Acceptability and Efficacy of Self-sampling for Cervical Cancer Screening: A Pilot Study
Acceptability and Efficacy of Self-sampling for Cervical Cancer Screening: A Pilot Study
In Singapore, the current cervical cancer screening uptake among women in Singapore has
 remained at low 50% since its introduction in 2004. It has been widely reported that
 under-screened women have the highest risk of cervical cancer. Self-sampling HPV DNA
 screening may be a solution to the low uptake rates of local women, particularly among the
 under-screened population in Singapore. Self-sampling comprises women using a swab to obtain
 samples from their vagina.

 In this study, we are comparing the sensitivity of detecting HPV positive women using HPV DNA
 test with self-sampling using flocked swab with the current physician sampling method. We
 also aim to determine acceptability of self-sampling HPV DNA test using flocked swab in
 cervical cancer screening. Designed as a feasibility study, it will comprise a prospective
 study of 300 women attending clinics in National University Hospital (NUH) and National
 Cancer Institute Singapore (NCIS).
Cervical cancer is one of the leading causes of death worldwide. The recognition that
 cervical cancer is caused by persistent oncogenic HPV virus has caused a considerable
 paradigm shift in screening and prevention of cervical cancer by the introduction of HPV DNA
 test and the HPV vaccine. HPV DNA test as an alternative to the current and more traditional
 cytology only screening has been shown to have higher sensitivity in detecting high grade
 cervical intraepithelial neoplasia (CIN) to allow for earlier treatment of pre-cancer thus
 preventing development of cervical cancer in future. Singapore as the rest of the world are
 in the transition toward the paradigm shift of using HPV DNA test as part of the cervical
 cancer screening strategy compared to the traditional cytology only screening. However, any
 cancer screening program to make an impact, an uptake of 70% of more is desired and currently
 this strategy resulting to the reduction in cervical cancer incidence are only seen in
 countries adopting an organized cervical cancer screening strategy such as the United
 Kingdom. Currently, HPV DNA testing has widely been shown to be higher sensitivity to pick up
 pre-cancer and allow for earlier treatment of pre-cancer. Uptake for cervical cancer
 screening has remains suboptimal since introduction of the national cervical cancer screening
 using cytology only method in 2004.

 A study published by Jin et.al. in Singapore Medical Journal in 2013 evaluating the progress
 of cervical cancer screening Singapore (CSS) since its introduction showed that CSS did not
 make its aim to get 80% uptake for cervical cancer screening for eligible women using
 cytology only method

 Self-sampling in cervical cancer screening

 Cervical cancer screening with HPV DNA test is more sensitive than cytology only method to
 detect pre-cancer cervical cells. It is now well established that cervical cancer screening
 with HPV DNA test is a much more sensitive method to detect pre-cancer cervical cells
 compared to cytology only method.

 The traditional way of taking a cervical cancer screening involves a physician inserting a
 speculum into the vagina to visualize the cervix and brushing the surface of the cervix using
 a cytology brush or spatula. This will collect exfoliated cervical cells to be sent for
 cytology review to detect any abnormal or pre-cancerous looking cells. Currently HPV DNA test
 is performed using the same method as taking a pap smear. However, various studies have shown
 that for HPV DNA test, self-sampling method is a good alternative to physician sampling
 (Appendix C). Current self-sampling methods in the market are expensive and not cost
 effective especially if targeting under screeners. There are however, various self-sampling
 HPV DNA test device in the market. These devices such as the Delphi Screener are expensive
 and would not be a cost-effective alternative method for women especially in the under
 screeners in Singapore. Studies have shown that those who do not come for regular cervical
 cancer screening are usually associated with a lower socioeconomic background. To encourage
 the under screeners to take up screening, the method should not only be accessible to them
 but also affordable. The Copan Floq swab has already been used in NUH for Chlamydia testing
 and it is highly affordable at 3 SGD per swab. Our study would like to determine that using
 this affordable swab for self-sampling is as sensitive in detecting high risk HPV as a
 physician sampling method.

 There is no local data on the acceptability of self-sampling method using a Floq swab among
 women in Singapore. The acceptability of self-sampling has been reported to be high among
 women especially in the western countries. Women in the Asian population in particular
 Singapore may differ in their acceptability of a self-sampling method compared to a physician
 sampling method. Self-sampling HPV DNA test will require a woman to insert the cotton swab
 into the vagina and currently there is no local data to show wether it is an acceptable
 method for women in Singapore for all ages from 25 to 69 years old. The use of tampons is a
 much more acceptable method during menstruation in the western country which may influence
 the acceptability data of self-sampling in the western countries. However, tampon use is not
 a norm in Asian population including Singapore and may be a factor to influence the
 acceptability of self-sampling among Singaporean women especially in the older age group.

 This study is thus also designed to elucidate this issue. Cervical cancer is a marker of
 health disparities. Looking to the future, data has shown that failure to go for cervical
 cancer screening, which is a highly preventable disease, may also be linked to failure of
 uptake to other screening in a woman. It may also be linked to failure of basic health
 screening not only for the woman but also for her family. Hence to overcome barriers for
 cervical cancer screening especially in giving women a reliable alternative option may in
 future not only help to prevent cervical cancer but also indirectly encourage uptake of other
 screening such as breast cancer and colorectal screening for her and her family. Our study
 will attempt to address two questions. 1) Does the self-sampling HPV DNA test as sensitive as
 the physician sampling HPV DNA test in Singapore? And 2) If Singaporean women have the option
 of self-sampling, are they more likely to regularly participate in future cervical cancer
 screening.

 STUDY DESIGN

 The study is a prospective feasibility study composed of healthy women aged between 30-69
 years who are attending clinics in NUH will be identified through the gynaecologist. Ethical
 approval for this study from the Domain Specific Review Board for O&G is being sought.

 Subjects: Three hundred women who meet the inclusion & exclusion below will be invited to
 participate and complete the consent process. Those that decline will have age, ethnicity,
 education, work status & reason for declining collected.

 Study Visit: Each potential participant will initially see their doctor as clinically
 intended and offered to participate in the study as identified by each physician in the
 clinic. Upon agreeing to participate in the study, each participant will be given a study
 information leaflet and introduced to the research coordination for further explanation of
 the study and to sign the study consent form. Once consent form is signed, the participant
 will be given a study self-sampling kit and instructions on how to perform the self-sampling
 (see Appendix A). The participant performed the self-sampling test in the clinic in a private
 area and hand over the completed kit to the research coordinator who will label and keep the
 sample for process.

 Post assessment: On completion, the participant will be invited to complete a 10 to 15
 minutes questionnaire to assess women's acceptability on self-sampling method. Upon
 completion of the questionnaire, the participant will be awarded a study token of
 appreciation prior to leaving the clinic. The participant clinical management will not be
 affected by the study.

 SAMPLE SIZE AND STATISTICAL ANALYSIS

 Data collected for this study will be in a password protected Microsoft Excel software. Only
 the primary investigator and co-investigators will have access to the database for the
 purpose of data analysis. Sample size was calculated based on the number of women between the
 ages of 30 and 69 in Singapore's population (as of June 2017). Using a 95% confidence level,
 it was determined that a sample size of 120 - 150 women would be ideal. The sample size was
 calculated using G*Power. SPSS will be used to analyze the data collected. Descriptive
 analyses will be done on the survey data to get demographic data, and to determine
 participants' perceptions and ratings of the self-sampling methods. Multivariate analyses
 will be used to determine the sensitivity of the self-sampling method with physician-taken
 swab as the reference standard.

 Data collected will include:

 -  Patient details: Name and NRIC

 -  Patient demographics: Age, Race, area code, parity, social economic status

 -  Reason for HPV DNA test: Primary screening or secondary screening

 -  Screening results:

 -  Physician sampling HPV DNA test

 -  Self-sampling HPV DNA test

 -  Completed questionnaire

 Our specific aims are to:

 1. To determine the sensitivity of self-sampling method compared to physician sampling
 method for HPV DNA test in cervical cancer screening

 2. To determine acceptability of self-sampling HPV DNA test using flocked swab in cervical
 cancer screening

 The study is designed to give a more accurate local view of the sensitivity of floq swab and
 acceptability for self-sampling to Singaporean women. Published studies on self-sampling are
 mainly from the western countries and perception may not be similar for local women.
 Currently available self-sampling in the market are expensive and thus will not be cost
 effective if to be introduced to the current Singapore cervical cancer screening program. As
 Singapore is also moving towards HPV primary screening in the very near future, this study
 will aid in providing the next step to the screening program by introducing a method that can
 help to increase uptake of screening in particular in the underscreen population in
 Singapore.
Inclusion criteria: All women aged between 30-69 years who are attending clinics in NUH.

 Exclusion criteria:

 1. Women who are pregnant

 2. Previous total hysterectomy

 3. Previous history of cervical cancer

 4. Virgin Intacto

 5. Negative Pap smear less than 3 years ago.