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Turning the tide—Recommendations to increase cervical cancer screening among women who are underscreened

2024; Elsevier BV; Volume: 166; Issue: S1 Linguagem: Inglês

10.1002/ijgo.15600

1879-3479

Philippe Descamps, Samantha Dixon, Francesc Xavier Bosch Jose, Maria Kyrgiou, Joseph Monsonégo, Ody Neisingh, Lananh Nguyen, Mairead O’Connor, Jennifer S. Smith,

Global Cancer Incidence and Screening

Cervical cancer is a largely preventable disease, yet far too many women still die from it. HPV vaccination is a highly effective prevention intervention, but it will take decades for it to offer population-wide protection. In most high-income countries, organized cervical cancer screening programs have been in place for decades and have helped significantly to reduce the incidence and mortality rates of the disease. Despite this success story, participation rates in screening programs remain suboptimal. In Europe, screening participation rates vary hugely between countries—at 80% in some, but as low as 25% in others1—and are stagnant or have declined in some countries in recent years.2-4 Low participation rates in screening programs have a detrimental impact on women's health outcomes. This reality was exacerbated by the global COVID-19 pandemic which led to a further decrease in screening coverage. Women who do not receive regular screening are at higher risk of developing cervical cancer, and when diagnosed, they are more likely to have advanced disease and poorer outcomes.5 It is recognized that there are groups of women who are consistently underscreened due to a wide range of factors including, among others, lack of awareness, lack of access, or cultural beliefs. Empowering women in these groups to take up the offer of screening would deliver both individual health and societal benefits. In light of these challenges, the ACCESS Consensus Group has come together as an international, multidisciplinary expert group to accelerate cross-border collaboration, share best practices, and propose solutions. The present article presents evidence-based recommendations on how to improve outcomes in high-income countries by increasing participation in cervical cancer screening among underscreened women. The goal is to turn the tide and reverse the declines in screening uptake by supporting the underscreened population and ensuring women have optimal access to this vital cancer prevention tool. We urge decision makers to implement these recommendations and save lives. The time to act is now. For the first time we have the opportunity to eliminate a type of cancer. For high-income countries with organized screening and vaccination programs, cervical cancer elimination is a realistic possibility in the coming years. We have the tools to prevent cervical cancer, but low uptake rates of preventative measures mean that we risk going backwards rather than forwards. Screening is the most impactful intervention to reduce the burden of cervical cancer in the short term, but screening participation rates are suboptimal in many high-income countries, and, in some cases, they have been declining. Some of the women on the lowest incomes in the most disadvantaged communities are at the greatest risk from cervical cancer, partly as a result of lower rates of screening participation. Urgent action is needed to address low and declining screening participation rates and to stop women dying from this largely preventable disease. There is a particular need for initiatives targeted at underscreened groups to address this inequity. Develop national action plans for cervical cancer elimination within a defined timeframe, utilizing the WHO's elimination framework. The creation of the ACCESS Consensus Group is a timely and much-needed initiative. The burden of cervical cancer is an issue affecting women globally, and concerted efforts are needed to improve screening rates and reduce mortality worldwide. The establishment of this group of multidisciplinary experts will facilitate international collaboration and sharing of best practices in cervical cancer screening. With the diverse expertise of the members of the group, this initiative has the potential to make significant contributions to improving cervical cancer screening programs and ultimately to reducing the disease burden. Studies show that cervical cancer screening participation has been on the decline in some countries. In the UK, England, for example, has seen a decline over the last 20 years,6 with most recent data showing a decline of 2.3% between 2016 and 2022 in women aged 50–64 years and a decline of 1.1% for the same period in women aged 25–49 years.7 Additionally, a decrease in screening of 6.4% due to the COVID-19 pandemic was observed in 2020.8 Up-to-date screening has similarly declined by 8.6% in the USA (in 2019 compared with 2005, particularly among underserved populations9) and in the Netherlands where screening participation fell by 4% in 2016 after the introduction of a new cervical cancer screening program, and unexpectedly by another 3% in 2017.3, 10 The COVID-19 pandemic has exacerbated this decline in screening and in 2021, Dutch screening participation was still considerably below the 60% observed in 2016.11 Given this concerning international trend in screening uptake, which puts women at increased health risks, the ACCESS Consensus Group has come together to consider cervical cancer screening participation in high-income countries with established cervical cancer screening programs. Group members provide international expertise as well as pertinent insights from their local contexts. Findings and resulting recommendations of the Group are intended to serve the ongoing efforts of policymakers and those involved in planning and delivering cervical cancer screening programs to increase participation rates. Some of the recommendations and best practices in this article may also support ongoing work in low- and middle-income countries (LMICs) where cervical cancer incidence and mortality are the highest. It is envisaged that, as a next stage, the Group will consider the particular challenges faced by these countries and identify solutions that address their specific needs. The ACCESS Consensus Group currently consists of 10 members bringing diverse expertise from across the EU, UK, USA, and Canada—these members are listed in full at the end of this document. In high-income countries, the burden of cervical cancer has been dramatically reduced due to the availability of comprehensive healthcare services, widespread availability of cervical cancer screening, innovation in screening technologies, and vaccination coverage against HPV, the primary cause of cervical cancer. However, cervical cancer still poses a significant health burden in these countries and, in 2022, many women still died from the disease, including 238 in Sweden, 1530 in France, and 5932 in the USA.12-14 These cases are often associated with women who are screened irregularly, or not at all—known as underscreened or non-responders. These women are often among those insufficiently informed about cervical cancer, with limited access to health care or who face barriers to timely diagnosis and treatment. Cervical cancer therefore represents a significant health inequality based on socioeconomic factors, geographic location, and access to health care. Marginalized populations such as ethnic minorities, individuals on low incomes, immigrants, and rural communities are typically at a higher risk of cervical cancer due to lower participation in screening.15 Although this article is primarily focused on high-income countries, it is important to acknowledge that the greatest burden of cervical cancer is in LMICs. Despite ongoing efforts to improve screening and vaccination programs in these countries, there is a need for further support to strengthen health systems and increase access to essential services. The ACCESS Consensus Group will seek opportunities to translate the relevant findings from this article to LMICs, where appropriate and feasible. By adapting the present recommendations to the unique challenges and contexts of LMICs, policymakers, in collaboration with healthcare professionals and patient and women's representatives, can identify strategies that are implementable and effective in improving cervical cancer prevention and treatment in these settings. Cervical cancer screening programs have been in place across the EU, UK, USA, and other middle- to high-income countries since the 1980s and have led to a reduction in cervical cancer rates by up to 80%.16 In Europe, research has shown that women who attend regular screening reduced their chances of dying from cervical cancer by up to 92% compared with those who did not attend screening.5 Once detected, treatment of precancerous lesions is highly effective, and most women treated will not develop cervical cancer.17 As we look at new approaches and solutions to screening, such as self-sampling, a key priority is always to consider the best interests of women, the need for the highest standards of test accuracy, and effective follow-up and treatment. The full continuum of cervical cancer care is vital for optimizing outcomes, improving survival rates, and reducing the burden of this disease. In February 2021, the European Commission published its Europe's Beating Cancer Plan Communication—a forward-looking initiative including a Cancer Screening Scheme to "help EU Member States ensure that 90% of the EU population who qualify for cancer screenings are offered screening by 2025".18 This was reinforced by the 2022 Council Recommendation on strengthening prevention through early detection: A new EU approach on cancer screening.19 Prior to that, in May 2018 the WHO announced a global call for action to specifically eliminate cervical cancer, underscoring a renewed political will to make elimination a reality and calling on all stakeholders to unite behind this common goal. In August 2020, the World Health Assembly adopted the Global Strategy for Cervical Cancer Elimination.20 High-income countries with advanced healthcare systems and prevention programs could be expected to surpass these targets and achieve elimination much more quickly than LMICs, including by reaching a lower cervical cancer incidence than the recommended four per 100 000 women. Since 2020, in response to the WHO's Global Strategy,21 countries including Australia and Canada22, 23 have committed to eliminating cervical cancer. Ireland is also set to define its elimination target in late 2023 and, in the context of a wider strategy on women's health, England has set an ambition to see a future where "almost no one develops cervical cancer".24 There are many high-income countries, however, that are yet to explicitly commit to the goal of elimination of cervical cancer. The ACCESS Consensus Group calls on authorities to use these screening guideline review processes and cross-country collaborations to carefully assess existing best practices and implement measures that will address the current challenges in optimizing participation in cervical cancer screening, particularly among underscreened women. When considering emerging technologies, it is advised to adhere to thorough research and clinical validation, as often required by regulatory authorities, and to ensure feasibility and effectiveness prior to implementation. High-income countries vary in relation to their current screening participation rates.1, 29 Table 1 presents examples of screening participation rates and frequency of screening in a set of high-income countries for which data are available. Age 25–29: every 3 years Age 30–65: every 5 years31 Age 25–29: every 3 years Age 30–65: every 5 years34 Age 25–34: every 3 years Age 35–65: every 5 years37 Age 25–49: every 3 years Age 50–64: every 5 years39 Age 21–29: every 3 years Age 30–65: every 3 or 5 years, depending on test method40 The introduction of HPV vaccination has the potential to significantly reduce the incidence of cervical cancer. Studies have shown that HPV vaccination is highly effective in preventing infection with the oncogenic types of HPV that are most commonly associated with invasive cervical cancer.41 In vaccinated cohorts, therefore, a reduction in the incidence of these types of HPV is expected and has been demonstrated in countries with high rates of vaccination such as the UK and Sweden.42 Vaccination rates vary significantly among high-income countries, however, and in 2019, the average coverage rate of 43 WHO Member States for a first dose in girls was just 50%.43 The full impact of HPV vaccination on cervical cancer incidence will be seen over decades. When combined with regular cervical cancer screening, HPV vaccination has the potential to dramatically reduce the burden of cervical cancer in future generations. However, vaccination alone is not sufficient to prevent all cases of cervical cancer, and regular screening remains critical for prevention and early detection.44, 45 Follow-up after a positive oncogenic (high-risk) HPV test and/or detection of abnormal cervical cell changes is of paramount importance as it allows for appropriate treatment upon indication and ongoing monitoring. It ensures that women receive the necessary interventions to manage their condition effectively and minimize the potential progression of cervical cancer. Treatment of precancerous cervical lesions is also critical in reducing the burden of cancer and improving outcomes for affected women. Treatment options depend on the stage and severity of the precancer or cancer and may include partial cervical excision or resection, hysterectomy surgery, radiation therapy, chemotherapy, or a combination of these approaches. Early-stage invasive cervical cancer is typically more treatable than advanced-stage cancer and, once detected, treatment of precancerous cervical lesions is highly effective.46 In the USA, the 5-year relative survival rate for women with early-stage cervical cancer is 91%, while the 5-year survival rate for women with advanced-stage cervical cancer, when the cancer has spread to other parts of the body, is 19%—highlighting the importance of regular screening and early detection.47 Despite significant advances in screening programs, the rate of participation in cervical cancer screening varies widely between countries and regions.1, 29 Even in countries with relatively high participation rates, women who do not receive regular screening according to national recommendations are at a higher risk of unnecessary disease and death.48, 49 It is common across countries to see inequities in screening rates, with certain populations having lower rates of participation than others. There are many reasons for low participation rates. Some women may decide not to attend screening due to cultural or personal beliefs, concerns about the procedure or outcomes, or simply the lack of awareness of the importance of screening.50, 51 Others may want to attend screening, but face barriers to access such as language, lack of transportation, insurance coverage, chronic health conditions, lack of access to screening facilities, or have caring or work responsibilities.52 Addressing these different challenges requires tailored approaches that consider the specific barriers that different populations may face. It is critical to address the root causes of low participation rates to improve screening uptake. There are also several underserved and/or marginalized populations that are typically underscreened for cervical cancer, and each faces unique challenges in accessing screening. For example, a review of factors—such as sociodemographic, healthcare system, psychological, migration, knowledge, and language and cultural—associated with cervical cancer screening participation among some underscreened migrant women in Europe found that multiple barriers exist and are leading to screening participation lower than that among nationals.69 It demonstrates the need for healthcare services to adapt and strengthen their resources to meet the needs of all underscreened populations. Table 2 presents an overview of some of the underserved groups and the specific issues they are exposed to. Members of the Consensus Group debated the merits of setting universal targets for high-income countries with established cervical cancer screening programs. However, given the variation between countries, including, but not limited to, differential current cervical cancer screening rates, screening modalities, set-up of national screening programs, and available resources and approaches to resource allocation, the Consensus Group does not believe a one-size-fits-all target is appropriate. The Consensus Group recommends that each country develops a cervical cancer national elimination plan targeting elimination by a defined date. In this context, each country should model the impact of increasing screening participation, alongside other prevention interventions, and should set its own locally appropriate targets that represent ambitious yet achievable goals, enabling a significant number of lives to be saved over the coming years. Countries should furthermore conduct a scientific audit of their screening programs to understand potential gaps that need to be addressed. Screening targets should go beyond the headline participation rate and address other key indicators such as equity, testing approaches, screening frequency, and ensuring follow-up treatment and management. Canada represents a best practice example, having set an ambition to eliminate cervical cancer by 2040.23 Its action plan targets a headline screening participation rate of 90% of eligible individuals and an equity target of no less than 80% of eligible individuals in any identifiable group to be up to date with cervical cancer screening. The Consensus Group expressed particular concern about the inequities in screening participation including low rates of participation among lower socioeconomic groups and among certain underserved populations.89 The ACCESS Consensus Group recommends specific targets aimed at improving cervical cancer screening participation among the most underscreened populations. It is common to see lower rates of participation in cervical cancer screening among different demographic groups. Lower socioeconomic groups or those with lower levels of education tend to be underscreened, as do some ethnic minorities. In the UK, for example, evidence shows that women from black, Asian, and minority ethnic backgrounds are less likely to attend screening than white British women. This was found to be due to a range of factors including language barriers and, for older age groups, a belief that their risk of cervical cancer was lower due to sexual inactivity.90 To address the challenge of low rates of cervical cancer screening participation among different social groups, it is essential that policymakers understand the reasons for nonattendance in their communities. If not currently available, research, including a review of existing literature, should be conducted to provide a foundation on which to build effective policy responses. From the results of a mass media education campaign, an Australian study reported a 27% increase in the uptake of cervical cancer screening across all socioeconomic groups.91 A 60-day quality improvement project was carried out in a clinic in the USA where the majority of women attending the clinic were not properly screened for cervical cancer in 2016. Following the project, a total of 87% of women were starting to receive effective care, which consisted of same-day Well Woman Health Care Program enrollment and a same-day Pap test or an appointment to return for a well-woman visit.92 For underscreened women, the Consensus Group placed a particular emphasis on targeted education and information initiatives, co-designed with the underscreened population in question. Initiatives should be adapted according to age, language, ethnicity, gender identity, and culture, and should address barriers or drivers to participation specific to each underscreened group. Additionally, women should be empowered to take control of their own health by providing them with comprehensive information about the importance of cervical cancer screening so that they can make informed choices and actively participate in their own healthcare decisions. The Dutch National Institute for Public Health and the Environment (RIVM) researched nonparticipation rates among Turkish and Moroccan Dutch migrants, which has led to better-tailored information for this group of women, such as simple infographics and video animations in different languages.95 In spring 2023, the Dutch Cancer Society (KWF) and the Dutch Research Council (NWO) financed research that builds upon this prior study, focusing on exploring preferences for self-sampling, urine test, or the original Pap test among this target group. The "See, Test & Treat" program of the College of American Pathologists (CAP) Foundation aims to provide comprehensive healthcare services to underserved women in the USA.96 The program is funded by the CAP Foundation based on grant applications from pathologist-led sites. It focuses on offering free cervical and breast cancer screenings, along with immediate diagnostic results and access to follow-up care. The program is designed to remove barriers that prevent women from receiving timely and essential healthcare services. It targets low-income, uninsured, or underinsured women who may face challenges in accessing health care due to financial constraints, lack of awareness, or other systemic factors. Events are held at local community health centers, hospitals, or clinics, where women receive Pap and HPV testing for cervical cancer screening, clinical breast exams, mammograms, and other necessary tests. The initiative started in 2001 and has completed 107 programs in the period 2011–2021. Lack of accessible screening is one of the main barriers that stops women from getting screened, for instance, due to difficulties in fitting appointments around work and caring commitments. In some cases, problems can be exacerbated by overstretched primary healthcare services including limited availability of appointments. The COVID-19 pandemic also significantly impacted access to screening services. The Consensus Group proposes several different options for improving the accessibility of cervical cancer screening: To specifically increase screening coverage among underscreened individuals, HPV self-sampling has been introduced into some high-income country screening programs.97 In some countries, HPV self-sampling has been introduced not only for underscreened women, but also for the entire screening population, including individuals who have been regularly screened according to schedule, per national screening guidelines.35, 97 Performance of self-sampling for detecting cervical intraepithelial neoplasia (CIN)2+ in high-risk referral populations, and in research settings, has shown similar relative sensitivity compared with cervical cancer screening conducted by a healthcare professional (also known as clinician-collected).98 In contrast, according to the largest population-based, real-world study to date,99 relative detection of CIN2+ with self-sampling has been estimated as low as 76% compared with clinician-collected samples.100, 101 Given current unknowns concerning the risks to women who have previously regularly attended screening appointments who switch to self-sampling,102 such as potential lower follow-up for individuals who received positive HPV self-test results,103-105 sampling by a healthcare professional should remain the preferred option for the majority of women, especially those who regularly attend clinician screening. However, for those women who do not attend cervical cancer screening appointments (e.g. habitual nonattenders), it is considered that self-sampling is undoubtedly better than no screening at all. In the Netherlands, data from the Ministry of Health suggest that self-sampling has so far not led to a significant overall increase in screening participation. In fact, since 2013, participation rates have been on the decline.11, 106, 107 While some research studies in high-risk populations point to the potential of self-sampling to improve screening participation among underscreened women,103, 108 there is a recognition that further research is needed around the implementation of self-sampling in real-world settings to optimize its use as a screening option for underscreened populations.109 Research needs include enhancing sample and workflow parameters to improve the accuracy of self-test results and identifying how to ensure successful follow-up testing after an initial positive HPV self-test.99-101, 110 Reducing the screening interval should also be considered as a potential mitigation for lower test accuracy. Based on currently available evidence, the Consensus Group recommends that self-sampling should be reserved as an option for underscreened women who are habitual nonattenders while further research is being carried out for population-based screening and while implementation challenges are addressed in terms of potential disadvantages for frequently screened women switching from clinician- to self-collection approaches. This research is currently underway in the UK and Ireland.111, 112 As a prerequisite, self-sampling products should also first be approved by regulatory authorities. In 2021, the UK's NHS cervical screening program set up the study HPValidate whose results are expected in December 2023. The study involves people undertaking a self-sample as well as the usual clinician-taken sample when they attend their GP practice for cervical cancer screening. The laboratories test both the self-sample and clinician-taken sample for sensitivity and specificity. The aim of the study is to gather real-world evidence, evaluate the effectiveness of vaginal self-sampling and determine if it could be offered as an alternative option alongside the traditional clinician-taken cervical screening test.113 Good practice projects in assessing self-sampling implementation have been developed in Canada where CervixCheck, the province of Manitoba's cervical cancer screening program, conducted a pilot study to assess whether screening participation could be improved in unscreened women by offering a mailed HPV self-sampling kit.114 Establishing an intentional and fit-for-purpose invitation and reminder system can prove effective in reaching women and increasing participation in cervical cancer screening for underscreened women who are engaged in the healthcare system. Adopting technological solutions can support better accessibility and information around appointments; for example, moving toward email and text invitations and reminders. A randomized controlled trial run in the London borough of Hillingdon found that text message invitation reminders can help increase the number of women taking up the offer of cervical cancer screening. Text message reminders were implemented across all London boroughs between September 2018 and March 2019 and attendance increased by 4.8% over those 6 months—the equivalent of 13 400 more women being screened.115 In the Netherlands, a few weeks before a woman's 30th birthday, the Dutch RIVM mails a pre-invitation postal letter to announce the invitation to screening. The Ontario Cervical Screening Program in Canada sends letters to eligible people inviting them to participate in screening by talking to their primary care physician and reminding participants when it is time for their next screening test (recall letter).116 Providing non-GP locations for screening (including integrating cervical cancer screening with vaccination services) with other women's health services or with sexual health services or nontraditional healthcare settings such as pop-up surgeries in community centers or workplaces should be envisaged. Providers should also consider offering cervical cancer screening appointments at varied times, including weekday evenings or weekends, as a potentially simple fix to avoid clashes with work and other commitments. In Ireland, the health promotion team of the National Screening Service has worked in partnership with the Pavee Point Traveler and Roma Centre to promote cervical screening.118 Pavee Point is a national NGO addressing Traveler and Roma issues and promoting Traveler and Roma human rights. The partnership project engaged directly with the Traveler community to develop initiatives that are culturally sensitive, community-centered and community-led to address primary cancer prevention, early detection, and screening, as well as liaising closely with the health workers within the community. The project is enhanced by the collection of data intelligence to help understand the health needs and barriers of this community. Ontario Health (Cancer Care Ontario) provided guidance in the form of tip sheets to primary care providers and colposcopists to support the screening participation in eligible populations during the COVID-19 pandemic.116, 121 Ontario Health works with regional cancer programs to educate primary care and colposcopy providers on cervical cancer screening recommendations (e.g. screening summary tool, stock decks). Regional cervical screening and colposcopy leads and regional primary care leads provide expertise and education to healthcare providers in each region to support screening participation.116 In Spain, extensive use has been made of e-learning courses that provide up-to-date information on cervical cancer screening and vaccination. Targeted editions of the courses have addressed different groups of healthcare professionals with involvement in preventive practices such as screening programs, gynecology, pediatrics, and GP and public health practices. There is also high circulation of a weekly e-newsletter (HPV World122) with concise results and recommendations from the research and public health fields. As part of sample-taker training and education in Ireland, the Screening Training Unit has developed a series of training events aimed at addressing learning and training needs of sample takers in increasing participation in cervical cancer screening. Topics covered have included increasing participation in cervical cancer screening from a primary care perspective, working with women with intellectual disabilities, assessing barriers and best practice in providing cervical cancer screening to autistic people, supporting the transgender community to participate in cervical cancer screening, LGBT+ awareness for cervical cancer screening, consent, menopause, HPV vaccination, and others. These learning opportunities have provided the space for sample takers to reflect on how they can implement good practice to support different communities in accessing cervical cancer screening.123 In the UK, Pay for Performance (P4P) schemes such as the Quality and Outcomes Framework (QOF) support GPs who are granted payments representing up to 20% of their income for compliance with target indicators set across the spectrum of clinical activity.124 In contrast to most other high-income countries, the USA does not have a national cervical cancer screening program in place that covers the costs of screening. The Consensus Group highlighted that health insurance policies in all countries should cover all available screening options, and programs that provide access to cervical cancer screening to those who do not have health insurance should be available. The Catalan Institute of Oncology (ICO) has invested significant efforts to create modern communication strategies to update healthcare professionals on the novel options for cervical cancer prevention such as via the cervical cancer and HPV program of e-oncologia.126 These materials are being translated into other languages and the platforms are open to collaborate with any interested preventive program. The French patient association "1000 Femmes 1000 Vies" developed an information leaflet entitled "Cervical cancer, Pre-cancer and Papillomavirus infections: why, how and for whom?" to educate women about key facts and figures surrounding cervical cancer and what one can do to prevent it, including highlighting the importance of screening.127 Ireland's roadmap to eliminate cervical cancer was published in January 2023.128 In early 2022, different national authorities established a working group with academics in Australia to develop a model to work toward cervical cancer elimination in Ireland and set Ireland's specific target date to reach this goal. This involves using Irish data, for example, on screening and HPV vaccine uptake, to tailor the model for the Irish population and allow Ireland to set a target date for the elimination of cervical cancer. The outcome will be made public later in 2023.129 The National Screening Service in Ireland is also currently developing a strategic framework to improve equity in screening for cervical, bowel, and breast cancer.130 The framework, which aims to improve women's understanding of what screening is and being able to participate in screening if they want to, is currently in the consultation phase and will be published in 2023. It envisages helping those with the highest risk of poor health, who would benefit most from screening but are often the least likely to participate for various reasons. Addressing the many unfair barriers that can prevent people from engaging with the available screening services is of primary concern. The Canadian Partnership Against Cancer coordinated efforts with a broad group of partners, experts, and stakeholders, including the Public Health Agency of Canada, as well as First Nations, Inuit, and Métis organizations and patients to create the Action Plan to Eliminate Cervical Cancer in Canada, 2020–2030. The Plan includes concrete priorities, targets, and actions, engaging partners across the country in work to eliminate cervical cancer in Canada by 2040.23 In 2021, NHS England launched the YouScreen study, trialing HPV self-sampling in more than 31 000 women in London who were 15 months overdue for their cervical cancer screening.132 As part of the trial, women were able to access a video explaining how to carry out the test at home. GPs, practice nurses, and healthcare assistants were also able to offer YouScreen kits opportunistically to women overdue for their tests. The study aims to find out the best way to offer HPV self-sampling to women who have not responded to their invitation and is the first study of self-sampling in the UK. Study results are yet to be published. Being led by both GPs and gynecologist-oncologists, the study also serves as a good practice example for interdisciplinary collaboration. This article has highlighted many actions that can be undertaken to increase participation in cervical cancer screening and reduce the impact of cervical cancer on women. International collaboration between experts should be intensified to allow for more frequent and much-needed knowledge exchange and best-practice sharing. Policymakers and health authorities should urgently consider the highest impact interventions for their local context to address the devastating impact of cervical cancer and reduce the health inequalities that it creates. The ACCESS Consensus Group looks forward to partnering with stakeholders who share this critical mission. Members of the Consensus Group were initially asked to provide their views on the content of the article via an online survey. The secretariat of the Consensus Group then produced the first draft based on members' feedback and additional desk research. Members of the Consensus Group contributed further to the content by providing written comments to the secretariat. Virtual meetings were also held to inform the content of the paper and discuss and debate the Group's recommendations. An interview was held with one external expert to gather additional insights on cervical cancer elimination modeling and screening targets. Where there were differences of opinion within the Group, the Co-Chairs guided the recommendations based on the majority view and their own expert judgment. All members of the group reviewed and approved the content of the article. The ACCESS Consensus Group expresses its deepest appreciation to Professor Karen Canfell for providing her expert insights during the development of this article. This article was developed with input from all members of the ACCESS Consensus Group, with administrative support provided by the Group's secretariat. The work of the ACCESS Consensus Group is supported by Hologic. Hologic has no editorial control over the content produced by the group. SD reports support from Hologic to attend and speak at patient-advocacy meetings and unpaid participation as Co-Chair of the HPV Coalition. PD was FIGO Vice President from 2021 to 23. FXB reports lecture honoraria from MSD and Editorship of HPW, a weekly newsletter. MK reports various research grants from NIHR, CRUK etc, honoraria from Hologic for lectures, and is Chair of the BSCCP Research Committee. JM reports receiving consulting fees from Hologic and MSD France, plus board participation for MSD France. ON reports receiving consulting fees from WOMEN Inc. LN reports receiving consulting fees and travel support from Hologic, and leadership roles and associated payments from the College of American Pathologists and Accreditation Canada. MO'C reports receiving consulting fees from Hologic. JSS has received research grants, supply donations, and consultancies for Hologic and BD Diagnostics, and supply donations from Rovers Medical Devices during the past 5 years. Samantha Dixon: CEO, Jo's Cervical Cancer Trust, UK. Philippe Descamps: Professor and Chairman, Department of Obstetrics and Gynecology, University Hospital Angers, Vice President of FIGO, and President of International Relations Committee, CNGOF (French College of Obstetricians and Gynecologists), France. Francesc Xavier Bosch Jose: Clinical oncologist, epidemiologist, former Board member of Papillomavirus Society (IPVS), Codirector of HPV Information Center (ICO and IARC), Spain. Anne Connolly: GPSI in gynecology, Royal College of General Practitioners (RCGP) women's health clinical champion, Chair of Primary Care Women's Health Forum (PCWHF), UK. Maria Kyrgiou: Consultant surgeon in gynecology and gynecological oncology, Imperial College London, UK. Joseph Monsonego: Gynecologist-oncologist, President of EUROGIN, President of 1000 Femmes 1000 Vies patient association, France. Ody Neisingh: Independent consultant and public affairs advisor, with extensive working experience at WOMEN Inc. and UN Women, and member of the European Economic and Social Committee on behalf of gender equality civil society, The Netherlands. Lananh Nguyen: Director of Cytopathology and Assistant Professor, Department of Laboratory Medicine, Unity Health Toronto, University of Toronto, Canada. Mairead O'Connor: Research Officer, National Screening Service Ireland, behavioral scientist, Ireland. Jennifer S. Smith: Professor, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, USA. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.