Urine HPV Testing: A Promising Alternative for Cervical Screening -- BAC webinar report

Cervical screening has saved thousands of lives since the NHS programme began, reducing deaths from cervical cancer in the UK by 75% over the last four decades. The move to primary HPV testing in 2019 increased sensitivity and reliability compared with traditional cytology. Yet, uptake remains a major challenge: only 68% of eligible women are screened, leaving an estimated 5 million overdue.

Barriers include the invasiveness of speculum examinations, embarrassment, difficulty accessing appointments, and lack of available healthcare staff. New approaches are urgently needed to increase participation, particularly among under-screened groups.

Self-Sampling: Progress and Limitations

Vaginal self-sampling has been adopted in several countries, offering women privacy and convenience. However, UK trials show limited uptake — only about 13% of non-attenders return a self-sample kit. While sensitivity is comparable to clinician-collected samples, self-swabs cannot be used for reflex cytology, meaning follow-up appointments are still required.

Studies such as the YouScreen trial highlight potential, particularly when kits are offered opportunistically in GP practices, but uptake remains modest.

Urine HPV Testing: The Manchester Studies

Professor Emma Crosbie and her team at the University of Manchester have explored whether urine samples could provide a more acceptable alternative. A pilot study in 2019 suggested that urine testing, when collected with preservatives, performs as well as vaginal and cervical samples in detecting high-grade precancerous lesions (CIN2+). Importantly, women overwhelmingly preferred urine collection.

Key Findings

- ACES Colposcopy Study (465 women): Using a specialised first-void device (Colli-P), urine HPV testing achieved 92% sensitivity for CIN2+ detection, compared with 75% using a standard urine pot.
- ACES Primary Care Study (1,517 women): Urine testing showed 97% specificity compared with matched cervical samples, with performance comparable to, or better than, vaginal self-sampling workflows tested in the UK HPValidate study.

Acceptability

Surveys show women rate urine self-sampling as more private, easier, and less embarrassing than traditional screening. Preferences were strongest among older women, sexual and gender minorities, and those with cultural or personal reasons for avoiding vaginal procedures.

Environmental and Cost Benefits

Urine self-sampling is cheaper and less carbon-intensive than clinic-based screening. Early economic modelling suggests it could significantly reduce NHS costs while also cutting the carbon footprint by up to seven times.

Ongoing Research

The Manchester ACES programme is running several trials:
- ACES At Home: Randomising 10,000 non-attenders to receive either vaginal kits, urine kits, or both, to test uptake.
- ACES Choice: Investigating preferences among minority groups (LGBT+, ethnically diverse communities, survivors of sexual violence).
- ACES 65: Exploring the feasibility of screening women over 65, where early results show HPV prevalence remains significant.
- International pilots: Early work in Kenya is testing feasibility in low-resource settings.

The Future: A Menu of Screening Options

While the UK will introduce vaginal self-sampling for non-attenders from 2026, Professor Crosbie argues for a “menu of choices.” Women could select from clinician-based screening, vaginal self-sampling, or urine testing, depending on their preferences. This flexibility could help address the diversity of barriers and ensure more women are screened in the way that suits them best.

“Urine self-sampling has the potential to be a game-changer, particularly for women who avoid screening due to intimacy or cultural barriers. A choice-based approach may be the key to eliminating cervical cancer as a public health problem.” — Professor Emma Crosbie