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bottaro: new cervical cancer screening guidelines still fail to consider the other small but significant minority
the new hpv-focused cervical cancer screening continues to forget about the 3 to 8 per cent of cases that have nothing to do with hpv. so, is this really progress?
5 minute read
cervical cancer guidelines continue to test only for hpv-related cancers, showing that screening is still not where it should be.
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when i had my most recent cervical cancer screening, i was made aware of some changes to the procedure. instead of checking for cancerous or pre-cancerous cells using a pap smear, the guidelines in ontario have been changed to screening only for human papillomavirus (hpv).
because the majority of cervical cancer cases are caused by hpv, this new technique appears, at first glance, an adequate unit of measure to help people catch cancer early so that it can be treated effectively.
however, being privy to the fact that between three and eight per cent of cervical cancers are hpv negative, i had to ask: why has the screening changed to just hpv, and what happens to those who develop cervical cancer without a positive hpv result?
her answer? i don’t know.
while i don’t fault my family physician for being unaware of the procedures in those rare cases, the answer left me wanting. what does happen to those women who develop cervical cancer, but believe that they’re in the clear because their hpv result told them so?
from one faulty screening to another
while guidelines for pap smears have varied from province to province, we used to be told to start getting a pap test every three years beginning at age 21 if you are sexually active. of course, if abnormal cells were present or people fell into higher-risk categories, yearly or bi-yearly testing was required.
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however, changes have already begun in this process to facilitate the switch from pap to hpv testing. british columbia and prince edward island adopted the new screening method for cervical cancer in 2024 and 2023, respectively. other provinces, including ontario, which revised its guidelines in march of this year, have also begun following suit.
but why the change?
according to cancer care ontario, hpv testing is now used because the pap smear only looked for cell changes, whereas the new hpv testing route looks for hpv types that cause cervical cancer. it’s supposed to be better at detecting cancer and pre-cancer cells when compared to pap smears and can help produce fewer false negative results, according to the ontario college of family physicians. other reports indicate that it enhances access to care, improves patient comfort and promotes equity.
however, the test doesn’t directly test cells in the cervix for all types of cervical cancer, much like the pap smear, but rather the dna of high-risk hpv. if the result is negative, you’re sent on your way until your next round of testing. but what if the cells in your cervix have become pre-cancerous, but hpv’s not the culprit?
these parameters, which are being hailed as a step in the right direction, aren’t improved for everyone. so, why are they switching up new guidelines while still being fully aware that they’re missing an entire group of potential cancers, a group of people who almost always fall into the poor-prognosis category?
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new screening guidelines put people at risk
roughly 1,550 canadians will get cervical cancer each year. if you look at this from a statistics perspective, that means a minimum of 46 people will develop the disease without hpv being the cause each year. on the higher end, that number is 124.
this is all based on averages, of course, so those numbers aren’t exact, but the point is that neither of those values is 0.
in the grand scheme of things, people may say that’s not a lot of cases or people. but tell that to the one person who has stage four terminal cervical cancer because they didn’t have it detected earlier. the fact of the matter is, even one missed cancer diagnosis is too many.
it wouldn’t be as big an issue switching over to guidelines that completely ignore non-hpv-related cancers if the symptoms of cervical cancer screamed, but they don’t. they’re barely a whisper.
for example, when cells turn pre-cancerous, that’s the best time to catch the disease. they can be removed, and the cancer never develops. but those changes don’t cause symptoms at all.
now, the disease develops, the cells are multiplying, and the person now has stage 1 cervical cancer. their symptoms? non-existent, for the most part. if they do appear, they are non-specific in nature.
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they can include abnormal vaginal bleeding, menstrual changes, vaginal discharge, pain during sex, and pelvic or lower back pain—all of which, let’s face it, could be several different things. but typically speaking, these symptoms aren’t likely to begin until after the cancer has spread beyond the cervix. by then, for some, it’s too late.
no attempt to close the gap
the current gap in screening acts as a recipe for disaster for a small, albeit equally important, group of people. are these new guidelines a result of tunnel vision in the medical community? or is it just all about dollars and cents?
the hpv test, after all, is more cost-effective in the long term. but it also has a higher sensitivity, allowing people to go longer periods between tests.
but even so, when making progress, isn’t the idea to actually make a change as opposed to looking at the same view but with a new, slightly sharper lens?
both pap smears and hpv screening tests are beneficial for the majority, and if hpv tests improve access to care and lead to earlier diagnosis, then i’m all for it. but when the minority of rare cervical cancer cases and the people that they affect are being forgotten, i wouldn’t call this a step in the right direction. at best, it’s nothing more than a side shuffle.
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after all, when compared to other screening tests for various types of cancer, the cause is often left out of the equation. they look for precancerous cells or early-stage tumours. so, why can’t that same approach be used for cervical cancer?
it appears that people aren’t willing to allocate resources to creating a catch-all cervical cancer screening program because it’s only three to eight per cent. people lack interest in the underdog of cervical cancer.
but what about those people who develop it and their families? what about the other three to eight per cent?
i hope one day someone will have a good answer. but until then, they will remain a forgotten group at the mercy of late-stage cancer treatment.
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