In 2021, the Health Council of the Netherlands published an advisory report on improving cervical cancer screening options with recommendations for the further optimisation of the screening programme. Invitations and referrals could be more specific, taking into account the risk profile of a client. Accessibility could be improved by removing barriers and increasing the use of the self-sampling kit. These recommendations have led to a number of new developments for the cervical cancer screening programme.
Use of the self-sampling kit
The self-sampling kit has existed since 2017 when the cervical cancer screening was renewed. The self-sampling kit contributes to promoting the accessibility of the population screening for cervical cancer. In its latest advice , the Health Council advised to strengthen the use of the self-sampling kit and to make the kit available to everyone. The Ministry of Health, Welfare and Sport has adopted the advice of the Health Council, with which the following changes are effective since 3 July 2023: The self-sampling kit is positioned similarly next to the smear test. The invited person decides how to take part: with a smear test or with a self-sampling kit. The methods are equally reliable for detecting HPV.
All 30-year-olds will receive the self-sampling kit immediately with the invitation. They also still have the choice to have a smear taken. All 35-60 year olds will receive an invitation in which the self-sampling kit and the smear are both offered as a method of participation. Invitees can choose whether and how they want to participate. If they do not respond to the invitation, they will receive a reminder after 12 weeks with a self-sampling kit included.
The screening programme aims for high accessibility, with as few barriers as possible. Despite high awareness of the screening programme and a high intent to participate, more than 40% of invited clients do not take part. This is often due to unnecessary barriers or misconceptions. In 2019–2020, a number of studies were carried out into client experiences. These provided a considerable amount of knowledge about clients’ motivations for taking part and the barriers that they experience.
To lower the threshold for participation, the information materials have been improved in order to make them more accessible to people with limited health literacy. Additionally, more specific information has been made available for 30-year-olds, such as a pre-announcement and a separate website.
Changes for 45-/55-/65-year-olds
Starting with the second screening round (January 2022) since the renewal of the screening programme, previous HPV results will be taken into account in the invitation policy. Clients who were 40 or 50 years old in the first screening round and had a negative HPV result will not be invited in the next round (i.e. when they are 45 or 55 years old). On the other hand, clients who were 60 years old in the first screening round and had a positive HPV result, but were not referred, will receive an invitation in the second round at the age of 65.
Clients who did not take part at 40 or 50 will receive an invitation at 45 or 55.
Modified referral policy
Each year, approximately 14,000 participants are referred to a gynaecologist. Clinically relevant lesions (CIN2+) are found in approximately 5,000 of them. However, a large number of them are subsequently referred unnecessarily, leading to unnecessary anxiety, unnecessary healthcare costs and the risk of unnecessary treatment.
In order to reduce the number of clinically irrelevant referrals, it has been decided to change the referral policy based on risk stratification. The following changes are involved:
Use of genotyping whereby:
- HPV 16/18 from a ASC-US is referred to the gynaecologist;
- HPV other from a HSIL is referred to the gynaecologist;
- the advice for HPV other and a ASC-US or LSIL is to repeat the smear test after 12 months for cytological evaluation;
- the timing of the control examination has been changed from six to 12 months.
In 2023, the first HPV-vaccinated cohorts reach screening age and will gradually enter the screening programme. HPV-vaccinated persons will be told that it is still important to participate in the screening programme, despite their previous vaccination against HPV. Communications about this will address questions from this group.
It is likely that the screening strategy for this group will need to be adjusted in the long term. This adjustment will require a recommendation from the Health Council of the Netherlands based on data that are yet to be collected. This includes data on the first vaccinated persons to take part in the screening programme. These data can only be collected from 2023 onwards. An adjustment of the screening strategy for vaccinated persons is therefore not expected before 2028.
Participation of transgender people
The invitations for the screening programme are sent out on the basis of data from the Key Register of Persons. For the cervical cancer screening programme, selection takes place based on gender. A new procedure has been worked out for transgender people or people with an O/X gender registration. They will only have to register once for the population screening. They will then be invited according to the usual screening algorithm.
Strengthened role of the GP
In its recent advisory report, the Health Council of the Netherlands specifically addressed the role of the GP in the screening process. As a result, the Centre for Population Screening is exploring whether it is possible to strengthen this role.
Loss to follow-up
When clients receive a recommendation for follow-up action based on the (partial) results of the screening, they do not always follow up. This puts them at risk of their cervical cancer (or a precancerous stage) not being detected. Loss to follow-up in the programme occurs for the following reasons:
- After a positive HPV result from a self-sampling kit, the control smear test is not performed.
- The invitation for the control smear test after 12 months is not followed up.
- A referral to a gynaecologist is not followed up.
Together with the chain partners, the Centre for Population Screening is investigating the possibilities of reducing the loss to follow-up in the cervical cancer screening programme.
The National Institute for Public Health and the Environment (Ministry of Health, Welfare and Sport) publishes an international newsletter, in which you can read the latest about the Dutch cervical cancer screening programme.
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