Prof Young-Tak Kim, President of AOGIN, discusses AOGIN’s recently released 2024 Position Statement to improve cervical cancer screening in the region.

Interview transcript:

Introduction

My name is Young-Tak Kim, a gynecologic oncologist and president of AOGIN. Also, the CEO of CHA Global and Women’s Hospital.

What is AOGIN’s goals for cervical cancer screening?

AOGIN, the Asia Oceania Research Organization in Genital Infection and Neoplasia was founded 20 years ago with 22 member countries, focuses on improving cervical cancer screening and prevention in the Asia-Oceania region.
Their goals include increasing awareness, enhancing screening programs, improving assess, and developing new guidelines.

The 2024 AOGIN Position Statement for Cervical cancer screening was announced at the recent AOGIN 2024. Please briefly introduce the AOGIN Position Statement.

The AOGIN Position Statement outlines key recommendations from 14 countries for enhancing cervical cancer screening in the Asia-Oceania region.
The statement aims to guide countries in improving screening programs, increasing access for underserved populations, and integrating HPV vaccination efforts.

Why is it important to use clinically validated HPV tests, especially for primary screening?

The 2024 AOGIN Position Statement emphasizes the importance of clinically validated HPV tests for primary cervical cancer screening, aligned with the WHO goals for effective cancer prevention and control.

Clinically validated HPV tests have a higher sensitivity compared to traditional Pap smears, meaning they are more effective at detecting cervical pre-cancerous lesions and cancer.
Also, HPV testing allows for longer intervals between screening, typically every 5 years, reducing the frequency of unnecessary exams and associated healthcare costs while still maintain high safety standards.
Lastly, HPV testing provides better stratification of risk of progression. Positive result can lead to immediate follow-up and management, while negative results offer reassurance for longer periods.

Why is it important for those 25-65 years to undergo testing?

It’s important for individuals aged 25 to 65 to undergo cervical cancer screening not only for early detection, but for effective prevention and risk stratification. By ensuring regular screenings, individuals can significantly contribute to their health and well-being while helping to lower the overall incidence of cervical cancer in the community.

What are AOGIN’s upcoming plans for HPV testing and cervical cancer elimination in the APAC region?

AOGIN has several upcoming plans focused on HPV testing and cervical cancer elimination in the APAC region.
First, AOGIN plans to advocate for the widespread adoption of clinically validated HPV testing as the primary screening method, emphasizing its effectiveness in early detection.
Also, AOGIN aims to work closely with government health departments to integrate HPV testing into national screening programs and align policies with international guidelines.
Lastly, ongoing research to gather data on HPV prevalence and cervical cancer incidence in the region will support evidence-based decision-making and policy formulation.

What countries does AOGIN plan to work with and why?

AOGIN plans to focus on several countries in the Asia-Pacific region, particularly those with high disease burden.

Countries like India, Indonesia, and Vietnam have high cervical cancer incidence and mortality rates, making targeted interventions vital. Also, countries such as Bangladesh, Pakistan, and the Philippines exhibit substantial gaps in achieving the WHO’s screening and vaccination targets, necessitating focused efforts to improve access and awareness.

How has HPV self-sampling helped to improve screening rates?

HPV self-sampling has shown promising results in improving cervical cancer screen rates. Studies have found that self-sampling can increase screening participation rates by 20 to 50% compared to traditional clinician-collected samples. Women often prefer the convenience and privacy of self-sampling.

Also, self-sampling helps to eliminate some barriers to screening, such as fear of the clinical environment, discomfort during examinations, and stigma, leading to more women engaging in regular screening.

Based on the Position Statement and AOGIN’s upcoming plans, how can clinicians work together with AOGIN to implement cervical cancer screening into their clinical practice?

Clinicians can collaborate with AOGIN to effectively implement cervical cancer screening in several ways. They can integrate the recommendations from AOGIN’s Position Statement into clinical practice, ensuring that screening protocols align with the latest evidence and WHO guidelines. Lastly, clinicians can join AOGIN’s networks and forums to exchange knowledge, share their best practices, and collaborate with other clinicians in the region to strengthen cervical cancer prevention efforts.

The views and opinions expressed by Prof. Young-Tak Kim are his own views and opinions. Roche disclaims all liability in relation to these views and opinions.

While cervical cancer is preventable, an estimated 14,000 new cases are diagnosed in the United States every year, leading to almost 4,300 deaths from the disease.

In this recording from the 21st International Congress of Cytology (ICC), Prof Mark Stoler shows evidence that the use of HPV DNA tests as the primary form of screening, followed by using p16/Ki-67 dual staining in triage can prove effective in identifying women who are at the highest risk of cervical cancer. This testing method gives actionable results that allows clinicians and health systems to prioritise resources for those who are in need of them.

The World Health Organisation recommends HPV self-sampling to ease emotional and psychological barriers that prevent many women from pursuing screening, thus empowering women to choose the approach that works best for them. Following WHO’s recommendations, Dr Gino Venegas, while serving as Director of Cancer at the Ministry of Health in 2017, developed the National Cervical Cancer plan and implemented a HPV primary screening program. To help achieve a target of 70% screening coverage, Peru dedicated substantial resources to public education and setting up HPV testing facilities in primary care settings in both urban and rural areas.

In this recording from IPVC 2023, Dr Gino Venegas shares how Peru tackled cervical cancer by addressing numerous barriers to screening, such as lack of awareness, affordability challenges, and social stigma around HPV testing.

Since 2020, Thailand has used HPV DNA tests as a way to optimise primary screening programmes for cervical cancer. The country conducted internal studies on the cost-effectiveness of HPV tests within primary screening and found it to be economical. To increase coverage amongst the unscreened or under-screened population, self-sampling was introduced to address cultural and/or religious barriers and increase convenience for those who had routine healthcare services delayed due to Covid-19.

In this recording from AOGIN 2022, Prof Wichai Termrungruanglert of Chulalongkorn University in Bangkok, Thailand, shares how the Thai healthcare system has responded to the changing needs of the screening population. Watch the recording to find out more.

HPV screening programmes are being rolled out across many countries in a bid to eliminate cervical cancer by 2030, a target that has been set out by the World Health Organisation. As more countries gain access to innovative technology and greater experience in cervical cancer screening, some are exploring updating screening algorithms in order to improve the cost effectiveness and efficiency of existing programmes.

In this presentation recording from AOGIN 2022, Prof Tay Sun Kuie of Singapore General Hospital outlines the experience of HPV screening and detection in Singapore. Watch the recording to find out more.

Prof Woo Yin Ling discusses her study on cervical cancer screening and self-sampling in pregnant women in Malaysia for cervical cancer elimination

Interview transcript:

Introduction

I’m Woo Yin Ling, a Professor of Obstetrics and Gynaecology at University of Malaya and a consultant gynaecological oncologist at University Malaya Medical Centre. My daily work involves caring for women with gynaecological cancers and so working towards cervical cancer elimination with equity in mind is of great interest to me.  This was the basis of innovating Program ROSE where I am now a founding trustee for ROSE Foundation.

What is the objective of your recent study on screening pregnant women for cervical cancer using HPV DNA testing? What are the key outcomes?

As we are all aware, the burden of cervical cancer is predominantly in the Lower Middle Income Countries (LMICs) where healthcare is stretched and infrastructure for organized screening is often non-existent; there isn’t even a formal system of call and recall when it comes to screening.

We know that to reach the 2030 targets for cervical cancer elimination, 70% of eligible women will require at least 2 HPV testing in their lifetime. This then begs the question: ‘What do we even do to reach these women?’ ‘How do we get to them?’

For the majority of women, they only see a doctor when they are unwell. Preventive screening is not a norm for them.

So where are the touchpoints between a woman of reproductive age and a healthcare professional (HCP)? The most obvious would be when she accesses antenatal care. In fact, the World Health Organisation (WHO) has recently updated its recommendations from a minimum of 4 antenatal care contacts to a minimum of 8 to improve women’s experience of care.

To me, this means that we have at least 4-8 opportunities to educate and screen a woman.  And we know how much time women wait in turn in the clinics before they see a doctor at such clinics. This provides us with ample opportunity to offer them self-sampling for HPV testing.

This was the basis of our study. The primary aim of the study was to ascertain the acceptability and performance of self-sampling in an antenatal population.

We approached approximately 2200 women, above 15 weeks gestation for this study, where 1600, which is 70% of them, agreed to participate. What does this suggest to you? It means that if you offered screening to this population, 70% of pregnant women would accept the invitation.

In this urban group attending a tertiary teaching hospital, 50% had never been screened before. 2/3 were between 28-40 weeks pregnant, meaning that they had a significant bump. Except for seven women out of this 1600, everyone opted for self-sampling. That is a whopping 99.6%! Of those who attempted self-sampling, only 24 abandoned the procedure. This is less than 2% and they asked for help from a HCP.

Overall, 98.8% of women who took part in the study expressed a preference for self-sampling.

So how did they fair? In terms of the performance, 1571 women, which is 95.7% of women, had a valid test result; with 68 women, which is 4.3%, having an invalid result.  The invalid rates in the general population is around 2%.

15 women, which is 0.9%, had blood stained swabs after sampling with no further complication. They had an uneventful pregnancy. There were no other adverse outcomes reported!

In this cohort, the HPV positive rate was 6.3%, which is similar to the Malaysian general population.

How may countries think about using this information for screening?

We now have information to show that it is safe to swab a woman for HPV testing from 15 weeks up to term. The idea of swabbing during pregnancy is not a new one. For example, in many countries, women are swabbed by HCPs for Group B Streptococcus as a predictor for preterm labour. So I do think this will allow opportunities for doctors to speak to women to screen and perhaps integrate cervical screening into the antenatal population.

How has this study influenced your overall clinical workflow?

This was a piece of meaningful research which has led to us expand it further.

We are now in the midst preparing a cross-over study to evaluate if women prefer self-sampling or a HCP sampling in pregnancy.

What we know from this study that more than 50% of women will accept HPV testing when offered during antenatal visits. Among them, more than 90% are willing to perform their own self-sampling.

The prevalence in the pregnant population is similar to the general population in Malaysia.

Based on your study findings, what recommendations do you have for improving cervical cancer screening in Malaysia and other Asia Pacific countries?

We have previously demonstrated the acceptability of self-sampling among Malaysian women. In fact, this is now offered to women as part of our national screening program.

This study confirms the acceptability and safety of self-sampling for HPV testing even among pregnant women.  In our study, the HPV DNA detection rate in pregnancy was not higher in the general population. It is evident that self-sampling allows for scalability and to reach more women during their reproductive age.  So here we have an acceptable tool to screen women when they encounter a HCP during their pregnancy.

As with all screening programs, you do need to think about follow up of those with abnormal screening results. In this study, among the antenatal population, the follow up of women was marginally lower at 70%. This is totally understandable as the responsibilities towards a newborn is great.  This needs to be factored in when thinking about introducing an antenatal program.

My recommendation has always been to have a systematic approach to cervical screening, ensuring that as many women have access to screening and treatment. Most importantly, you need to be able to follow up women who have a positive screen.  This study is a ‘technical study’ in that it shows that we can screen women during pregnancy.

But as countries transition to HPV testing, a screening registry to monitor population outcomes becomes very critical.

The views and opinions expressed by Prof. Woo Yin Ling are her own views and opinions. Roche disclaims all liability in relation to these views and opinions.

In Hong Kong, cervical cancer ranked as the 8th most common cancer and cause of mortality amongst women in 2019 [1]. Despite a national screening programme implemented in 2004, studies show that close to 40% of women have never been screened before in their lives [2]. With cervical cancer incidence increasing, there is a clear need for action to drive HPV awareness and education, as well as to improve screening rates, especially in underserved communities.

The Karen Leung Foundation (KLF) is the only charity in Hong Kong dedicated to tackling gynaecological cancers, including cervical cancer. Through Project Teal and other initiatives, it is partnering with key stakeholders to increase access to cervical cancer diagnostics in various communities.

To learn more about their efforts toward eradicating this preventable disease, read this interview article with Katharina Reimer, Executive Director of the Foundation.