In June 2016 the BC Cancer Agency released updated recommendations for cervical cancer screening.[1] The age to initiate cervical cancer screening has increased to 25 years, and the routine screening interval has increased from 2 to 3 years. This is consistent with changes being made globally in response to clinical evidence demonstrating that screening in younger women is ineffective and is an unnecessary burden on health care systems. The updated screening recommendations are strongly supported by provincial leadership; however, these new guidelines may have unintended consequences if they lead to a delay in engagement in health care for young women under 25 years of age.

Screening for sexually transmitted infection (STI) has traditionally been offered concurrent with cervical cancer screening in young women. By starting cervical cancer screening at a later age there would likely be decreased STI screening rates among young women in BC. This trend was observed in Ontario by Bogler and colleagues,[2] where a 60% decrease in Pap testing was seen, along with a 50% decrease in screening for chlamydia and gonorrhea, following updated cervical cancer screening guidelines. The current Canadian Guidelines on Sexually Transmitted Infections recommend STI screening for any patient who reports risk factors for infection.[3] Key components captured in the STI risk assessment are sexual activity, number of partners, contraception use (including condoms), STI history, presence of symptoms, pregnancy history, and substance use. Young people, particularly women under the age of 25, experience high rates of STIs, especially gonorrhea and chlamydia, with the latter having its highest overall rates in this group.[4,5] It is critical that health care providers find alternative ways to ensure STI screening is offered to at-risk women in the absence of cervical cancer screening.

Opportunities for STI screening among young people

Primary care providers should offer STI risk assessment and screening to sexually active women under the age of 25 at all clinically appropriate encounters, consistent with Canadian guidelines,[3] and the BC Lifetime Prevention Schedule.[6] Ideal opportunities to perform an STI risk assessment and STI screening are when young women consult health care providers for contraceptive advice, reproductive health, sexual health, human papillomavirus (HPV) vaccination, or family planning.

Beyond the need for health care providers to encourage screening, there are opportunities for public health to promote engagement. The BC Centre for Disease Control (BCCDC) provides provincial leadership and guidance around STI clinical service delivery. This includes STI treatment guidelines, monitoring disease rates and trends provincially, as well as ongoing evaluation of access and uptake of STI screening. The BCCDC is committed to enhancing access to sexual health and STI screening in the province through low-threshold clinics, anonymized testing, effective use of electronic medical records, innovative service delivery models such as GetCheckedOnline (https://getcheckedonline.com), text message reminders for screening, and online tools such as the SmartSexResource (http://smartsexresource.com).

Programs should also consider opportunities afforded by innovative and novel interventions that improve access to screening, including self-collection, where participants can take their own sample at home using a swab that can be sent by mail for STI screening. A recent systematic review demonstrated that self-collected sampling for chlamydia and gonorrhea through home-based screening had similar sensitivity and specificity when compared to clinician-collected samples.[7] Self–collection based screening is not intended to replace routine clinical care; however, it is a highly acceptable and effective alternative for those who are unable or unwilling to undergo a clinical examination.

Though the new recommendations for cervical cancer screening in BC will allow women to continue receiving optimal, evidence-informed care, it is important to ensure that potential gaps in care—such as missed opportunities for STI screening—are mitigated. Under the provincial leadership of the BCCDC and the BC Cancer Agency’s Cervical Cancer Screening Program, primary health care providers can be key partners in ensuring that at-risk women continue to be screened for STIs.
—Dirk van Niekerk, MD
—Troy Grennan
—Gina Ogilvie, MD

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This article is the opinion of the BC Cancer Agency and has not been peer reviewed by the BCMJ Editorial Board.

References

1.    BC Cancer Agency Cervical Cancer Screening Program. Cervical cancer screening policy change: Frequently asked questions. 2016 reference guide supporting healthcare professionals in communicating screening information to patients. Accessed 8 August 2016. www.bccancer.bc.ca/screening/Documents/CCSP_GuidelinesManual-CervicalCancerScreeningPolicyChangeReferenceGuide.pdf.

2.    Bogler T, Farber A, Stall N, et al. Missed connections: Unintended consequences of updated cervical cancer screening guidelines on screening rates for sexually transmitted infections. Can Fam Physician 2015;61:e459-466.

3.    Public Health Agency of Canada. Canadian guidelines on sexually transmitted infections. Accessed 8 August 2016. www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/index-eng.php.

4.    Public Health Agency of Canada. The Chief Public Health Officer’s report on the state of public health in Canada, 2013: Infectious disease—the never-ending threat. Sexually transmitted infections—a continued public health concern. Accessed 10 August 2016. www.phac-aspc.gc.ca/cphorsphc-respcacsp/2013/sti-its-eng.php.

5.    BC Centre for Disease Control. STI in British Columbia: Annual surveillance report 2014. Accessed 10 August 2016. www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/STI/STI_Annual_Report_2014-FINAL.pdf.

6.    Office of the Provincial Health Officer. Lifetime prevention schedule. Accessed 25 August 2016. www2.gov.bc.ca/gov/content/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/current-health-topics/lifetime-prevention.

7.    Lunny C, Taylor D, Hoang L, et al. Self-collected versus clinician-collected sampling for chlamydia and gonorrhea screening: A systemic review and meta-analysis. PLoS One 2015;10:e0132776.