Clinical yield and operational cost-threshold analysis of HPV self-sampling send-outs for long-term non-attenders in cervical cancer screening: a population-based, real-world, registry study in Sweden
4 affiliations
- 1University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- 2Department of Women’s Health, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- 3Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- 4School of Health Sciences, Örebro University, Örebro, Sweden
Abstract
Objectives: To evaluate the clinical yield and operational costs of a targeted ‘send-to-all’ human papillomavirus (HPV) self-sampling strategy for long-term non-attenders in cervical cancer screening.
Design: Population-based, real-world observational registry study.
Setting: The regional organised cervical cancer screening programme in Region Örebro County, Sweden.
Participants: A total of 9123 women identified as long-term non-attenders. Long-term non-attendance was defined as having no recorded cervical screening test for at least one routine screening interval plus an additional 4 years.
Interventions: A total of 11 283 vaginal HPV self-sampling kits were dispatched via direct mail to the registered home addresses of all 9123 eligible women between 2022 and 2024.
Primary and secondary outcome measures: Clinical yield was evaluated using the number of tests analysed (NTA) and number of kits dispatched (NKD) to detect one case of high-grade squamous intraepithelial lesion or worse (HSIL+). Resource utilisation was measured as the average cost per screened woman/detected HSIL+, and the economic break-even point against standard letter invitations was established using a deterministic threshold analysis.
Results: Of the 11 283 self-sampling kits dispatched, 1826 kits were returned and analysed. This direct response yielded 27 HSIL+ cases (NTA: 68; NKD: 418), at an average cost of 2031 SEK (€183) per screened woman and 134 103 SEK (€12,114) per histologically confirmed HSIL+ case. Incorporating an additional 190 long-term non-attenders who underwent clinical screening within 1 year of dispatch yielded a total of 32 HSIL+ cases. This cumulative response decreased the NTA to 63 and the NKD to 353, with an average cost of 2045 SEK (€185) per screened woman and 126 068 SEK (€11 388) per HSIL+ case. To match the cost per screened woman of the self-sampling strategy, standard letter invitations must achieve a participation rate of 9.5% (based on kit returns alone) or 6.4% (based on cumulative participation).
Conclusions: Direct mailing of HPV self-sampling kits effectively identifies high-grade lesions in a hard-to-reach population. From an operational perspective, previous research indicates that participation from standard letters rarely reaches the calculated 6.4%–9.5% break-even points, suggesting self-sampling is a resource-efficient initial outreach strategy for long-term non-attenders. However, full economic evaluations incorporating long-term health outcomes are required to establish comprehensive cost-effectiveness.
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BibTeX
@article{fridljung2026clinical,
title = {{Clinical yield and operational cost-threshold analysis of HPV self-sampling send-outs for long-term non-attenders in cervical cancer screening: a population-based, real-world, registry study in Sweden}},
author = {Jasmine Fridljung and Lovisa Bergengren and Gabriella Lillsunde-Larsson and Linda Ryen},
journal = {BMJ Open},
year = {2026},
month = oct,
doi = {10.1136/bmjopen-2026-125034},
url = {https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2026-125034},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Clinical yield and operational cost-threshold analysis of HPV self-sampling send-outs for long-term non-attenders in cervical cancer screening: a population-based, real-world, registry study in Sweden
AU - Jasmine Fridljung
AU - Lovisa Bergengren
AU - Gabriella Lillsunde-Larsson
AU - Linda Ryen
PY - 2026
DA - 2026/10/22
JO - BMJ Open
DO - 10.1136/bmjopen-2026-125034
UR - https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2026-125034
AB - Objectives: To evaluate the clinical yield and operational costs of a targeted ‘send-to-all’ human papillomavirus (HPV) self-sampling strategy for long-term non-attenders in cervical cancer screening. Design: Population-based, real-world observational registry study. Setting: The regional organised cervical cancer screening programme in Region Örebro County, Sweden. Participants: A total of 9123 women identified as long-term non-attenders. Long-term non-attendance was defined as having no recorded cervical screening test for at least one routine screening interval plus an additional 4 years. Interventions: A total of 11 283 vaginal HPV self-sampling kits were dispatched via direct mail to the registered home addresses of all 9123 eligible women between 2022 and 2024. Primary and secondary outcome measures: Clinical yield was evaluated using the number of tests analysed (NTA) and number of kits dispatched (NKD) to detect one case of high-grade squamous intraepithelial lesion or worse (HSIL+). Resource utilisation was measured as the average cost per screened woman/detected HSIL+, and the economic break-even point against standard letter invitations was established using a deterministic threshold analysis. Results: Of the 11 283 self-sampling kits dispatched, 1826 kits were returned and analysed. This direct response yielded 27 HSIL+ cases (NTA: 68; NKD: 418), at an average cost of 2031 SEK (€183) per screened woman and 134 103 SEK (€12,114) per histologically confirmed HSIL+ case. Incorporating an additional 190 long-term non-attenders who underwent clinical screening within 1 year of dispatch yielded a total of 32 HSIL+ cases. This cumulative response decreased the NTA to 63 and the NKD to 353, with an average cost of 2045 SEK (€185) per screened woman and 126 068 SEK (€11 388) per HSIL+ case. To match the cost per screened woman of the self-sampling strategy, standard letter invitations must achieve a participation rate of 9.5% (based on kit returns alone) or 6.4% (based on cumulative participation). Conclusions: Direct mailing of HPV self-sampling kits effectively identifies high-grade lesions in a hard-to-reach population. From an operational perspective, previous research indicates that participation from standard letters rarely reaches the calculated 6.4%–9.5% break-even points, suggesting self-sampling is a resource-efficient initial outreach strategy for long-term non-attenders. However, full economic evaluations incorporating long-term health outcomes are required to establish comprehensive cost-effectiveness.
SN - 2044-6055
SN - 2044-6055
ER -