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Are we ready for human papillomavirus testing?

Assessment of patient knowledge of and preferences for cervical cancer screening in Ontario

Praniya Elangainesan, Michelle S. Naimer, Sahana Kukan and Amanda Selk
Canadian Family Physician July/August 2024; 70 (7-8) 479-490; DOI: https://doi.org/10.46747/cfp.700708479

Article Figures & Data

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Tables

  • Table 1.

    Participant characteristics, N=413

    CHARACTERISTICOVERALL (N=413)FAMILY PRACTICE PARTICIPANTS (n=234)SOCIAL MEDIA PARTICIPANTS (n=179)P VALUE*
    Mean (SD) age, y44.6 (11.7)†46.6 (12.18)41.9 (10.4)<.01
    Education, n (%).49

    • High school diploma or equivalent

    		12 (2.9)9 (3.9)3 (1.7)

    • University or college degree

    		185 (44.8)102 (52.1)83 (46.4)

    • Graduate degree

    		215 (52.1)122 (43.6)93 (52.0)

    • Missing data

    		1 (0.24)1 (0.43)0 (0)
    Community size, n (%)<.01

    • Small town, village, or hamlet (<20,000)

    		9 (2.2)1 (0.43)8 (4.5)

    • Large town (20,000-100,000)

    		25 (6.1)11 (4.7)14 (7.8)

    • City (>100,000-300,000)

    		40 (9.7)18 (7.7)22 (12.3)

    • Large city (>300,000-<1,000,000)

    		47 (11.4)18 (7.7)29 (16.2)

    • Metropolis (1,000,000-3,000,000)

    		164 (39.7)101 (43.2)63 (35.2)

    • Megalopolis (>3,000,000)

    		127 (30.8)84 (35.9)43 (24.0)

    • Missing data

    		1 (0.24)1 (0.43)0 (0)
    Birthplace, n (%).01

    • Canada

    		322 (78.0)172 (73.5)150 (83.8)

    • Outside Canada

    		91 (22.0)62 (26.5)29 (16.2)
    Age when moved to Canada, n (%)‡.36

    • 0-10 y

    		30 (33.7)20 (32.2)10 (37.0)

    • 11-20 y

    		17 (19.1)11 (17.7)6 (22.2)

    • 21-30 y

    		23 (25.8)17 (27.4)6 (22.2)

    • 31-40 y

    		15 (16.9)11 (17.7)4 (14.8)

    • 41-50 y

    		4 (4.5)3 (4.8)1 (3.7)
    Has a family doctor, n (%)<.01

    • Yes

    		398 (96.4)232 (99.2)166 (92.7)

    • No

    		10 (2.4)1 (0.4)9 (5.0)

    • Missing data

    		5 (1.2)1 (0.4)4 (2.2)

    • ↵* P values reflect Embedded Image2 test comparisons between participant groups or Fisher exact test where applicable.

    • ↵† Age estimates provided for 303 of 413 participants due to missing data.

    • ↵‡ Missing data present.

  • Table 2.

    Participant experiences with Pap and HPV screening tests

    SURVEY QUESTION AND POSSIBLE RESPONSESOVERALL (N=413), n (%)FAMILY PRACTICE PARTICIPANTS (n=234), n (%)SOCIAL MEDIA PARTICIPANTS (n=179), n (%)P VALUE
    What percentage of cervix cancer do you think is caused by HPV?.63

    • 0%-25%

    		35 (8.5)21 (8.9)14 (7.8)

    • 26%-50%

    		94 (22.8)53 (22.7)41 (22.9)

    • 51%-75%

    		138 (33.4)84 (35.9)54 (30.2)

    • 76%-100%

    		141 (34.1)73 (31.2)68 (38.0)

    • Missing data

    		5 (1.2)3 (1.3)2 (1.1)
    Have you ever had a Pap test done by a health professional?

    • Yes

    		404 (97.8)229 (97.9)175 (97.8).65

    • No

    		6 (1.5)4 (1.7)2 (1.1)

    • Missing data

    		3 (0.7)1 (0.4)2 (1.1)
    What is the gender of the physician that normally completes your Pap test?*.20

    • Male

    		67 (16.6)31 (13.5)36 (20.6)

    • Female

    		331 (81.9)194 (84.7)137 (78.3)

    • Unsure

    		1 (0.3)1 (0.4)0 (0)

    • Other

    		5 (1.2)3 (1.3)2 (0.5)
          

    • Both genders

    		4 (80)3 (60)1 (20)
          

    • Male until now

    		1 (20)0 (0)2 (20)
    Thinking about your experience in general of having a Pap test, please rate the following:*
    The procedure was painful.62

    • Not at all

    		83 (20.5)42 (18.3)41 (23.4)

    • Minimally

    		162 (40.1)93 (40.6)69 (39.4)

    • Neutral

    		58 (14.4)34 (14.8)24 (13.7)

    • Moderately

    		88 (21.8)50 (21.8)38 (21.7)

    • Extremely

    		12 (3.0)9 (3.9)3 (1.7)

    • Missing data

    		1 (0.2)1 (0.4)0 (0)
    The procedure was uncomfortable.82

    • Not at all

    		20 (5.0)11 (4.8)9 (5.1)

    • Minimally

    		145 (35.9)88 (38.4)57 (32.6)

    • Neutral

    		29 (7.2)17 (7.4)12 (6.9)

    • Moderately

    		171 (42.3)92 (40.2)79 (45.1)

    • Extremely

    		34 (8.4)19 (8.3)15 (8.6)

    • Missing data

    		5 (1.2)2 (0.9)3 (1.7)
    I was embarrassed.40

    • Not at all

    		151 (37.4)92 (40.2)59 (33.7)

    • Minimally

    		116 (28.8)65 (28.4)51 (29.1)

    • Neutral

    		53 (13.1)26 (11.4)27 (15.4)

    • Moderately

    		64 (15.8)33 (14.4)31 (17.7)

    • Extremely

    		17 (4.2)12 (5.2)5 (2.9)

    • Missing data

    		3 (0.7)1 (0.4)2 (1.2)
    It was time consuming.11

    • Not at all

    		180 (44.6)112 (48.9)68 (38.9)

    • Minimally

    		131 (32.4)75 (32.8)56 (32.0)

    • Neutral

    		36 (8.9)18 (7.8)18 (10.3)

    • Moderately

    		45 (11.2)18 (7.8)27 (15.4)

    • Extremely

    		7 (1.7)4 (1.8)3 (1.7)

    • Missing data

    		5 (1.2)2 (0.9)3 (1.7)
    Have you had a Pap test in the past 3 years?*

    • Yes

    		360 (89.1)204 (89.1)156 (89.1).09

    • No

    		35 (8.7)17 (7.4)18 (10.3)

    • Unsure

    		9 (2.2)8 (3.5)1 (0.6)
    If you answered no, what is your main reason for not having a Pap test in the past 3 years?†.59

    • A Pap test performed by a doctor is/would be embarrassing

    		2 (5.7)1 (5.9)1 (5.6)

    • A Pap test performed by a doctor is/would be too uncomfortable/embarrassing

    		4 (11.4)2 (11.8)2 (11.1)

    • I am not sexually active

    		3 (8.6)2 (11.8)1 (5.6)

    • I don’t know if or when you should have a Pap test

    		1 (2.9)0 (0)1 (5.6)

    • I have not received a reminder to have a Pap test

    		4 (11.4)4 (23.5)0 (0)

    • It is hard to find the time to have a Pap test

    		8 (22.9)3 (17.6)5 (27.8)

    • It is hard to get an appointment

    		4 (11.4)1 (5.9)3 (16.7)

    • It is hard to travel to an appointment

    		1 (2.9)0 (0)1 (5.6)

    • My doctor has not suggested a Pap test

    		2 (5.7)1 (5.9)1 (5.6)

    • Other

    		6 (17.1)3 (17.6)3 (16.7)
    If you answered no, what are your other reasons for not having a PAP test in the past 3 years?†‡.89

    • A Pap test performed by a doctor is/would be too uncomfortable/embarrassing

    		4 (11.4)0 (0)4 (22.2)

    • I don’t/wouldn’t feel comfortable asking for a Pap test from my doctor

    		2 (5.7)0 (0)2 (11.1)

    • I have not received a reminder to have a Pap test

    		3 (8.6)1 (5.9)2 (11.1)

    • I am not sexually active

    		4 (12.5)2 (11.8)2 (11.1)

    • My doctor has not suggested a Pap test

    		5 (14.3)3 (17.6)2 (11.1)

    • I have not received a reminder to have a Pap test

    		4 (11.4)1 (5.9)3 (16.7)

    • I don’t know if or when I should have a Pap test

    		6 (17.1)5 (29.4)1 (5.6)

    • It is hard to get an appointment

    		4 (11.4)2 (11.8)2 (11.1)

    • It is hard to find the time to have a Pap test

    		1 (2.9)0 (0)1 (5.6)

    • Not applicable

    		4 (11.4)2 (11.8)2 (11.1)

    • Other

    		8 (22.9)3 (17.6)5 (27.8)
    If you answered yes, have you heard of HPV testing as a test for cervical cancer screening?§.02

    • Yes

    		208 (57.8)104 (51.0)104 (66.7)

    • No

    		118 (32.8)77 (37.7)41 (26.3)

    • Unsure

    		30 (8.3)20 (9.8)10 (6.4)

    • Missing data

    		4 (1.1)3 (1.5)1 (0.6)

    • HPV—human papillomavirus, Pap—Papanicolaou.

    • ↵* For this question N=404.

    • ↵† For this question N=35, with 17 family practice participants and 18 social media participants.

    • ↵‡ More than 1 response allowed per participant.

    • ↵§ For this question N=360, with 204 family practice participants and 156 social media participants.

  • Table 3.

    Participant knowledge regarding HPV testing options for those who have not had a Pap test in the past 3 years

    SURVEY QUESTION AND POSSIBLE RESPONSESOVERALL (N=35), n (%)FAMILY PRACTICE PARTICIPANTS (n=17), n (%)SOCIAL MEDIA PARTICIPANTS (n=18), n (%)P VALUE
    Based on your current knowledge, do you think HPV testing would be better than Pap testing?.04

    • Yes

    		13 (37.1)3 (17.7)10 (55.6)

    • No

    		2 (5.7)1 (5.9)1 (5.6)

    • Unsure

    		20 (57.2)13 (76.5)7 (38.9)
    Are you aware of the option of self-sampling for cervical cancer screening?.16

    • Yes

    		3 (8.6)0 (0)3 (16.7)

    • No

    		31 (88.6)17 (100)14 (77.8)

    • Unsure

    		1 (2.9)0 (0)1 (5.6)
    Do you agree people with a cervix should be given the option of HPV self-sampling?.66

    • Not at all

    		0 (0)0 (0)0 (0)

    • Minimally agree

    		0 (0)0 (0)0 (0)

    • Neutral

    		2 (5.7)0 (0)2 (11.1)

    • Moderately agree

    		5 (14.3)3 (17.7)2 (11.1)

    • Strongly agree

    		28 (80.0)14 (82.4)14 (77.8)
    In the future, what method would you prefer for cervical cancer screening?.32

    • I’d prefer the provider to take an HPV sample

    		7 (20.0)4 (23.5)3 (16.7)

    • I’d prefer to take my own sample

    		24 (68.6)11 (64.7)13 (72.2)

    • I’d prefer to continue with Pap testing

    		2 (5.7)2 (11.8)0 (0)

    • I don’t know

    		2 (5.7)0 (0)2 (11.1)
    For most people, a Pap test should occur:.63

    • Every year

    		4 (11.4)3 (17.7)1 (5.6)

    • Every 3 years

    		27 (77.1)12 (70.6)15 (83.3)

    • Every 5 years

    		4 (11.4)2 (11.8)2 (11.1)
    I’d prefer cervical cancer screening to occur:.57

    • Every year

    		15 (42.9)9 (52.9)6 (33.3)

    • Every 3 years

    		11 (31.4)4 (23.5)7 (38.9)

    • Every 5 years

    		9 (25.7)4 (23.5)5 (27.8)
    HPV testing is so much more accurate than Pap testing that, for most people, a negative HPV test makes it safe to have an HPV test every 5 years. The risk of over testing is doing the test too often finds many minor abnormalities that correct on their own and can lead to stress and unnecessary treatment. Given this information, I’d prefer HPV testing to occur:.30

    • Every year

    		2 (5.7)2 (11.8)0 (0)

    • Every 3 years

    		7 (20.0)4 (23.5)3 (16.7)

    • Every 5 years

    		26 (74.3)11 (64.7)15 (83.3)
    There is new technology examining the ability to detect HPV in urine (pee) samples. If urine samples have similar accuracy to HPV tests that are collected by swabs, what would you prefer:.85

    • I’d prefer a Pap test

    		0 (0)0 (0)0 (0)

    • I’d prefer a provider-acquired HPV test (clinician uses speculum to obtain cervix swab)

    		1 (2.9)1 (5.9)0 (0)

    • I’d prefer HPV self-sampling (I collect a vaginal swab)

    		10 (28.6)5 (29.4)5 (27.8)

    • I’d prefer giving a urine sample to test for HPV

    		24 (68.6)11 (64.7)13 (72.2)

    • HPV—human papillomavirus, Pap—Papanicolaou.

  • Table 4.

    Participant knowledge regarding HPV testing options

    SURVEY QUESTION AND POSSIBLE RESPONSESOVERALL (N=413), n (%)FAMILY PRACTICE PARTICIPANTS (n=234), n (%)SOCIAL MEDIA PARTICIPANTS (n=179), n (%)P VALUE
    Based on your current knowledge, do you think HPV testing would be better than Pap testing?.03

    • Yes

    		115 (27.8)53 (22.7)62 (34.6)

    • No

    		40 (9.7)28 (11.9)12 (6.7)

    • Unsure

    		251 (60.8)149 (63.7)102 (57.0)

    • Missing data

    		7 (1.7)4 (1.7)3 (1.7)
    Are you aware of the option of self-sampling for cervical cancer screening?.03

    • Yes

    		48 (11.6)20 (8.5)28 (15.6)

    • No

    		343 (83.1)205 (87.6)138 (77.1)

    • Unsure

    		15 (3.6)5 (2.1)10 (5.6)

    • Missing data

    		7 (1.7)4 (1.7)3 (1.7)
    Do you agree people with a cervix should be given the option of HPV self-sampling?.77

    • Not at all

    		3 (0.7)3 (1.3)0 (0)

    • Minimally agree

    		6 (1.5)3 (1.3)3 (1.7)

    • Neutral

    		26 (6.3)14 (5.9)12 (6.7)

    • Moderately agree

    		77 (18.6)41 (17.5)36 (20.1)

    • Strongly agree

    		291 (70.5)167 (71.4)124 (69.3)

    • Missing data

    		10 (2.4)6 (2.6)4 (2.2)
    In the future, what method would you prefer for cervical cancer screening?.06

    • I’d prefer the provider to take an HPV sample

    		141 (34.1)83 (35.5)58 (32.4)

    • I’d prefer to take my own sample

    		191 (46.2)95 (40.6)96 (53.6)

    • I’d prefer to continue with Pap testing

    		27 (6.5)19 (8.1)8 (4.5)

    • I don’t know

    		45 (10.9)31 (13.2)14 (7.8)

    • Missing data

    		9 (2.2)6 (2.6)3 (1.7)
    For most people, a Pap test should occur:<.01

    • Every year

    		76 (18.4)56 (23.9)20 (11.2)

    • Every 3 years

    		309 (74.8)162 (69.2)147 (82.1)

    • Every 5 years

    		12 (2.9)8 (3.4)4 (2.2)

    • Missing data

    		16 (3.9)8 (3.4)8 (4.5)
    I’d prefer cervical cancer screening to occur:.02

    • Every year

    		207 (50.1)133 (56.8)74 (41.4)

    • Every 3 years

    		151 (36.6)72 (30.8)79 (44.1)

    • Every 5 years

    		36 (8.7)19 (8.1)17 (9.5)

    • Missing data

    		19 (4.6)10 (4.3)9 (5.0)
    HPV testing is so much more accurate than Pap testing that, for most people, a negative HPV test makes it safe to have an HPV test every 5 years. The risk of over testing is doing the test too often finds many minor abnormalities that correct on their own and can lead to stress and unnecessary treatment. Given this information, I’d prefer HPV testing to occur:<.01

    • Every year

    		68 (16.5)47 (20.1)21 (11.7)

    • Every 3 years

    		147 (35.6)95 (40.6)52 (29.1)

    • Every 5 years

    		181 (43.8)85 (36.3)96 (53.6)

    • Missing data

    		17 (4.1)7 (3.0)10 (5.6)
    There is new technology looking at the ability to detect HPV in urine (pee) samples. If urine samples have similar accuracy to HPV tests that are collected by swabs, what would you prefer:.55

    • I’d prefer a Pap test

    		8 (1.9)6 (2.6)2 (1.1)

    • I’d prefer a provider-acquired HPV test (clinician uses speculum to obtain cervix swab)

    		63 (15.3)40 (17.1)23 (12.8)

    • I’d prefer HPV self-sampling (I collect a vaginal swab)

    		89 (21.5)47 (20.1)42 (23.5)

    • I’d prefer giving a urine sample to test for HPV

    		237 (57.4)133 (56.8)104 (58.1)

    • Missing data

    		16 (3.9)8 (3.4)8 (4.5)

    • HPV—human papillomavirus, Pap—Papanicolaou.

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Are we ready for human papillomavirus testing?
Praniya Elangainesan, Michelle S. Naimer, Sahana Kukan, Amanda Selk
Canadian Family Physician Jul 2024, 70 (7-8) 479-490; DOI: 10.46747/cfp.700708479
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