Self‐collected Pap smears may provide an acceptable and effective method of cervical cancer screening

Abstract Background and aims The role of the Papanicolou (Pap) smear in the early detection and prevention of cervical cancer is well established. However, many women fail to undertake the test because of embarrassment or other reasons. To address this problem, we evaluated the feasibility of implementing self‐sampling of cervical cytology as an alternative to clinician‐collected Pap smears and compared it with the gold standard of colposcopy in terms of specificity. Materials and methods A prospective preliminary study of 40 women recruited from the colposcopy clinic of a tertiary referral hospital was undertaken. Participants were instructed in the technique of self‐sampling and asked to collect their own Pap smears. Colposcopic examinations were performed and biopsies taken, if indicated. Clinician‐collected Pap smears were performed 4 weeks later. Pairwise agreement was calculated between the outcomes of self‐collected, colposcopic, and clinician‐collected samples using the weighted κ statistic. Results Self‐collected Pap smear had a high level of acceptability among the women, all of whom were able to collect adequate tissue. The agreement of self‐collected Pap smears with colposcopic assessment was no worse than that of clinician‐collected Pap smears (Cohen's κ statistic 0.54 [95% CI, 0.27‐0.82]; cf 0.49 [0.2‐0.78], respectively). The specificity of self‐collected Pap smears was almost identical to that of clinician‐collected samples (specificity: 86% vs 81%, respectively). Direct comparison between patient and clinician collected Pap smears showed fair agreement (κ statistic 0.38 [0.07‐0.68]). There were no adverse events in either group. Conclusions Self‐collection of Pap smears is an effective and acceptable alternative to clinician‐collected samples and may provide a strategy for improving compliance with cervical testing programs.

the sample was collected by introducing a cervibroom into the endocervix. The self-collected and the physician-collected specimens were sent for analysis to the same laboratory on the day of collection.
A pathologist, blinded to the method of collection, reviewed the cervical cytology. The results of the cervical cytology collected, and both reports, were reviewed by the investigators following the review, to ascertain the extent of agreement or disagreement between the results of the patient-collected Pap smear with that collected by the clinician. Squamous abnormalities were classified according to the Australian modified Bethesda AMBS 2004 into the following 4 categories: "negative," "low grade squamous intraepithelial lesion" (LSIL), "high grade squamous intraepithelial lesion" (HSIL), and "squamous carcinoma." Any abnormality confirmed by colposcopy was managed according to NHRMC Guidelines. 13 Pairwise agreement between the numbers of abnormalities identified by self-collected, colposcopic, and clinician-collected samples, and 95% confidence intervals were computed. Chance-corrected agreement was assessed by weighted κ statistics. 24 A κ value of above 0.8 was taken to indicate "very good agreement"; between 0.6 and 0.8, "reasonable agreement"; 0.4 and 0.6, "moderate agreement"; 0.2 and 0.4, "fair agreement"; and less than 0.2, "poor agreement." 25 Calculations were performed using SAS version 9.3.

| RESULTS
A total of 40 women participated in the study. One woman was  Table 1, and pairwise comparisons are presented in Table 2. Importantly, no high-grade abnormality identified from clinician-collected or colposcopic samples was missed by the self-collected sampling.
The overall agreement between detection of any abnormality of the self-collected Pap smear with that collected by a clinician was "fair"  While geographic location was not a significant variable, participation rates varied markedly across socioeconomic groups, ranging from 52% among women from low socioeconomic to 63% in higher socioeconomic areas. 2,13 The proven effectiveness of the cervical screening smear program, combined with the nonparticipation rate of around 40%, suggests the need for novel methods to increase screening coverage. 7 This study suggests that self-sampling might have a role to play in this process. 3 All the participants in this study found the technique of self-sampling acceptable, comfortable, and easy to learn. Many women may prefer a test that can be performed by the woman herself, if necessary in the privacy of her own home. [3][4][5][6]9,22 Self-sampling may also obviate known obstacles to participation in screening, such as embarrassment or discomfort within the clinical relationships.
For our study, we used cervibroom, a standard brush used in gynecology clinics. There have been few other devices like solopap, dacronswabs, and digene conical collection used for this test as well. 19,20,35,36 The cervibroom is already used for pap smears and comes at no extra cost; it is also easy to use. The most important difference is that with cervibroom-collected samples, a liquid-based cytology slide can be made if required. All of these facts make it potentially a better device to use. It is also true that the difference in HPV prevalence between the self-collected and clinician-collected sampling was not significantly different from 0, regardless of the sampling devices and diagnostic methods used. 19 Our findings show that the agreement of the results of self-sampling with the gold standard of colposcopically guided sampling is no worse than that of physician sampling. In addition, the specificity for the detection of abnormalities of self-sampling and clinician sampling are very similar. Accordingly-at least in the cases of women otherwise disinclined to undergo sampling at all-self-sampling would seem to be an acceptable and effective alternative that might be recom-