extended genotyping can minimize the harm from unnecessary procedures in vaccinated women, while unvaccinated women still benefit from screening every five years and risk-based management. 

“Over time, as vaccinated cohorts age more into the screening population and herd protection extends to older unvaccinated populations, increased start ages and longer intervals can be considered for the entire population and the optimal strategies for vaccinated individuals and the entire screening population will ultimately converge,” they concluded.