Discussion
cancer, cervical cancer
CANCER, CERVICAL CANCER
Offering a catch-up HPV test to 65- to 69-year-old women, including the possibility to allow women to choose between a clinician-collected sample or vaginal self-sampling, resulted in an overall uptake of 62.2% and an HPV prevalence of 6.5%. The intervention was associated with a significantly higher CIN2+ detection rate as compared to the reference group (3.9 per versus 0.3 per 1,000 eligible women) and was not associated with a significantly higher number of colposcopies needed to detect one CIN2+ (11.6 versus 10.1, respectively). Whereas clinician-based sampling was the preferred screening modality overall (71.1%), a substantially higher percentage of insufficiently screened women underwent self-sampling than sufficiently screened women (52.1% versus 27.3%).The screening uptake of 62.2% in the intervention group was substantially higher than the uptakes of 44.0% [In all screening initiatives, it is essential to carefully evaluate the trade-off between benefits and harms. From a population-based perspective, the intervention contributed to a significantly higher detection of CIN2+ and CIN3+ per 1,000 eligible women. Not all CIN3 lesions, and especially CIN2, detected at age 65 and older would have progressed into cancer in the remaining lifespan [The key strength of the study was that the intervention was undertaken within a real-world setting of a national screening program, using the same screening invitation protocol and follow-up algorithms that are used routinely in the Danish program. Furthermore, this study included several times as many women as the previous studies exploring the utility of vaginal self-sampling among older women [Our study informs the current debate as to whether women over 65 years of age should be offered a catch-up HPV test if they never had an HPV test. Offering catch-up HPV screening resulted in higher detection of CIN2+ and CIN3+ without significantly increase in the number of colposcopies per detected CIN2+/CIN3+. Furthermore, women with HPV negative screening results in this study will be expected to have an extremely low risk of developing cervical cancer in their remaining life time [In countries with limited resources, collecting an opportunistic cervical cytology sample due to gynecological symptoms seems appropriate from a clinical point of view based on the higher CIN2+ detection per 1,000 tested women in the reference as compared to the intervention group (14.8 versus 6.3 per 1,000 tested, reflecting a per protocol analysis).Based on this study, vaginal self-sampling might be the optimal screening modality for women aged 65 and above based on its ability to reach older insufficiently screened women and its more favorable cost than clinician-based sampling [