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Can you prevent cervical cancer? How do you prevent cervical cancer? Can I check for cervical cancer at home? Who should get screened for cervical cancer? Does the HPV vaccine work?
Our guest is Ritu Nayar, MD, professor of pathology and medical education and executive vice chair of pathology at Northwestern University Feinberg School of Medicine. In this episode, Dr. Nayar talks about where cervical cancer rates are on the rise and how new screening tools can help reverse that trend. AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Ritu Nayar, MD, professor of pathology and medical education; executive vice chair of pathology, Northwestern University Feinberg School of Medicine
Transcript
Dr. Nayar: The HPV vaccine, which when given at the recommended ages, can prevent 90% of cervical cancer. In 2023, only 61% of adolescents were fully vaccinated in the U.S. against HPV. We need to underscore that this vaccine can actually prevent six human HPV cancers.
Unger: Hello and welcome to the AMA Update video and podcast. Today, we're talking about where cervical cancer rates are on the rise and how new screening tools can help reverse that trend. Our guest today is Dr. Ritu Nayar, professor of pathology and medical education and executive vice chair of pathology at Northwestern University Feinberg School of Medicine here in Chicago.
She also serves as the Board of Governors for the College of American Pathologists, also known as CAP. I'm Todd Unger, AMA's chief experience officer. Dr. Nayar, welcome.
Dr. Nayar: Thank you. Todd.
Unger: Well, like many types of cancer we've been talking to physicians about lately, we're seeing an increase in cervical cancer among certain populations. Why don't we just start with a little bit of background about this trend? Where are rates rising?
Dr. Nayar: While the global burden of disease is unfortunately quite high, the U.S., currently at 7.6 new cases per 100,000, is among countries with the lowest incidence rate, which had been relatively stable over the past decade. However, between 2012 and '19, we've seen rates increase by 1.7% each year in women between the ages of 30 and 44. There is good news, however. In women ages 20 to 24, rates have declined by 11% each year, likely reflecting the first signs of prevention from HPV vaccination.
Overall screening compliance is currently estimated at 74%, which means that a quarter of us women are overdue for screening by current national guidelines. An assessment of cancer screening compliance three years after the COVID-19 pandemic showed that, while breast and colon cancer screening rates rebounded and are actually above pre-pandemic levels, for cervical cancer, they remain 14% below 2019 levels.
Cervical cancer incidence and mortality highlights inequities in every part of the world and disproportionately affects low-income and minoritized populations. In the U.S., for example, women living below the federal poverty level are four times as likely to die from cervical cancer. Black women are twice more likely to die compared to white women, and women in rural areas are 25% more likely to be diagnosed and 42% more likely to die. Another disturbing trend that's emerged is higher rates and mortality in women over 65 years, which is the age at which we typically stop screening an average-risk patient.
Unger: It's especially concerning since cervical cancer is largely preventable. So let's talk a little bit about what do you do in a situation where you're seeing those rates rising for the reasons that you discussed?
Dr. Nayar: At the primary prevention level, we have a vaccine to prevent cervical cancer, the HPV vaccine, which when given at the recommended ages, can prevent 90% of cervical cancer. In 2023, only 61% of adolescents were fully vaccinated in the U.S. against HPV. We need to underscore that this vaccine can actually prevent six human HPV cancers.
At the secondary prevention level, screening guidelines, which include the age, the type of testing and the interval of screening, are currently in flux. Management guidelines for abnormal test results have also evolved and are now risk-based and focus on balancing the benefits and harms of screening. So it takes considerable time for providers, labs and patients to understand and then adopt new guidelines. The lack of understanding the rationale for the change, the lack of a centralized EMR and limited clinical decision support makes it difficult for everyone to do less but do better. Therefore, providing education, support and resources at every level is key.
Unger: Well, those are some pretty significant challenges. When you think about those, how in the short term can we make a big change there?
Dr. Nayar: So first, I want to emphasize that screening is not just the initial test. For the approximately 10% to 15% of patients who test positive for a screen test, there must be access to primary care and GYN providers and coverage for additional testing, colposcopy and treatment of precancer to complete the screening process. Traditionally, the screening process required a physician visit, a speculum exam and collection of cervical specimen or pap test.
In 2003, we added HPV testing to increase sensitivity. And currently primary HPV screening is the preferred method after age 25. Self-collection of a vaginal specimen by the patient is an alternate way to provide a sample for doing the primary HPV screen without undergoing a pelvic exam.
So this type of testing, self-collection, has been consistently shown in multiple studies globally to have similar sensitivity to clinician-collected cervical samples and a higher sensitivity than the pap test. In 2024, the FDA approved two self-collection kits for screening in a health care setting. Most providers and laboratories are still getting used to this new test methodology, doing quality control, setting up different workflows. So implementation and practice is just starting.
This year, very recently, the FDA has also approved a new at-home dry swab self-collection device, which will require a clinician order, where the provider will offer virtual medical support. And this will follow a similar workflow, say, for example, as is done for colon cancer at-home screening tests, this is a promising alternative that still needs to be translated into real-world experience.
Unger: That's so interesting that you would say that because as you were talking about these at home tests, I was thinking about a physician I recently spoke to about the home collection kits for colon cancer testing. And it seems very analogous here. With the advent of these at-home tools that will increase access, what impact do you think they'll have on screening rates?
Dr. Nayar: Well, definitely, the home self-collection approval provides increased opportunity for health equity, which is what we all want, expands access, and addresses many personal and logistic issues for women. Other countries with organized screening programs have shown a 2.5 fold increase in screening uptake with mailed self-collection kits. A recent randomized clinical trial out of a safety net system in Houston, Texas, has shown significantly higher recruitment than reported earlier using self-collection mail kits that included a telephone reminder.
Most importantly, the self-collection specimens for screening are dependent on the availability and the use by providers of FDA-approved primary HPV screening. However, currently in the U.S., screening by this method primary HPV is estimated at being less than 5%. So successful implementation of self-collection will require a very structured approach.
The NCI has a funded effort called the SHIP trial, which is a large and very diverse study looking at self-collection at 25 enrollment sites across the United States. This will provide a more representative picture over a very wide spectrum of health system settings, as is seen in the U.S. and enroll geographically and socioeconomically diverse participants and generate independent clinical evidence that will inform the FDA and future practice. The ultimate goal, Todd, here is to increase access to accurate, cost-effective, convenient and less complex approaches to home based self-collection methods that are needed to reach those 25% under-screened and never-screened women in the U.S.
Unger: Well, it sounds like a terrific development with a lot of potential benefits. As physicians look to incorporate tools like these into their practice—I know you were talking about the realities, which are workflows and reminder calls and things like that. Is there anything else that they should keep in mind? And what should patients be aware of?
Dr. Nayar: Yeah, let me focus on just a few key considerations. For physicians, having access to and actually offering primary HPV screening is a prerequisite to be able to offer the self-collection option to their patients. Keeping abreast of the rapidly evolving space of cervical cancer prevention is essential for those providing this preventive service. Many educational resources are available to these providers, including guidance for the use of self-collection and recommendation for managing these results, which do differ from the follow-up of clinician-collected cervical samples.
For patients, it's important to understand first if they are in fact eligible for HPV self-collection. It is only an option for asymptomatic average-risk patients. And patients should also realize the importance of following up on abnormal test results. They should be cognizant of the fact that self-collection does not replace your annual PCP or GYN visit and that no test, however good it might be, is perfect. So be vigilant about your own health.
Unger: Now, I know this is also a topic that CAP is paying close attention to. Can you tell us a little bit more about the work that you're doing in this area?
Dr. Nayar: Yeah, laboratories are a key stakeholder in cervical cancer prevention. The College of American Pathologists' core mission is to advance the field of pathology and lab medicine through education, advocacy and lab quality initiatives. As the global leader in lab accreditation and proficiency testing, the CAP's accreditation program sets rigorous standards to ensure the highest quality in lab testing, which directly impacts patient outcomes.
Detailed checklists that are updated annually by the volunteer expert members are provided by the CAP to guide laboratories in meeting these standards and staying current with evolving practices. Changes pertaining to the new testing for cervical cancer prevention were addressed in 2024, and additional updates will be released later this year.
I've also had the opportunity, Todd, to be working with the American Cancer Society's National Roundtable on Cervical Cancer. And through multi-professional volunteer teams that include patient advocates, we've developed several educational resources to support health systems, labs, providers, patients and payers as they transition to primary HPV screening, including by the self-collection method.
Unger: Well, Dr. Nayar, thank you so much for all of the work that you're doing to support physicians and for joining us today to tell us more about it.
Dr. Nayar: Thank you. In conclusion, I'd like to reiterate that today we have the scientific knowledge and tools to eliminate this cancer by systematically continuing to provide education and access to all stakeholders, while ensuring that both primary and secondary preventive strategies are centered in equity so that no one is left behind.
Unger: Well, thank you. What a great way to summarize our discussion today. And if you found this valuable, you can support more programming like this by becoming an AMA member at ama-assn.org/joinnow. That wraps up today's episode and we'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today and please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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