Mailing patients a human papillomavirus (HPV) self-sampling kit increased cervical cancer screening for those due and overdue for screening, the randomized STEP trial showed.
Among patients who were due for screening at randomization, screening completion was 14.1% higher in those who received kits through the mail and 3.5% higher for those who had the option to request a kit compared with those who received educational materials about screening alone (61.7% and 51.1% vs 47.6%), reported Rachel Winer, PhD, MPH, of the University of Washington in Seattle, and co-authors.
For those who were overdue, screening completion was 16.9% higher in the direct-mail group compared with the education group (35.7% vs 18.8%), while for those with unknown screening history, completion was 2.2% higher in the opt-in group versus the education group (18.1% vs 15.9%), they noted in JAMA.
“To increase screening adherence, systems implementing HPV self-sampling should prioritize direct-mail outreach for individuals who are due and overdue for screening,” Winer and team wrote. “For individuals with unknown screening history, testing alternative outreach approaches and additional efforts to document screening history are warranted.”
Winer told MedPage Today that “this direct mail approach was very effective for increasing screening rates regardless of whether you were overdue or previously due for screening.”
“Cervical cancer screening in the U.S. has been declining, so even for populations who have been adherent to screening, it’s challenging to keep them continually engaged in routine screenings,” she explained, adding that past research has focused on the overdue population.
The STEP trial results indicate that “you can still increase participation even further” with self-sampling kits, she noted.
Jacqueline Hirth, PhD, MPH, a population health researcher at Baylor College of Medicine in Houston, told MedPage Today that these strategies offer new options for patients.
“Direct mailed self-screening offers patients another option for screening that is private and potentially more convenient, as it could reduce the need to make an appointment and find transportation to a clinic,” Hirth said. “It would also be convenient for patients who may avoid medical exams for any number of reasons, including trauma, fear of stigma, or religious reasons.”
She also noted that in the context of public health emergencies, such as the COVID pandemic, mailed tests could be helpful when people are more hesitant to seek in-person medical care.
The STEP trial was conducted at Kaiser Permanente Washington and included 31,355 participants ages 30 to 64 (mean age 45.9) who were enrolled from Nov. 20, 2020 to Jan. 28, 2022, with follow-up through July 29, 2022. Eligible participants had no hysterectomy and were identified through electronic health records (EHRs).
Patients who had been previously screened but were due for their next one were randomized to usual care (patient reminders and clinician EHR alerts); usual care plus educational materials about screening; usual care plus educational materials and a mailed self-sampling kit; or usual care plus educational materials and the option to request a kit.
People overdue for a screening were randomized to usual care, education, or direct mail, while those with unknown history for screening were randomized to usual care, education, or to opt-in.
Screening completion within 6 months was the primary outcome. Secondary outcomes included time from randomization to screening completion, which was a median of 28 days for those who were due for screening and received a self-sampling kit and a median of 39 days who chose to opt-in. For overdue patients, the median was 28 days for those received kits, and for those with unknown history, the median was 41 days for the opt-in group.
A total of 9% of the participants who returned kits required follow-up for detection of HPV or unsatisfactory results.
Winer and team acknowledged several limitations to their study, including that the HPV testing kits had instructions only in English, excluding 6% of otherwise eligible participants. Additionally, participants who opted in did not receive additional reminders. Lastly, the study took place during the COVID pandemic, which may have affected patients’ behavior.
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Disclosures
The research was funded by the National Cancer Institute (NCI) and the NIH.
Winer received grants from the NCI, as did several co-authors. Others also received grants from the CDC and Kaiser Permanente Washington Health Research Institute.
Co-authors had other financial ties to the Patient-Centered Outcomes Research Institute, the National Colorectal Cancer Round Table, Washington Permanente Medical Group, and UnitedHealthcare Community and State.
Hirth had no conflicts of interest.
Primary Source
JAMA
Source Reference: Winer RL, et al “Strategies to increase cervical cancer screening with mailed human papillomavirus self-sampling kits: a randomized clinical trial” JAMA 2023; DOI: 10.1001/jama.2023.21471.
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