HPV screening and follow-up pathway

Invitations and reminders

holding handsKey takeaway: Meeting population needs

HPV primary screening invitations should be tailored to meet population needs and include resources to support participant education and informed decision-making.

While opportunistic recruitment can be common with cytology-based primary cervical screening, HPV primary screening offers an opportunity for jurisdictions to consider a coordinated approach to invitation that could be orchestrated through an organized cervical screening program. Table 1 and 2 below outline available approaches for inviting participants to HPV primary screening: opt-in, opt-out and community-based. Each approach should be weighed based on the specific needs of the community being served:

Table 1: Opt-in and opt-out approaches

Approach Invitations for HPV testing in clinic Direct mailing for HPV testing 
Opt-in approaches Participants are invited to book an appointment with their primary care provider for cervical examination and HPV sample collection or self-sampling in clinic.
Opportunistic recruitment can occur when an individual visits their primary care provider for other health concerns and is eligible and due for screening.
Participants request testing kits, usually after receiving a screening invitation describing the different options for sampling.1
This approach is more cost-effective than opt-out approaches: kits are less likely to be wasted because they will be sent only to those who request them.
Opt-out approaches  Participants are provided a location, date and time for screening within the screening program or a provider invitation. They are then prompted to request a different date and time (or to opt out) if needed.
Finland found that including this information increased participation by 6.6–9.4%.1
Participants are automatically sent testing kits by the screening program with invitation letters. This will reach more people than an opt-in approach, especially under/never-screened populations.1 However, this approach is more costly than an opt-in approach because kits are sent to all eligible participants. It may also result in many unused/unreturned kits.1
Participants who opt out of at-home screening should be invited for in-person screening (if program resources allow).
Providing participants with an opportunity for clinician-based sampling will help eliminate barriers, as participants may opt out because they are not confident with self-sampling.

Table 2: Community-based approaches

Approach Description
Community-based approaches  Some populations may benefit from a conversation with a health or community service provider in a drop-in health clinic, invitations through an Indigenous Friendship Centre, or invitations extended as part of a general wellness or health fair.2
Some individuals may prefer to pick up self-sampling kits anonymously to protect confidentiality and avoid stigma.
Example: A community centre may offer a health or wellness day where patrons can complete HPV primary screening and talk to a service provider about overall wellness.

testing swab and homeRecommendation: Approaches to inviting eligible individuals to participate in HPV primary screening should be informed by community or public engagements.

Key evidence and implementation considerations:

  • Engagement and dialogue with equity-deserving populations is critical when developing and selecting the invitation approaches to increase screening participation.
  • A culturally sensitive approach toward engagement with First Nations, Inuit and Métis communities and organizations should be taken to understand the preferred invitation method as there may not be one singular preferred invitation or collection approach across populations.
  • Jurisdictions should consider seasonal variations and the impact to screening participation. It is important to concentrate efforts to recruit participants when individuals are most able to participate.
    • A screening blitz where specific screening clinic hours are held to maximize volumes may also be considered.
    • Mobile screening, where it exists, may present an opportunity to reach individuals in their community.
  • A combination of different invitation options will help meet people where and when they are ready to screen.

Recommendation: Consider a mixed approach to screening invitations (e.g., emails, text messages, direct mail letters, phone calls) to maximize participation while also balancing effectiveness and cost considerations.

Key evidence and implementation considerations:

  • A mixed approach that leverages mailed letters and manual phone calls, while effective, can also be costly.1,3 Automatic calls, emails or text messages are most cost-efficient, while manual calls have been found to be most effective as they offer a more personalized experience.3
    • Processes should be in place to protect participants’ privacy when leaving voicemails for phone invitations and invitation letters. 1,2,3

Recommendation: Implement reminders for screening invitations and encourage primary care providers to promote screening participation to eligible patients at regular appointments. 

Key evidence and implementation considerations:

  • In Finland, using reminders increased participation by 8% among both the general and equity-deserving populations.1,4 Australia saw a 10% increase in participation among the general population.1
  • Consider individual risk, preferences, values and screening history when setting the frequency of reminders.

patient and doctorInviting unattached participants to cervical screening

Some people who are eligible for cervical screening may not have access to a primary care provider (i.e., “unattached” participants). HPV self-sampling may provide an opportunity for these individuals to participate in screening. Regardless of collection method (clinician or self-sampling), jurisdictions should consider how to reach these participants when developing their invitation methods. They should also ensure participants are connected to a primary care provider, if they do not already have access to one, to support follow-up care.

  1. Canadian Partnership Against Cancer. HPV primary screening and abnormal screen follow-up for cervical cancer environmental scan. 2021. Accessed January 19, 2022. Available from: https://www.partnershipagainstcancer.ca/topics/hpv-primary-screening-environmental-scan/
  2. Access Alliance. Critical discussion report: Reducing inequities in cervical cancer screening among newcomer women via HPV self-sampling. 2022
  3. Lofters A, Kiran T. A tool for healthcare professionals: Improving cancer screening rates in your practice and reducing related disparities. https://maphealth.ca/wp-content/uploads/2019/11/MAP-toolkit-for-health-care-professionals-Improving-cancer-screening-rates-in-your-practice-and-reducing-related-disparities.pdf
  4. Karjalainen L, Anttila A, Nieminen P, et al. Self-sampling in cervical cancer screening: Comparison of a brush-based and a lavage-based cervicovaginal self-sampling device. BMC Cancer.