<![CDATA[Restarting cervical screening programs during and after the COVID 19 pandemic]]>

How do you see COVID is going to impact screening programs?
At this time we are all aware of the pandemic due to coronavirus SARS-CoV-2.¹ At the moment of this interview there are over 10.5 Million confirmed cases and 512,331 deaths. The infection affects 216 countries or territories² and COVID-19, the illness caused by SARS-CoV-2, is overwhelming many health care systems globally. A series of measures have been taken across the globe including physical distancing, lockdown and use of protective gear. Health care institutions and hospitals have been re-designed to accommodate COVID-19 patients. Many preventive and routine medical activities have been stopped, and surgery for multiple conditions has been postponed or seriously delayed including gynecological oncology procedures.

Has the pandemic affected cervical cancer screening activities?
Cervical cancer screening programs have been curtailed almost everywhere worldwide. Many of my collaborators in low resource settings have re-allocated their screening personnel or the staff members have been sent home because of various levels of lockdown. Cancer screening has temporarily stopped being a priority.

Should we still promote cervical cancer screening during the pandemic?
While recommendations on how to return safely to providing services for cancer patients are being elaborated in many settings, and guidelines for proper management of clinic facilities are being specified³, no clear guidelines have been developed on how to manage asymptomatic individuals requesting preventive services such as cancer screening. Think of a woman attending a cervical screening visit who is, by definition, asymptomatic. The screening visit aims to protect her in the years to come; cervical cancer typically takes years to develop and a brief delay in screening will impact a small fraction of women. In this case there is not a priori an emergency and most likely, for most women, that visit could be safely postponed. However, considering that SARS-CoV-2 will prevail worldwide for an extended period of time, we need to design, as much as possible, an environment for such screening visits.

What can we do to move forward in a safe environment?
There are many layers to consider that will strongly depend on the geographical setting where we live. In some places, particularly in low resource settings, screening activities typically follow public announcements or promotion campaigns. The first action in moving forward, when the benefits are judged to outweigh possible harms, should focus on re-designing screening campaigns to avoid potential unnecessary exposure to coronavirus from provider/participants to women due to close contact. Most importantly, we have now the opportunity to emphasize the key goal of screening, which is to identify women with precancerous lesions as accurately as is feasible. Our understanding of cervical carcinogenesis and its prevention provide us with the certainty that by testing pre-menopausal adult women for oncogenic HPV types we can provide a highly sensitive risk stratification to refer only those that are positive for further management⁴. The good news is that sampling for HPV testing can be safely obtained by women themselves either at home or at a health center with no need for a gynecological exam, with a highly reliable result⁵. The additional good news is that, in many settings, between 80 to 85% or more of the women screened will be negative for HPV and this provides at least a 5 year or more safety period⁴. Self-sampled specimens can be handled safely, and test results can be notified electronically to the women, to the health facility or to the community health worker accordingly. The advent of SARS-CoV-2 serology can define seropositive women (and staff), and with results coming soon we will know whether harboring antibodies provide active protection. Lacking serostatus, we propose that women that are HPV positive and need a gynecological exam could then be tested for SARS-CoV 2 using a rapid test (with testing of clinical personnel as well on a regular basis), which are rapidly becoming available, prior to the clinical visit. This added care and expense will be temporary but would be optimal for making sure that the HPV-positive woman and staff can proceed more safely than a reliance on insensitive and lagging criteria like fever or cough. In women who have a positive SARS-CoV-2 test, examination would likely be postponed. CoV-test results will be shared by the team with the patients attending the clinic that given day. Ideally, routine regular tests for SARS-CoV 2 will be possible, using novel and relatively inexpensive RNA assays, among all the health personnel involved in the visit. The overall aim for restarting screening would be to risk only minimal levels of transmission of SARS-CoV-2 between the people involved in the activities that originate in screening visits, including the treatment of screen-positives. The setting of the triage and treatment clinics should be decentralized as much as possible to avoid overcrowding and contact with COVID patients. The triage and treatment visits should be well planned to avoid multiple women in the waiting room. Use of cellphones to schedule visits and comprehensive public health hygienic measures will need to be in place.

Admittedly, adding a SARS-CoV-2 test, and limiting the number of visits per provider will increase the screening cost at the benefit of both security to the population and health workers. The optimization of the selection of women in need for examination and possible treatment by HPV type restriction will add a reduction of the global cost. All in all, there is a need to develop efficient public health measures for major diseases afflicting the population such as cervical cancer, even in the presence of a deadly epidemic.

DISCLOSURE
Silvia de Sanjosé declares no conflict of interest.

References

1. Zhu N, Zhang D, Wang W, et al. China Novel Coronavirus Investigating and Research Team. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 2020;382(8):727-733. Available from: https://pubmed.ncbi.nlm.nih.gov/31978945/

2. WHO https://www.who.int/emergencies/diseases/novel-coronavirus-2019

3. Curigliano G, Cardoso MJ, Poortmans P, et al. Recommendations for triage, prioritization and treatment of breast cancer patients during the COVID-19 pandemic. Breast 2020;52:8-16. Available from: https://pubmed.ncbi.nlm.nih.gov/32334323/

4. Demarco M, Egemen D, Raine-Bennett TR, et al. A Study of Partial Human Papillomavirus Genotyping in Support of the 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24(2):144-147. Available from: https://pubmed.ncbi.nlm.nih.gov/32243309/

5. Arbyn M, Smith SB, Temin S, Sultana F, Castle P; Collaboration on Self-Sampling and HPV Testing. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. BMJ. 2018;363:k4823. Available from: https://pubmed.ncbi.nlm.nih.gov/30518635/

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Silvia de Sanjosé, MD, PhD
PATH, Seattle, US
sdesanjose@path.org

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