Sisters can do it for themselves

It's the blight of every woman's three-year calendar. The smear test, that dreaded half-hour where we sit with our legs open as someone prods us with a metal speculum like something out of a medieval torture chamber. No surprise then that almost one fifth of women neglect to have smears - and a significant majority choose not to because of the uncomfortable nature of the examination itself.

All women between 25 and 64 are recommended to have a Pap smear test every three years, a gynaecological examination that tests for cell changes in the cervix that may go on to become cervical cancer. The examination itself is straightforward but unpleasant: a metal speculum is inserted into the vagina to hold open the vaginal walls, while the doctor or nurse inserts a spatula to obtain a sample of cells from the cervix. But could the smear and its invasive speculum soon be a thing of the past?

The case for self-sampling, where women do a test at home without the need for a speculum, is slowly gathering momentum. Research published in the US last month suggested that self-testing may provide an alternative to cervical testing by a clinician for detecting the human papilloma virus (HPV), which causes almost all cases of cervical cancer. Meanwhile this month, in South Africa, a biotechnology company has launched the first DIY smear test on the market - not only is it said to be just as effective as the Pap smear but can be done in the comfort and privacy of the woman's own home. Could self-sampling be used here?

Cancer Research scientists are attempting to find out. "We all know that women hate to have smears and of the certain proportion that don't turn up for smears at all, a fair number don't turn up because they hate the examination itself," says Dr Anne Szarewski, clinical consultant at Cancer Research UK. "We thought that if you could do a test at home in your own bathroom, it would be much less stressful and hopefully appeal to the women at the moment who are too scared to go for tests."

The aim of the study is clear: to assess whether women would find self-sampling a more acceptable procedure. According to Szarewski, studies so far have exclusively focused on the effectiveness of DIY kits without taking into consideration the very real anxiety and discomfort that the present method with its invasive speculum can cause. This study, which is due to be completed in the middle of next year (04), is the first study of self-sampling which not only compares the effectiveness of self-sampling to clinical HPV tests and the existing Pap smear, but looks at the psychological element too: how do women feel about each of these different methods?

Of course the idea that women dislike the smear test is hardly a revelation. Although the NHS Cervical Screening Programme's target that 80 per cent of eligible women are screened is being reached overall, the uptake is not consistent throughout the population. Women in inner-city areas are not attending in high levels, as well as women from certain ethnic groups who that feel being examined by men is culturally unacceptable. Another problem with the current smear is the anxiety caused by the high incidence of "false positives". Because the smear detects cell changes, and not cervical cancer itself, there are a huge amount of women who are detected to have "cell abnormalities" who turn out not to have cervical cancer. Research has shown that women with positive smear results experience high levels of anxiety, fear about cancer, and concerns about physical attractiveness and sexual function.

With experiences like this, it is hardly surprising that more women are choosing to stay away and bin their smear invites. So why hasn't self-sampling been considered before? "The problem with HPV self-testing is that of the little research that has been done, the results have varied hugely," says Szarewski. "This is largely because different studies have used different methods with varying results, which makes it hard to draw definite conclusions. Our study is the first that has tested women using the kit on their own. So far previous studies looked at women using the kit while in the presence of the nurse, which we think defeats the whole object."

So how would the test work? Methods vary depending on the study; they include a cytobrush and even a special tampon, but the Cancer Research kit consists of a cotton swab being inserted into the vagina to obtain a sample, and then dipped into a tube. The sample is then sent to a laboratory where it is tested for HPV. Exponents say that not only would the system be cheaper and easier to manage, cutting down on the need for trained clinicians, but it could also be done less often than the smear - potentially every five or six years.

Other scientists are less sure. Henry Kitchener, professor of gynaecological oncology at the University of Manchester, is one HPV expert who has doubts. "Given the fact that obtaining samples specifically from the cervix is crucial, I doubt whether someone using the test at home could be as accurate as a trained clinician. If you just insert a device to pick up HPV, you can't be sure where it's coming from - it could be from around the vulva and not the cervix." Other critics say that more research into HPV testing is neededbefore they consider self-sampling. One complication of testing for HPV is that the virus is sexually transmitted, which could make positive testing doubly traumatic.

"The main issue is to investigate whether HPV testing can be used as a primary screening tool instead of the smear," says a spokesperson for the NHS Screening Programmes. "HPV testing is very accurate and sensitive and will pick up large numbers of women who have the virus but won't go on to get cervical cancer. The HPV virus is very prevalent, particularly in young women - it is estimated that 80 per cent of us have had the virus at some point. In most cases it is harmless and will go away of its own accord, but some women receiving a positive HPV test may feel very anxious. We need to look at how this will be handled."

So, far from removing anxiety, self-sampling could actually increase the likelihood of "false positives"? Professor Peter Sasieni of cancer epidemiology at Queen Mary College, University of London doesn't think so. For one thing, self-sampling would only be used on women over 35 who have a much lower chance of having the virus. For another, the existing smear has almost as high a rate of "false positives". "Yes, the number of false positives with HPV testing is higher than with the smear," explains Professor Sasieni. "But if you add the fact that 70 per cent of smears are inadequate and have to be repeated within two months, HPV testing should, overall, cause less distress than the existing smear."

The main issue would be to educate women about the virus, that having a positive HPV test doesn't mean you have cervical cancer. Besides, he says, if performed on women aged over 35, around 90 per cent will test negative. Those who are HPV positive will have a one in three chance of getting cervical cancer. "One of the good points of HPV testing is that unlike the smear, when it tests negative it really is negative. We have all heard about women who have had negative smear tests and gone on to develop cervical cancer."

For fans of self-sampling, the benefits are clear: to coax in women who otherwise might avoid screening. Says Professor Sasieni: "At the end of the day, self-sampling can encourage women who are not currently having smears to be screened. This has to be an improvement." So, is it goodbye to the speculum and hello to the cotton swab? To smear-haters everywhere - keep your fingers crossed.