Ask the Expert: Using Self-Tests for HPV to Screen for Cervical Cancer

Jan. 29, 2025

Dr. Mitchell Linder Answers Our Questions

Cervical cancer is predominantly caused by the human papillomavirus (HPV). HPV is one of several cancer-causing viruses, along with Hepatitis B (HBV), Epstein-Barr Virus, and human immunodeficiency virus (HIV). All told, infections are responsible for roughly 13% of cancers worldwide, and 30% of cancers in low- and middle-income countries.

The significant role that HPV plays in cervical cancer development presents two powerful opportunities to significantly reduce its incidence, morbidity, and mortality: the HPV vaccine and HPV testing.

The HPV vaccine has been highly effective at preventing high-risk HPV infections and cervical cancer and precancer. This, combined with greater access to HPV screening, has led the World Health Organization to launch a global initiative to eliminate cervical cancer by 2030.

Screening for cervical cancer is conducted in one of three ways:

Cytology (Pap test): A cytological specimen is retrieved from the cervix and endocervical canal and examined by a cytopathologist, looking for cancerous or abnormal, precancerous cells
Primary HPV Testing: A cervical or vaginal sample is collected and tested for high-risk strains of HPV, either through DNA amplification or identification of proteins exhibited by high-risk strains
Co-Testing: Cervical cytology and HPV test are collected and analyzed at the same time

The most recent advance in the fight against cervical cancer is the development and approval of self-collection kits, which allow individuals to collect their own specimen for HPV testing, rather than requiring a speculum exam.

To better understand this new approach, I sat down with Dr. Mitchell Linder, the Division Director for the Generalist Ob/Gyn Practice at the University of Rochester Medical Center, and an expert on cervical cancer screening. He was kind enough to answer my questions on the topic:

There is a great deal of enthusiasm around HPV self-swabs. Why is that?

Primary HPV self swabs allow for more patient control over their health care.

There are estimates that up to 30% of people eligible for cervical cancer screening do not get their testing done at regular intervals. There are a number of reasons for this, as some patients have difficulty getting to appointments, live in health care deserts, have high anxiety around pelvic exams, have disabilities or medical conditions that preclude a speculum exam, or have certain religious beliefs or personal preferences. For patients in these circumstances, using a self-swab would help improve their access to vital cervical cancer screening.

There has also been some public discourse around self-swabs being helpful for patients who experience pain with speculum exams. While this is certainly true, I want more people to know that significant pain with exam might indicate that there is an underlying condition. Vulvar pain specialists like myself can help identify the cause and find ways to relieve the pain.

Regardless of the reason why a self-swab is preferable to an exam, catching abnormal results earlier will help with early detection of precancerous lesions and help curb rates of cervical cancer.

While initially the swabs have only been approved for self swab while in a clinic, I would expect that eventually home kits would be approved as well.

What's the theory underlying the self-swab test?

When screening "Pap smears" were first invented, the test was to look for cytologic abnormalities (abnormal cells). The test was conducted each year because each individual test could only assess the status of cells on the day the specimen was collected. They knew that the cells could become abnormal over time.

Once we learned more about HPV and its role in transformation of normal cells to pre-cancerous and then cancerous ones, we began testing for the HPV as well. We could predict which cells would become abnormal in advance.

Now that we know HPV is the cause of 95+% of cervical cancers, we can move to screening for HPV first and avoid false positives in the cytologic results.

How trustworthy is a self-administered test?

Self-collect tests have been approved in many other countries, including the Netherlands, Denmark, Sweden, and Australia. In total there are 17 countries where self swab has become recommended for use and in 9 of them it is the primary recommended screening strategy.

What are the drawbacks to self-collected HPV testing?

If the HPV test is positive, then the patient would need a traditional Pap test to examine the cells (cytology) for abnormalities.

There also is a very small subset of cervical cancers that are HPV negative that could be potentially missed with this process, or any primary HPV test.

Who is eligible?

This will be a decision made by patient and their provider.

Will we offer self-swabs?

Recently FDA-approved at-home HPV tests will allow some patients to collect a vaginal swab themselves instead of having the sample collected by a clinician. These new tests will help improve access to cervical cancer screening—especially for people who live in rural areas or have difficulty getting to in-person appointments.

The FDA-approved tests perform very similarly to clinician-collected samples. However, clinician-collected screening remains the preferred option for many patients. If you’ve had abnormal Pap smears in the past, abnormal bleeding, or have other risk factors, talk with your healthcare provider to find out whether at-home testing is right for you.

Where do you see this going in the future?

Home testing for sure. There are a handful of trials already underway to help get that approved.

In the more distant future, it'd be awesome if there was an HPV blood test that might avoid the need for any type of primary vaginal sampling.