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opinion: ontario needs culturally sensitive, self-collection hpv screening for all women

the ontario provincial government’s current hpv screening strategy has left many structurally marginalized women on the sidelines.

by mandana vahabi, phd, rn, fcan

published sep 27, 2024

6 minute read

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6 minute read

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although early detection through screening can save lives, pap test uptake remains extremely low among structurally marginalized women, such as racialized immigrants, indigenous people, 2slgbtqi+ individuals, and sex workers. getty images

cervical cancer, being among the top five most commonly diagnosed cancers among women aged 25-44 in ontario ¹, could become a disease of the past with screening options that are women-centred and culturally appropriate. however, the provincial government’s current screening strategy has left many structurally marginalized women on the sidelines. this is a serious public health issue in ontario that demands urgent attention from policymakers and healthcare providers alike.

hpv screening is crucial to preventing cervical cancer

cervical cancer, primarily caused by human papillomavirus (hpv), the most common sexually transmitted infection (sti), is now the fastest increasing cancer ( up 3.7 per cent per year since 2015) ². current estimates indicate that 660 women in ontario will be diagnosed and 150 will die from cervical cancer in 2024 ³. although early detection through screening can save lives, pap test uptake remains extremely low among structurally marginalized women, such as racialized immigrants, indigenous people, 2slgbtqi+ individuals, and sex workers ^{4, 5, 6, 7}.

these equity-deserving groups face systemic barriers to screening services, including geographic isolation, the lack of culturally safe care, a history of trauma, mistrust of the healthcare system, service accessibility issues (distance, transportation), service availability (lack of a family physician, inconvenient clinic hours, long wait times) and limited education about cervical cancer and screening ^{8, 9, 10, 11}.

adopting culturally sensitive practices to promote women’s health

overcoming these barriers requires a concerted effort from both healthcare providers and policymakers to take immediate action. investing in culturally sensitive outreach and sexual health education is an important first step to raising awareness about the benefits of hpv screening ¹². additionally, implementing innovative and effective population-based hpv screening can bridge the gap to life-saving preventive care. this screening method, which identifies the viral cause of cervical cancer, can be enhanced by offering the option of self-collection, a safe and effective alternative to clinician-collected samples ¹³. this allows women to perform the procedure at both a time and a place that are convenient for them.

ontario must accelerate the transition to hpv primary screening with sample self-collection

the hpv test offers several advantages over the traditional pap test for cervical cancer screening. it detects high-risk hpv strains, the primary cause of cervical cancer, with greater sensitivity and accuracy ¹⁴. a negative hpv test allows for a longer screening interval of five years compared to three years for the pap test, reducing the frequency of testing for most women ¹⁵. it also allows the option of self-collection that is not possible with the traditional pap test.

although ontario will adopt hpv as the primary test for cervical cancer in spring 2025, it has already lagged behind other canadian provinces in transitioning to hpv primary screening. pei adopted the strategy in may 2023 and quebec has launched hpv primary screening in select regions, with full implementation expected in 2025.

when it comes to hpv primary screening with sample self-collection, british columbia is the first and only province that has both implemented primary hpv screening and made the option of self-collection available to all screening-eligible individuals with a cervix. the response to their self-collection option has been overwhelmingly positive, with 30,000 self-screening kits requested in the first two months of the program. more importantly, 30 per cent of those requesting a kit had never been screened before ¹⁶.

ontario remains in the planning phase, and it is yet to be determined if the self-collection option will be available. in the meantime, women across the province must wait, and screening disparities for women continue.

it is time for government and healthcare professionals in this province to commit to primary hpv screening, including the self-collection option, and to support dedicated community education efforts to ensure access to care for all ontarians with a cervix. we urge policymakers and healthcare leaders to prioritize this issue and take swift action to ensure equitable access to hpv screening and close this unacceptable gap in preventive care. the time for change is now.

mandana vahabi, phd, rn, fcan, professor at the university of toronto – lawrence bloomberg faculty of nursing and women’s health research chair at unity health – st. michael’s hospital

eduardo franco, distinguished james mcgill professor, departments of oncology and epidemiology & biostatistics, faculty of medicine and health sciences, mcgill university

doris grinspun, rn, phd, lld (hon), dr(hc), dhc, dhc, faan, fcan, chief executive officer, registered nurses’ association of ontario

valerie grdisa, phd, rn, chief executive officer, canadian nurses association

stuart edmonds, executive vice president of mission, research and advocacy, canadian cancer society

jenna hynes, strategic director in case management, parenting & drop-in program, maggie’s toronto

heather jamieson, women’s clinic lead, hassle free clinic

axelle janczur, executive director & cliff ledwos, director of primary care and associate executive director, access alliance

aisha lofters, medical director for the peter gilgan centre for women’s cancers and family physician at women’s college hospital

jennifer rayner, director of research and policy at the alliance for healthier communities and an adjunct professor at the centre for studies in family medicine at western university

—

[1] statistics canada. table 13-10-0111-01 number and rates of new cases of primary cancer, by cancer type, age group and sex. doi: https://doi.org/10.25318/1310011101-eng (accessed: august 25, 2024)

[2] canadian cancer society – the annual report – canadian cancer statistics 2023. p. 20

[3] brenner dr, gillis jl, demers a, ellison lf, billette jm, zhang sx, liu j, woods, rr, finley c, fitzgerald n, saint-jacques n, shack l, turner d, for the canadian cancer statistics advisory committee. projected estimates of cancer in canada in 2024. cmaj 2024 may 13;196:e615-23. doi: 10.1503/cmaj.240095.

[4] xiong h, murphy m, mathews m, gadag v, wang pp. cervical cancer screening among asian canadian immigrant and nonimmigrant women. am j health behav. 2010;34:131–143. https://doi.org/10.5993/ajhb.34.2.1

[5] cancer care ontario. ontario cancer screening performance report 2023 (2024). available at https://www.cancercareontario.ca/sites/ccocancercare/files/assets/ocsprfullreport.pdf

[6] agénor m, bailey z, krieger n, austin sb, gottlieb br. exploring the cervical cancer screening experiences of black lesbian, bisexual, and queer women: the role of patient-provider communication. women health. 2015;55(6):717-36. doi: 10.1080/03630242.2015.1039182. epub 2015 apr 24. pmid: 25909663.

[7] sex work in canada: the public health perspective. ottawa: canadian public health association; 2014. available: www.cpha.ca/sites/default/files/assets/policy/sex-work_e.pdf (accessed 2022 dec. 15).

[8] uba l., “cultural barriers to health care for southeast asian refugees,” public health reports, vol. 107, no. 5, pp. 544-548, 1992. available at https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1403696/

[9] vahabi, m, kithulegoda, n., wong, j, lofters, a.k., (2024) knowledge and attitudes towards cervical cancer screening and acceptability of hpv self-sampling (hpv-ss) among under or never screened racialized immigrant women in gta, ontario, canada, journal of environmental science and public health,.8(2), 32-48, doi:10.26502/jesph.96120204.

[10] vasilevska, m., ross, s. a., gesink, d., & fisman, d. n. (2012). relative risk of cervical cancer in indigenous women in australia, canada, new zealand, and the united states: a systematic review and meta-analysis. journal of public health policy, 33(2), 148-164. https://doi.org/10.1057/jphp.2012.8

[11] dick a, holyk t, taylor d, et al. highlighting strengths and resources that increase ownership of cervical cancer screening for indigenous communities in northern british columbia: community-driven approaches. int j gynecol obstet. 2021; 155: 211–219. https://doi.org/10.1002/ijgo.13915

[12] gesink, d., mihic, a., antal, j., filsinger, b., racey, c. s., perez, d. f., norwood, t., ahmad, f., kreiger, n., & ritvo, p. (2014). who are the under- and never-screened for cancer in ontario: a qualitative investigation. bmc public health, 14, 495. https://doi.org/10.1186/1471-2458-14-495

[13] cancer care ontario. ontario cervical screening program guidelines. available from: https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/61636

[14] koliopoulos, g., nyaga, v. n., santesso, n., bryant, a., martin-hirsch, p. p., mustafa, r. a., schünemann, h., paraskevaidis, e., & arbyn, m. (2017). cytology versus hpv testing for cervical cancer screening in the general population. cochrane database of systematic reviews, (8). https://doi.org/10.1002/14651858.cd008587.pub2

[15] canadian task force on preventive health care. (2013). recommendations on screening for cervical cancer. cmaj: canadian medical association journal, 185(1), 35-45. https://doi.org/10.1503/cmaj.121505

[16] http://www.bccancer.bc.ca/screening/documents/cervix-updatebulletin-apr2024.pdf .

opinion: ontario needs culturally sensitive, self-collection hpv screening for all women

the ontario provincial government’s current hpv screening strategy has left many structurally marginalized women on the sidelines.

hpv screening is crucial to preventing cervical cancer

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opinion: ontario needs culturally sensitive, self-collection hpv screening for all women

the ontario provincial government’s current hpv screening strategy has left many structurally marginalized women on the sidelines.

hpv screening is crucial to preventing cervical cancer

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