Abstract

Human papillomavirus (HPV) infections cause nearly all cervical cancer, leading annually to over 4,000 deaths in the US and nearly 300,000 deaths worldwide. With early detection and treatment, most of these deaths could be avoided. One new method of cervical cancer screening involves HPV-DNA testing in cervical cells collected by a physician during gynecologic examination. However, recent data suggests that women may be able to perform cervical self-sampling, potentially expanding access to screening. This study compared women’s responses and attitudes following two HPV-DNA self-sampling methods: Dacron swab self-sampling (DSS) and tampon self-sampling (TSS); to physician-sampling. Participants (n=171) were women attending an urban colposcopy clinic. They were predominately Caucasian, single, and high school educated or less. After viewing an instructional video demonstrating DSS and TSS, participants performed cervical self-sampling followed by physician sampling. Participants completed surveys concerning preferences and attitudes regarding sampling procedures and cervical cancer. Results showed that participants preferred self-sampling (74%) to physician sampling (25%; p<.001) and 98% would recommend self-sampling. Women who preferred physician-sampling reported greater cervical cancer worries (p=.01). Self-sampling device preferences were equally divided between DSS (51%) and TSS (46%). Women who preferred TSS reported greater confidence in cervical cancer screening (p<.05). No other sociodemographic, attitudinal, or sexual/reproductive history variables were associated with sampling preferences. HPV-DNA selfsampling methods were well-received by participants. Offering women the option of self-sampling could reduce barriers to cervical cancer screening (access and privacy concerns) and lead to a reduction in cervical cancer morbidity and mortality.

Introduction

• The primary risk of developing cervical cancer is repeated infections with a high risk oncogenic type HPV (typically strains 16, 18, 31, and 45). When performed by a clinician HPV-DNA testing has proven to be effective in detecting abnormal cells that can develop into cervical cancer.
  
• 20 million Americans are currently infected with HPV. By age 50, at least 80% of women will have acquired a genital HPV infection.
• While the incidence rate of cervical cancer has declined in recent decades in the USA, cervical cancer continues to be a significant health problem in many developing countries and is the second leading cause of cancer mortality in women worldwide (288,000 per year).
  
• Use of the Pap smear has made cervical cancer one of the most preventable cancers. When detected and treated at an early stage, cervical cancer has high survival rates.
  
• Up to 92% of women who have terminal cervical cancer failed to have regular Pap tests. Recent research has indicated that women who fail to attend regular Pap smear screenings commonly site economic and logistical reasons for nonattendance.
  

• By providing women with the option of performing self-sampling in the convenience of their home, it is likely that more women will be tested for HPV. An increase in HPV screening has the potential to lead to a decrease in the incidence of cervical cancer.
  

Purpose:

AIM 1: To determine the preferred method of cell collection:
− Clinician obtained cell collection or self-sampling?

AIM 2: To determine the preferred method of self-sampling:
− Dacron swab or tampon?

AIM 3: Examine sociodemographic, reproductive, behavioral, and psychological variables that may be associated with clinician and self-sampling preferences

Method

Procedure:

Inclusion Criteria
Age ≥ 18 years
Abnormal Pap smear, ASCUS or higher

Exclusion Criteria
Prior hysterectomy
Currently Pregnant
Taking corticosteroids

• 171 patients with abnormal pap smears enrolled from University-based colposcopy clinic
  
• Following consent, participants watched an instructional video on self-sampling procedures using Dacron swab and Tampon
  
• Patients performed self sampling
  
• Clinician performed Pap smear and colposcopy using standard methods
  
• Participants completed study questionnaire
  

Sample Description:
AGE: Mean age of the sample was 28 years (SD = 9.0)
RACE: 61% were Caucasian, 37% were African-American, 2% Hispanic
MARITAL STATUS: 75% reported being single
EDUCATION: 76% had a high school education or more
INCOME: 61% reported an annual income of $10,000 or less
HEALTH HISTORY: 43% reported a history of having an STD
SEX HISTORY: Mean age of first sexual intercourse was 15.5 (SD = 2.4); Mean age of parity 19 (SD = 3.4)

Study Questionnaire:

• Sociodemographic Characteristics
  
• Sexual and Reproductive History
• HPV Self-testing Attitudes and Responses
  
• Cervical Cancer Worry
  
• Attitudes toward Cervical Cancer Screening
  
• Response Efficacy
  
• Self-efficacy
  
• Perceived Seriousness
  
• Perceived Susceptibility

Results

AIM 1: Physician vs. Self-Sampling - Participants preferred self-sampling to physician sampling (χ2 (1, N = 160) = 40.00, p < .001).

Sampling Preference
Physician Sampling: 25%
Self-sampling: 74%
Both: 2%

AIM 2: Dacron swab vs. Tampon - Participants had no preference for self-sampling device used (χ2 (1, N = 160) = 0.40, p = .527).

Sampling Preference
Dacron Swab: 51%
Tampon: 46%
No Preference: 2%

AIM 3: Correlates of Sampling Preferences: MD vs. Self

Sociodemographic Characteristics
• Age, income, education, ethnicity, and marital status were unrelated to sampling preference.

Sexual and Reproductive History
• Sexual and reproductive history were unrelated to sampling preference.

HPV Self-sampling Symptom Responses
• Symptom responses to self-sampling were unrelated to sampling preference.

Cervical Cancer Worry
• Greater reported cervical cancer worry was associated with a preference for physician sampling (t(158) = 2.58, p = .011).

Attitudes toward Cervical Cancer Screening
• Response efficacy, perceived seriousness, self-efficacy, and perceived susceptibility were unrelated to sampling preference.

AIM 3: Correlates of Sampling Preference: D-Swab vs. Tampon

Sociodemographic Characteristics
• Partnered women were marginally more likely to prefer tampon sampling (χ2(1, N = 156) = 3.43, p = .064).
• Age, income, education, and ethnicity were unrelated to device preference.

Sexual and Reproductive History
• Sexual and reproductive history were unrelated to device preference.

HPV Self-sampling Symptom Responses
• Symptom responses were unrelated to device preference.

Cervical Cancer Worry
• Cervical cancer worry was not associated with device preference.

Attitudes toward Cervical Cancer Screening
• Greater response efficacy was associated with a preference for tampon sampling (t(155) = 1.99, p = .048)
• Greater perceived susceptibility to cervical cancer was marginally associated with a preference for tampon sampling (t(155) = 1.92, p =.057).
• Self-efficacy and perceived seriousness were unrelated to preference.

Conclusions

• Overall, self-sampling methods were very well-received by women in the current study. Most participants stated they would be willing to recommend HPV-DNA self-sampling to a friend.
  
• Women found the self-sampling methods to be easy to use and most participants reported little to no pain using the self-sampling methods.
  
• Many participants reported worry about cervical cancer and most reported a belief that performing self-sampling for HPV-DNA would be effective in preventing cervical cancer.
  
• If samples adequate for testing can be collected via self-sampling, offering the option of performing HPV-DNA self-sampling may lead to a higher uptake of cervical cancer screening, leading to decreased incidence of cervical cancer.
  
• However, some participants preferred to have physician-performed examinations and sampling. Notably, participants who reported greater cervical cancer worry were more likely to prefer physician examination over self-sampling procedures.
  

Limitations

• Although the results suggest that women were receptive to HPV selfsampling, the sample was restricted to women in Louisville, Kentucky.
  
• The order in which self-sampling collection methods were presented to participants was not randomized.
  
• This study did not asses if women used the self-sampling devices correctly.
  
• This data did not address the adequacy of the samples collected. Data to be presented in the near future will address this question.