BMJ Open · Oct 22, 2026

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

By Fridljung J, Bergengren L, Lillsunde-Larsson G et al.

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.

doi.org/10.1136/bmjopen-2026-125034Open accessPubMed 42914540Interventions