No More Paps.
Did you know that within the next couple of years, we’re getting rid of pap tests? Soon people in many provinces in Canada will be screened with free testing for the Human Papillomavirus (HPV) instead of paps. HPV is a sexually transmitted infection. More than 75% of us will have it at some point in our lives. Most people have the infection for a year or two, but some of us have inherited an immune system that just can’t clear the virus. If the virus stays for many years, it can cause gradual changes that may eventually become a cancer. Cervical cancer is a sexually transmitted disease.
Pap tests have served us well in the 50 years since they were introduced in Canada. In my lifetime, cervical cancer rates have dropped from 20 to 7.5 per 100,000. This is because pap tests can find pre-cancerous changes when they’re easy to fix, and we can prevent progression to cancer with a simple outpatient procedure. The problem with pap testing is that a single pap test misses almost half of the existing abnormalities. This is why having a pap test every 3 years is important. However, even with repeated testing, some people are going to remain undiagnosed.
The Canadian Partnership Against Cancer has set a target to eliminate cervical cancer by 2040. This will be accomplished in 3 ways:
Improve HPV vaccination rates
HPV Primary Screening instead of paps
Improve follow-up of abnormal results
In this article, I’m going to focus on Priority 2, and we’ll address the other topics in future newsletters.
HPV testing is simply better than pap testing. The Canadian FOCAL trial showed that HPV testing detected 60% more precancers than paps. The HPV test is so powerful that the risk of finding a precancer in the 10 years after a negative HPV result is less than 1%. That’s why it’s safe to use at 5-year intervals. If you don’t have the virus that causes cervical cancer, you can’t get cervical cancer! There are rare types of cervical cancer that are not caused by HPV, but they are not preventable like HPV cancers are.
Now, 75% of us get HPV, and most of us never develop problems. So if you screen with HPV alone, you’re going to catch lots of healthy people who don’t need close follow-up. That’s why we will still be using pap tests at some point later in the screening process to determine if HPV is having any effect.
Most people will still be seeing their primary care provider for a speculum exam. That way we can collect a sample adequate for both HPV and pap testing. If you’re HPV negative, you’re perfect and you’ll be screened again in 5 years. But if the sample comes back positive, the lab will automatically send it for pap testing. If your pap is normal you’ll be tested again in a year. If it’s abnormal you’ll see a specialist like me for colposcopy where we examine the cervix with a microscope and do biopsies.
Now 80% of us are up to date on our paps. However, this percentage is much lower among Canadians who have barriers to accessing primary care, like recent immigrants, remote communities, people with precarious employment, and 2SLGBTQ+ Canadians. Studies have confirmed that a self-collected HPV sample from the vagina is as accurate as a cervical sample collected by a doctor. That means we can mail tests to underscreened people and they can mail the sample straight to the lab. If they test positive, they’ll still have to come in to see a doctor.
Right now, this type of sampling is available privately in Canada. You can ask your care provider to add HPV testing at the time of pap, and the lab that they send the sample to will mail you a bill for about $100. When HPV screening is implemented in your province, this test will be done automatically for free.
If you don’t have access to a family doctor, you can have a self-swab mailed to your home through Switch Health. It also costs about $100, whereas HPV testing with your family doctor will eventually be free of charge. Hopefully, the province will eventually cover home testing for at-risk populations.
I’m really excited about these new changes. I’ve been waiting for almost 20 years to be able to offer this testing to my patients without charge and that time is almost here. I expect that early 2025 Ontario will have implemented these changes, and PEI is already there. Quebec, BC and New Brunswick are next. It is a superior test for cervical cancer prevention that should be available to all.
I also think HPV testing is going to shed light on the prevalence of this virus. People who thought they were not at risk are going to test positive, and it’s going to start a renewed conversation about the importance of HPV vaccination for the prevention of cervical, anal, and throat cancers.