HPV Self-Sampling Symposium
Toronto – October 14, 2016
8:45-9:00 Registration, Breakfast
9:30-10:30 Opening plenary session
VP Research & Innovation, Ryerson University - Dr. Usha George
Dr. Usha George is the interim Vice President, Research and Innovation at Ryerson University. Usha came to Ryerson in 2006 from the University of Toronto, where she was associate dean of the Faculty of Social Work and the RBC Chair in Applied Social Work Research. Since joining Ryerson, she has held a number of positions, most recently the Dean of the Faculty of Community Services, before becoming the interim VPRI. A distinguished scholar, Dr. George continues to be an active researcher, whose research focus includes the areas of newcomer settlement and integration, and diversity and organizational change.
Dr. George is the author of more than 105 peer-reviewed publications and research reports, and the recipient of more than $5 million in peer-reviewed research grants and close to $8 million in sponsored research grants. She has fostered strategic partnerships that serve to further enhance Ryerson’s reputation.
Director, Chair in Inter-sectoral Solutions to Urban Health Problems, Li Ka Shing Knowledge Institute - Dr. Patricia O'Campo (St. Michael's Hospital)
As a social epidemiologist, Dr. Patricia O'Campo has conducted a number of longitudinal and cross-sectional studies in the areas of the social determinants of adult mental health, intimate partner violence, children’s well-being (such as youth violence or school readiness and perinatal health) as well as clinic and community based evaluations of programs concerning smoking cessation, prevention of perinatal transmission of HIV, prevention of infant mortality and homelessness. She has focused on methods development as part of her research, including application of multilevel modeling to understand residential and workplace contexts on women’s and children’s health, the application of concept mapping to increase understanding of how residential neighborhoods influence well-being and on the development of monitoring methods for rare health events in small geographic areas.
Presentation: Research at St. Michael's
Introduction and acknowledgement of sponsors, review of the project objectives and background information about HPV self-sampling: findings related to lit review, key informant interviews (Presentation by Drs. Mandana Vahabi & Aisha Lofters)
Mandana Vahabi, RN, MHSC, PhD is an Associate Professor at Ryerson University, Faculty of Community Services, Daphne Cockwell school of Nursing. She is the co-director of Centre for Global Health and Health Equity and co-chair of Diverse and At Risk Population Research Cluster. Dr. Mandana Vahabi joined Ryerson University in August 2007. Her research and scholarship focus on health equity and social determinants of health, particularly among women, immigrants, and refugees, particularly in the areas of Cancer screening, chronic disease prevention, Mental health, and HIV/AIDS,. Drawing on her extensive experience in social epidemiology and community health, she works closely with multidisciplinary teams and community stakeholders to develop research underpinned by the principles of cultural congruence and meaningful engagement. In her work with immigrant population she has also been involved in the design, implementation and evaluation of culturally sensitive and appropriate health promotion interventions.
Prior to joining Ryerson she worked as a project director for a MOHLTC initiative “POWER Study: A Project for an Ontario Women’s Health Evidence-Based Report”. She also was a policy consultant at the Ministry of Health Long Term Care, Population Health Policy & Planning and Women’s Health Branch. She worked as senior epidemiologist/ health planner at the Toronto District Health Council (TDHC) where she was involved in managing various system level projects such as "Heath System Monitoring and Evaluation", and "Toronto Small Planning Areas: A Population-Based Approach to constructing New Health Planning Areas in the City".
Dr. Aisha Lofters is a family physician with the St. Michael’s Hospital Academic Family Health Team and scientist with the Li Ka Shing Knowledge Institute of St. Michael’s Hospital. She is an assistant professor at the University of Toronto in the Department of Family & Community Medicine and adjunct scientist at the Institute for Clinical Evaluative Sciences. She currently holds a Career Development Award in Prevention from the Canadian Cancer Society Research Institute. Her research interests include cancer screening, immigrant health and health equity, using a broad range of methods including secondary database analysis and community-based participatory research.
Key note speaker: Dr. Kathleen Decker - Cervical cancer screening in Canada: Opportunities and Challenges
Dr. Kathleen Decker, Senior Epidemiologist in the Epidemiology and Cancer Registry Department, CancerCare Manitoba. She has worked with Manitoba screening programs to conduct program evaluation and research since 1995. Dr. Decker is an Assistant Professor, Department of Community Health Sciences, University of Manitoba. She is also Chair of the Pan-Canadian Cervical Cancer Screening Network.
Her research interests include cancer epidemiology, cancer screening, chronic disease prevention, and inequities in health care use. Dr. Decker holds a PhD in Community Health Sciences and Epidemiology from the University of Manitoba. She has a Master's degree from Dalhousie University and an Honours Bachelor of Science from the University of Waterloo.
Demonstration of HPV self-sampling by Eve medical
10:30-10:45 Coffee Break
10:45-12:15 Panel presentations (30 minutes each)
• Dr. Peter J.F. Snijders – Netherland (HPV self-sampling in Netherlands, Lesson learned)
Dr. Peter J.F. Snijders, Department of Pathology, VU University Medical Center Amsterdam (VUmc), Amsterdam, The Netherlands
Dr. Peter Snijders gained his degree in biology in 1987 from the Catholic University in Nijmegen. He holds a doctoral degree (cum laude) in Medicine from VU University in Amsterdam. From 1993 to 1997 he was post-doctoral senior fellow of the Royal Netherlands Academy of Arts and Sciences. Currently, he is Clinical Scientist in Molecular Pathology in the department of Pathology at the VU University medical center, Amsterdam. Since 1988, he has focused on studying HPV-mediated carcinogenesis and development of biomarker tests for HPV-induced precancers and cancers. He has published over 350 papers and (co)developed HPV and methylation markers tests that are nowadays increasingly applied.
HPV Self-Sampling in the Netherlands – Lessons Learned
Offering self-sampling for HPV testing (HPV self-sampling) may improve the cervical cancer screening program. In two studies in the Netherlands (PROHTECT-1 and -2), in which HPV self-sampling was offered to non-attendees of the regular screening programme, about 30% of women responded by submitting a self-sample. Moreover, HPV self-sampling appeared effective in detecting CIN2+/CIN3+. In a subsequent study (PROHTECT-3a), a molecular triage assay directly applicable to self-samples of HPV-positive women was evaluated against cytology triage on a physician-taken follow-up cervical scrape. Molecular triage (i.e. DNA methylation analysis of cancer-related genes) on HPV-positive self-samples was found non-inferior to cytology triage in the detection of CIN2+. Such a molecular approach may obviate the need for an additional visit to a physician for a cervical scrape.
HPV self-sampling could even be considered as alternative for physician-sampling for all women invited for cervical screening, provided that the clinical accuracy of HPV testing on self-samples is non-inferior to that of physician-samples. Data from a recent meta-analysis suggest that some PCR-based HPV tests display a similar clinical performance on self-samples compared to physician-samples. In an ongoing, randomized pilot implementation trial (IMPROVE), cervical screening by HPV self-sampling versus physician-sampling (using HPV PCR test followed by cytology triage) is compared in a regular screening population. When proven clinically non-inferior to HPV testing on physician-collected cervical scrapes, HPV self-sampling may not only be offered to screening non-attendees, but also as alternative to all women invited for cervical screening.
• Dr. Ahti Anttila – Finland (Finnish cervical screening programme and guidelines)
Ahti Anttila, PhD, is a Cancer Epidemiologist and the Director of Research of the Mass Screening Registry of the Finnish Cancer Registry, Helsinki; and an Adjunct Professor in Epidemiology at the School of Public Health, University of Tampere, Tampere, Finland. He has recently worked also as a Senior Visiting Scientist at the International Agency for Research on Cancer, IARC, Lyon, France, on the research area of quality assurance in cancer screening,
His research activities involve environmental and occupational risk factors and prevention of cancer, and evaluation of cancer screening programmes. Dr. Anttila is an editor of the current second edition of the EU Guidelines for Quality Assurance in Cervical Cancer Screening and an editor of the Supplements to the guidelines on HPV testing and HPV vaccination, published in coordination with the International Agency for Research on Cancer, and funded by the European Commission.
He has been involved also in the European networks and Joint Actions on cancer screening and cancer control for a couple of decades, and in European research networks on evaluation of cancer screening programmes. He has been a project leader in developing the European Schools of Screening Management, partially funded by the EU Joint Action Partnership Against Cancer. He has been the Principal Investigator for a large number of studies on cancer screening evaluation at the Finnish Cancer Registry and involved as an author of more than 150 scientific peer-reviewed publications. He is a member of the author team of clinical guidelines for the diagnosis and treatment of precancerous lesions of cervical, vaginal and vulvar cancers in Finland.
Background: High uptake is one key element of successful implementation of organized screening programmes for cervical cancer. Requirements to provide quality-assured services in all steps should be taken into account. Appropriate information in the population and medical staff; and a well-functioning call–recall system for inviting all eligible women to attend screening are essential. While updating the recommendations of the European and the corresponding national guidelines for cervical cancer screening, we have assessed various strategies on how to maximise the uptake.
Methods: Clinical questions related to attendance and screening coverage were assessed based on randomized trials and systematic reviews, using the PICOS methodology for the following options:
a. invitational letters with sample-taking location, time and date readily provided in the letter; b. reminder letter(s), also with sample-taking location, time and date readily provided; c. telephone reminders; d. self-sampling, test samples taken at home as a reminder strategy; e. removing or reducing payments for women to enter screening.
Results: There is consistent evidence that it is possible to increase screening uptake significantly with each of the above invitation strategies (levels of evidence varying from I to II). For instance in the Finnish programme, the attendance rate, usually without the recommended strategy yet, is on average about 70%; but with the optimal strategy the national average could increase to about 85% per one screening round.
Discussion: Screening attendance is still limited or rather low in a large number of cervical cancer screening programmes. Many programmes with low attendance do not utilise the current information on optimal invitational strategies. Based on studies in the Finnish programme, non-attendance may still associate with young age, immigrant background, low education level and having never been married; even after the improvement of the invitational strategy. HPV self-sampling participants have reported mainly good experiences. Negative experiences (difficulties in sample taking, pain, fear, anxiety, insecurity) were reported rarely, but more commonly among women with immigrant background than among Finnish or Swedish speaking. Most common reason for non-attendance in the screening programme in our country is still a recent Pap-smear in opportunistic testing. Based on a large number of studies, cervical cancer risk has been a magnitude higher in non-screened than in screening participants. Information on the optimal invitation strategies is nowadays available up to on screening performance (e.g., referral rate to colposcopy; detection of CIN2+ lesions; hrHPV positivity; and corresponding PPVs). There are not yet studies enabling assessments of the above strategies in cervical cancer prevention.
Anttila A, Ronco G, Nicula F, Nieminen P & Primic Žakelj M (2015). Organization of cytology-based and HPV-based cervical cancer screening. S2. In: European guidelines for quality assurance in cervical cancer screening. Second edition, Supplements. Anttila A, Arbyn M, De Vuyst H, Dillner J, Dillner L, Franceschi S, Patnick J, Ronco G, Segnan N, Suonio E, Törnberg S & von Karsa L (eds.). Office for Official Publications of the European Union, Luxembourg, pp. 69–108.
Virtanen A, Anttila A, Luostarinen T, Malila N, Nieminen P. Improving cervical cancer screening attendance in Finland. Int J Cancer. 2015 Mar 15;136(6):E677-84.
Virtanen A, Nieminen P, Niironen M, Luostarinen T, Anttila A. Self-sampling experiences among non-attendees to cervical screening. Gynecol Oncol. 2014 Dec;135(3):487-94. doi: 10.1016/j.ygyno.2014.09.019.
• Ms. Sandy Anderson – Australia (Sisters doing it for themselves: developing a safe and acceptable self-collection model for cervical cancer screening)
Sandy Anderson is an advanced sexual health nurse who has worked in the Aboriginal health service, Ballarat and District Aboriginal Cooperative (BADAC) for the past 5 years. Sandy is a nurse who has for many years provided cervical screening in a range of settings including general practice and community health services. She has more recently has been deeply involved in our trial of the acceptability of self-sampling in under-screened groups. BADAC is phase 1 location for a unique pilot in partnership initiative between an Aboriginal Community Controlled Health Service, with an Aboriginal-led University of Melbourne research centre , Victorian Cytology Service Pathology, and the Victorian Government, examining are piloting the acceptability of self-sampling with Aboriginal women.
Sandy has a Graduate Diploma in Community Nursing, Sexual and Reproductive Training and a Master of Health Management.
Ms Anderson was elected Chairman of the VCS Ltd Board in 2013, following on from a previous term as President from 2004 to 2007. She has served on the Board as a Director since 2000 and holds the position of nurse with expertise in preventative health. She has worked with PapScreen Victoria, at the Cancer Council of Victoria, for over fifteen years in a role working with nurses providing cervical screening and women’s health services throughout the state and, as part of this role, coordinates the Victorian Nurse Credentialing Program.
Sisters doing it for themselves: developing a safe and acceptable self-collection model for cervical cancer screening
Authors - Sandy Anderson, Professor Kerry Ararbena, Associate Professor Marion Saville, Rachael Andersen
Many Aboriginal and Torres Strait Islander (ATSI) women are empowered to seek health care; however there are still women who experience multiple barriers to accessing services due to their circumstances, lack of engagement and barriers associated with internal examination. ATSI women experience nearly three times the incidence and nearly four times the mortality due to cervical cancer compared to other Australian women.
Between 2011 and 2015, Ballarat and District Aboriginal Cooperative (BADAC) increased cervical screening participation among ATSI women attending their service from 38% to 73%. Community engagement, relationship building and a culturally safe screening service were critical to these results. In May 2017 the human papillomavirus (HPV) test will become the primary screening test in the renewed National Cervical Screening Program (NCSP). As part of the renewed NCSP, under-screened women can be offered the option of a self-collected HPV sample in a clinical setting.
BADAC, in partnership with an Aboriginal-led University of Melbourne research centre, VCS Pathology and the Victorian Government, are piloting the acceptability of self-sampling with ATSI women. At BADAC, community consultation led and enabled the engagement of researchers to reflect on each woman’s experience. In phase one, 78% of previously unscreened or under-screened women were screened. All women who had a positive screening test have had appropriate follow-up investigations.
The lessons learned from BADAC will inform other populations experiencing vulnerability in subsequent research pilot sites. Maximising cervical screening participation in under-screened women is expected to result in declines in the incidence and mortality of cervical cancer.
13:30-15:00 Panel presentation
• Dr. Gina Ogilvie – BC (Acceptability and Feasibility of Self collection)
Dr. Gina Ogilvie, Professor, Faculty of Medicine, UBC, Canada Research Chair, Global control of HPV related cancer, Assistant Director, Women's Health Research Institute, Senior Public Health Scientist, BC Centre for Disease Control, BC Women's Hospital and Health Centre, Vancouver, Canada
Gina Ogilvie, MD MSc FCFP DrPH is a Tier 1 Canada Research Chair in Global Control of HPV related diseases and prevention, and Professor at the University of British Columbia in the School of Population and Public Health. She is also Senior Public Health Scientist at BC Centre for Disease Control and Senior Research Advisor at the BC Women’s Hospital and Health Centre. She was previously Medical Director of Clinical Prevention Services at BC Centre for Disease Control where she provided both operational and scientific leadership to an integrated public health unit with over 100 staff. This unit focuses on providing public health leadership and service in STIs, HIV, Hepatitis and Tuberculosis provincially, nationally and globally. Dr. Ogilvie is currently principal investigator on over 13 million dollars in research grants and she has received funding from PHAC, CIHR, Michael Smith Foundation for Health Research, Canadian Foundation for Innovation and private foundations including BC Women’s Hospital Foundation among others. Her research is focused on both the public health and clinical aspects of reproductive health, sexually transmitted infections, HPV screening and the HPV vaccine, and her findings have been highly influential in setting and directing health policy both in Canada and globally. Among other research projects, she is principal investigator for the ASPIRE program, a global health initiative conducting research and providing women-centred, innovative solutions for cervical cancer prevention and reproductive health in sub-Saharan Africa. She also leads HPV FOCAL, which is a randomized trial of over 25,000 women comparing primary screening for cervical cancer, and QUEST, a pragmatic randomized trial defining the effectiveness of reduced dosing of the HPV vaccine.
She has published over 120 peer reviewed manuscripts and has provided advice and consultation to national and global institutions, including the Canadian Partnership Against Cancer, Public Health Agency of Canada, the World Health Organization and Ministries of Health globally on STI, HIV and HPV vaccine policy and programming. She speaks widely at international and national research and education conferences, and has supervised medical students, residents, and graduate students throughout her career. Dr. Ogilvie received her MD from McMaster University, and completed a specialty in Family Medicine and a fellowship in Population Health and Primary care. She received her Master of Science at UBC, and her Doctorate in Public Health from the University of North Carolina Gillings School of Global Public Health. Dr. Ogilvie is the recipient of several prestigious honors, including Provincial Health Officer’s Award for Excellence in Public health (2015); Researcher of the Year, College of Family Physicians of Canada (2014); YWCA Women of Distinction Nominee (2014); Distinguished Achievement in Research, Faculty of Medicine, University of British Columbia (2014). She is one of the inaugural recipients of the highly prestigious CIHR ‘Foundation Grant’ awards, given to leading scholars to pursue 7 years of research in a field.
Acceptability and Feasibility of Self collection
Self sampling for HPV for cervical cancer screening has the opportunity to increase access for screening with women who are vulnerable. In this presentation, data on the acceptability and feasibility of self collection as well as challenges of over screening and follow up will be reviewed.
• Dr. Mariam El-Zein - Quebec (Effectiveness of HPV testing)
Dr. Mariam El-Zein, Associate Director for Research in the Division of Cancer Epidemiology, McGill University, Montréal. Formerly, Dr. El-Zeim was a research associate at the INRS-Institut Armand-Frappier (2012-2014) and Sainte-Justine Hospital (2003-2005) research units. She holds a B.Sc. in Environmental Health (1993) and a M.Sc. in Public Health (1995) from the American University of Beirut, Lebanon. She earned a Ph.D. (2003) in Occupational Health from McGill University in the joint departments of Epidemiology, Biostatistics and Occupational Health. She completed her postdoctoral training in cancer epidemiology at the INRS-Institut Armand-Frappier, Université du Québec (2007-2010).
Dr. El-Zein has research interests in the area of occupational health and exposure assessment, epidemiology of inflammatory and auto-immune diseases, and cancer etiology (lifestyle and environmental exposures). Her current interests are in cancer epidemiology and clinical trials with special focus on human papillomavirus infections and prevention of cervical cancer.
We have just completed a study (Cervical and Self-Sample In Screening or CASSIS) designed to assess the value of self-sampling using different devices, relative to a physician’s cervical sample, in screening for cervical cancer. We enrolled women referred for colposcopic examination in three McGill-University affiliated hospitals for a diagnosis of cervical cancer or pre-cancer. Each woman collected her own cervicovaginal sample and also had a physician-collected specimen. We found that self-sampling has a good agreement with physician sampling in detecting HPV genotypes, and adequate performance in detecting high-grade lesions.
Effectiveness of HPV testing
In light of the low sensitivity and consequently high rate of false negative results of cytology, the future of cervical cancer screening in high-resource settings lies in testing for HPV, particularly in the post vaccination era. This is the topic of my presentation “Effectiveness of HPV testing”. Firstly, I’m going to present the science-driven change in the modality of cervical cancer screening, focusing on current prevailing scenarios: co-testing (cytology + HPV testing), HPV testing followed by cytology of HPV+, HPV genotyping and conditional cytology. Secondly, I intend to focus on the effectiveness of HPV screening in various populations and the scientific evidence for molecular HPV-based screening as a more cost-effective, clinically superior, and less burdensome compared to conventional cervical cytology-based screening. Then I’ll move to examine the current arguments against the adoption of HPV testing. Lastly, I’ll discuss self-sampled HPV testing which could overcome some of the barriers to cytology, thus promoting cervical cancer prevention among unscreened and under-screened women. To this effect, I’ll present results from our recently conducted Cervical and Self-Sample In Screening (CASSIS) study.
• Dr. Francesca Holme - USA (Women's Cancers Reproductive Health)
Dr. Francesca Holme manages and implements PATH's women's cancer prevention projects, with a special emphasis on cervical cancer prevention efforts underway in Latin America to scale up HPV screening within Central American public health care systems. Prior to joining PATH, Francesca served as a research coordinator for the University of Washington's Department of Global Health, where she managed, implemented, and evaluated reproductive health interventions in Latin America. Previously, Francesca worked as project director for the Herndon Alliance focusing on US national-level healthcare reform legislation via messaging and communications research, and training coordinator for the Northwest Center for Public Health Practice. As a Peace Corps Volunteer, Francesca carried out health promotion and extension activities aimed at reducing maternal mortality in Nicaragua. Francesca holds an MPH from the University of Washington.
HPV Testing Using Self-Sampling for Cervical Cancer Screening: Findings from Central American Government Health Systems
Francesca will share findings from PATH’s work with Central American government health systems to implement HPV testing in self-sampling modality for population-level cervical cancer screening programs. Self-sampling is being used effectively in Central America for rapid screening program scale-up and for reaching previously unscreened populations, including women in rural and indigenous communities. These experiences add to a growing body of evidence documenting the advantages of self-sampling in various contexts worldwide.
15:00: 15:15 Coffee break
15:15-16:15 Moderated Brainstorming session: Should primary HPV screening and HPV self-sampling be priorities in Canada? (see Appendix 1)
16:15-16:30 Concluding remarks and next step - Drs. Mandana Vahabi & Aisha Lofters
Appendix 1: HPV Self-Sampling Questions for Moderated Brainstorming Session
1) What are your opinions on the use of alternative cervical cancer screening formats in general and HPV self-sampling in particular?
2) What are the knowledge gaps in adopting HPV self-sampling into the cervical cancer screening program in your province or area?
3) What resources/changes are required for adopting HPV self- sampling as part of screening programs?