HPV swab self‐collection and cervical cancer in women who have sex with women

Clinical record

A 39‐year‐old woman was referred for colposcopy with a positive human papillomavirus (HPV) type 16 infection result on a self‐collected HPV vaginal swab. She was asymptomatic and was overdue by many years for cervical screening. Barriers to regular cervical screening were cited as having difficulty with speculum examination and having a female partner, with the subsequent perception that cervical screening was not required. She has no other significant past medical or surgical history. Biopsies obtained at colposcopy demonstrated cervical adenocarcinoma with depth of invasion of 3 mm. Positron emission tomography magnetic resonance imaging demonstrated no locoregional or distant metastatic cervical carcinoma. She underwent open radical hysterectomy, bilateral salpingectomy and bilateral pelvic lymphadenectomy for removal of stage 1b1 cervical adenocarcinoma. Histopathology demonstrated cervical adenocarcinoma with maximal diameter of 12 mm and depth of invasion of 5 mm, with no lymphovascular space invasion, as well as foci of adenocarcinoma in situ and high grade squamous intraepithelial lesions (HSIL). There was no involvement of the parametrium, margins or lymph nodes. Her post‐operative course was complicated by wound infection that resolved with antibiotics. She had no signs or symptoms of cancer recurrence after 6 months of follow‐up.

Discussion

Most cervical cancer diagnoses are made in women who are never screened or underscreened.1 Self‐collected vaginal swabs for HPV polymerase chain reaction have been shown to increase participation in cervical cancer screening and have acceptable sensitivity and specificity for the detection of HSIL.1 Furthermore, evidence shows that the accuracy of self‐collected specimens is comparable to that of the clinician‐collected samples.2 In December 2017, the Australian National Cervical Screening Program (NCSP) introduced HPV testing with or without reflex liquid‐based cytology. Self‐collected samples are now available as part of the NCSP for women over the age of 30 years who have never been screened or who are overdue for screening by 2 or more years.3 It is available to be collected in a practitioner‐supervised setting (ie, not at home) and is not available to women who are pregnant, symptomatic, or who have a past history of dysplasia.1

Women who have sex with women (WSW) are at risk of HPV infection and subsequent cervical dysplasia and malignancy. No large studies have been undertaken to accurately quantify the prevalence of HPV in WSW, but estimates vary between 13% and 51%.4 This is comparable with the HPV prevalence across the population. HPV can be transmitted intravaginally between female sexual partners via digital contact and fomites, such as sex toys.4,5 In addition, a proportion of WSW have had previous or have current male sexual partners.4,5 A 2001 study examined factors that affected screening practices in WSW and found that reduced uptake of cervical screening was multifactorial.5 The authors reported that 10% of women in their cohort had been told by health care practitioners that they did not need to be screened if they did not have sex with men.5 Other reasons for reduced uptake included lower perceived level of risk for HPV infection, provision of health care that was not sensitive or inclusive to non‐heterosexual women, and reduced provision of opportunistic health care due to the reduced need for contraception.6 While this article discusses cervical screening in WSW, health care professionals must also address the need for routine cervical screening in transsexual men and non‐binary people, who are also at risk of HPV infection.

Studies have demonstrated that HPV16 is associated with a higher risk of developing HSIL and cervical cancer than other HPV types, with HPV16 being detected in about 52.3% of cervical cancers.6 HPV18 also carries an increased risk relative to other oncogenic HPV types, although less than HPV16. The NCSP recommends that women who are HPV16/18‐positive be referred directly to colposcopy.6 Based on the new NCSP guidelines, which allow for self‐collected HPV specimens, our patient was directed to colposcopy examination, with the subsequent diagnosis of stage 1b1 cervical adenocarcinoma.

This case reminds us that underscreened and never screened women are at high risk for cervical cancer. Where the process of speculum examination and practitioner collection is a barrier to accessing cervical screening, self‐collect HPV testing presents an alternative, in women who meet the criteria, which will identify those who are at high risk for dysplasia and cancer. All women should access cervical screening as per the NCSP guidelines. Furthermore, it is important to address the knowledge about the risk of HPV infection in WSW among health care practitioners and patients.