There’s a better way than Pap tests to prevent cervical cancer. Why is Ontario taking so long to bring in HPV testing?
There will be a day when Pap tests for cervical cancer are replaced by less intrusive and more accurate HPV testing.
But as countries around the world, and some provinces here at home, start the transition, doctors say Ontario is among the jurisdictions lagging behind.
The stakes go well beyond comfort.
“If we switch sooner, we save potentially hundreds to thousands of lives every year,” says Michelle Halligan, the director of prevention at the Canadian Partnership Against Cancer. “The longer we put it off, the longer we put off our benefits and put people at risk.” The non-profit is mandated by the federal government to implement Canada’s goals for cancer prevention.
“There’s huge momentum happening in the country to make that switch.”
Even more appealing, the HPV testing, which can be self-administered, would only have to happen every five years.
Currently, Pap tests, which check for precancerous conditions including abnormal cells in the cervix, are nearly 50 per cent less sensitive than HPV tests, according to a 2007 study of 10,000 Canadian women published in the New England Journal of Medicine.
This means every Pap screening misses about half of all abnormalities. So the tests are done every two to three years to mitigate harm, starting between ages 21 to 25 depending on the province, according to an article published in the Canadian Medical Association Journal in May.
The HPV test, which can involve inserting a Q-tip into the vagina, is much more sensitive and accurate, and is considered the gold standard in cervical cancer prevention.
“There’s the ability to not have to use a speculum that goes in … no need to scrape cells off your cervix,” says Halligan.
Ontario Health told the Star that switching to the HPV test is a “large undertaking” and said the Ministry of Health announced in its 2017 budget that the test would be funded through the Ontario Cervical Screening Program. Ontario Health did not provide further details on the timeline or specific costs in time for deadline.
A 2019 report from the Canadian Agency for Drugs and Technologies in Health completed an economic evaluation and found the switch to HPV testing would cut the cost of cervical cancer screenings overall in Canada, as the more accurate test would reduce the need for multiple tests to confirm a cancerous strain of HPV.
This analysis did not include implementation costs, which differ across jurisdictions, the report stated. The cost of the switch could be “potentially significant,” so planning and funding are crucial, the agency stated.
The agency also emphasized that the public understand the rationale behind the switch is increased effectiveness, not cost.A public health information campaign is also needed so that women and those with female reproductive organs can understand the reason for the switch to HPV tests.
Cervical cancer is caused by the mutation of cells in the cervix; testing catches signs of precancerous cells before they evolve into cancer.
Most cervical cancer is caused by particular strains of HPV, or human papillomavirus. HPV is a common sexually transmitted, and most strains are not harmful and resolve on their own.
The incidence of cervical cancer in Canada in 2022 is about 7.5 people per 100,000, according to an article in the Canadian Medical Association Journal. Those numbers have declined from 20.05 per 100,000 in 1978, as screening efforts became more substantial, and from 12.6 per 100,000 in 2006, before the introduction of the HPV vaccine in schools.
But HPV testing will see those rates decline further, with the goal to eliminate cervical cancer by 2040, says Halligan.
Other provinces that have gone ahead with HPV testing are Quebec, which announced the switch in June, and P.E.I., in the process of switching.
A 2012 report by the Ontario Cervical Cancer Screening Program — an Ontario Health initiative that informs people when it’s time to be tested explained its priorities for the coming years included switching to HPV testing for women 30 and older. The 2017 Ontario budget also mentioned that the province would switch from Pap tests to HPV tests for women aged 30 to 69.
Now, Ontario plans to launch HPV testing in the Ontario Cervical Cancer Screening Program in 2024-25, according to the province’s business plan for this year.
The delays are frustrating, says Dr. Amanda Selk, an obstetrician-gynecologist at Sinai Health and Women’s College Hospital, and an associate professor at the University of Toronto.
HPV screening “is a much better test and this is not new knowledge, but Canada is falling behind,” she says.
There hasn’t been enough education for health-care providers and the public ahead of the change, she says..
“This is really the role of the provincial government and we’re not seeing too much from them,” she says. Ontario was one of the first provinces to say it would switch to HPV testing, so it’s unfortunate that hasn’t occurred, she says.
A Pap test searches for signs of precancerous cells, but it isn’t perfect, and false negatives can delay treatment, she says. Testing for HPV is getting at the root of cervical cancer, she says.
There are several possibilities for how Ontario can proceed with HPV tests, including having patients self-swab by inserting a Q-tip in their vagina (similar to how PCR testing is done within the nose for COVID-19), or having a health-care provider do a Pap test and an HPV test, but not process the cytology of the Pap test unless the HPV test is positive, she says.
The at-home test option would be especially important in rural areas and for Indigenous communities who do not have access to frequent screenings, or face barriers in travelling for a Pap test, says Selk.
Pap tests may still be required in Ontario for a few years after the switch occurs in order to triage who needs to be seen first, as the HPV test will detect even those who have a low-risk strain, says Selk. As young people who received the HPV vaccination in schools grow up, fewer and fewer instances of HPV will present in the population and fewer people will test positive for HPV at all, so the system won’t be overwhelmed, she says.
The HPV vaccine has been offered in Ontario for free for Grade 7 students starting in the 2007-08 school year. There has been concern about students who have missed the shot due to COVID school disruptions.
Moving to a new system is complex and people need to be informed so they feel comfortable doing the test, and to tackle stigma as HPV is a sexually transmitted infection, says Dr. Catherine Popadiuk, an associate professor of obstetrics and gynecology and specializes in cervical cancer.
“We have to take away that stigma that there’s something negative about this,” she says, “so that’s part of the concern in having a good strategy to roll this out.”
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