Transitioning from Cytology to HPV Test-Based Primary Cervical Screening in Canada: A Population-Based Survey of Women’s Screening and Information Preferences

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

My main point of concern is the fact that the paper is of interest solely to the Canadian readership (given that international/european guidelines differ from the Canadian ones) and the international readership may thus not profit from the implementation of these study results. As such, I would suggest submission to a Canadian national journal. 

 

Author Response

Reviewer 1:

My main point of concern is the fact that the paper is of interest solely to the Canadian readership (given that international/european guidelines differ from the Canadian ones) and the international readership may thus not profit from the implementation of these study results.

Response. We thank the reviewer for this comment. Respectfully, we note that while the study is grounded in the Canadian context, the ultimate goal of population-based cervical screening programs is to maximize participation; therefore, understanding women’s preferences is essential for developing carefully designed, effective communication and implementation strategies. From this perspective, we believe the manuscript addresses questions of broad relevance to organized screening programs internationally and is well aligned with the scope and readership of Current Oncology.

Reviewer 2 Report

Comments and Suggestions for Authors

Tatar et al. have conducted a Canada-wide, web-based survey (Aug–Sep 2022) to quantify women’s preferences for key design and delivery features of the planned transition from cytology-based screening to primary HPV testing, comparing adequately screened (n=1778) and underscreened (n=1570) participants. Using Best–Worst Scaling for trade-offs in screening modality/interval and screening initiation age, plus ranking analyses (Plackett–Luce) for information sources, provider type, and communication channels, they report strong overall preferences for co-testing, starting screening at age 21, and 3-year rather than 5-year intervals; underscreened participants show comparatively higher preference for HPV self-sampling and for gynecologist-based sampling. Across groups, respondents prefer receiving screening invitations/reminders/results by email (and distrust social media as an information source), and the authors conclude that current implementation plans (later start age and longer intervals) are misaligned with women’s stated preferences, supporting the need for targeted public and clinician education and scalable self-sampling strategies to support equitable uptake. 

The claims are properly placed in the context of the previous literature. The experimental data support the claims. The manuscript is written clearly enough that most of it is understandable to non-specialists. The authors have provided adequate proof for their claims, without overselling them. The authors have treated the previous literature fairly. The paper offers enough details of methodology so that the experiments could be reproduced.

Comments

1. The wording in the Introduction seems inaccurate/unclear. The manuscript states that “European guidelines recommend HPV testing as the sole primary screening method, starting at age 25 for HPV-positive individuals or 30 for average-risk populations, and explicitly advising against cytology-based programs”. This is internally inconsistent (you cannot define “HPV-positive individuals” before offering HPV-based screening) and misrepresents the guideline logic. European guidance recommends HPV detection as the primary screening test in organised programmes, discourages initiating new cytology/co-testing programmes (and recommends transition of existing programmes), and provides a conditional suggestion that programmes may start HPV-based screening at age 25 (vs 30) provided effective triage strategies are in place for HPV-positive individuals.

If the authors want to argue for starting at 25 years, they should cite the guideline’s conditional recommendation and explicitly describe the need for triage (e.g., genotyping/cytology/other risk-stratification), rather than framing 25 years as applicable only to “HPV-positive individuals”. If they additionally wish to discuss implementation options when starting at 25 years, they may note that triage and risk stratification (including partial/extended genotyping) become more important because HPV prevalence is higher at younger ages and unnecessary colposcopy referrals should be avoided.

2. In countries that introduced school-based HPV vaccination programmes around 2007–2010 and achieved high coverage, cervical cancer incidence in women <30 years has declined markedly in recent years. This supports that initiating routine cervical screening before age 30 may be of limited added value in such settings, and that starting primary HPV-based screening at age 30 can be reasonable where vaccination coverage is high and programme performance is strong.

Falcaro, M.; Castañon, A.; Ndlela, B.; et al. The effects of the national HPV vaccination programme in England, UK, on cervical cancer and grade 3 cervical intraepithelial neoplasia incidence: A register-based observational study. Lancet 2021, 398, 2084–2092. https://doi.org/10.1016/S0140-6736(21)02178-4

Lei, J.; Ploner, A.; Elfström, K.M.; et al. HPV Vaccination and the Risk of Invasive Cervical Cancer. N. Engl. J. Med. 2020, 383, 1340–1348. https://doi.org/10.1056/NEJMoa1917338

Palmer, T.J.; Kavanagh, K.; Cuschieri, K.; et al. Invasive cervical cancer incidence following bivalent human papillomavirus vaccination: A population-based observational study of age at immunization, dose, and deprivation. J. Natl. Cancer Inst. 2024, 116, 857–865. https://doi.org/10.1093/jnci/djad263

Falcaro, M.; Soldan, K.; Ndlela, B.; Sasieni, P. Effect of the HPV vaccination programme on incidence of cervical cancer and grade 3 cervical intraepithelial neoplasia by socioeconomic deprivation in England: Population based observational study. BMJ 2024, 385, e077341. https://doi.org/10.1136/bmj-2023-077341

3. The Introduction highlights implementation challenges when switching from cytology-based to HPV-based screening (e.g., Australia/UK). While these experiences are relevant, the framing may overemphasize resistance and could be balanced by acknowledging settings where implementation has been largely smooth and widely accepted in routine practice (e.g., Norway). In Norway, primary HPV screening was introduced as a randomized pilot in 2015 (women 34–69 years: HPV testing every 5 years vs cytology every 3 years; women 25–33 years continued cytology). After approximately three years, randomization stopped and HPV testing every 5 years was adopted for all women 34–69 years. National roll-out to ages 25–69 followed in 2023, and extended genotyping was implemented in 2025. Norway has not recommended routine screening for women <25 years. I suggest revising this section to distinguish (i) initial public debate/petitions from (ii) the feasibility of operational implementation and long-term programme acceptance, and to include examples of successful transitions to avoid an overly negative or one-sided depiction.

Nygård, M.; Engesæter, B.; Castle, P.E.; Berland, J.M.; Eide, M.L.; Iversen, O.-E.; Jonassen, C.M.; Christiansen, I.K.; Vintermyr, O.K.; Tropé, A. Randomized Implementation of a Primary Human Papillomavirus Testing-Based Cervical Cancer Screening Protocol for Women 34 to 69 Years in Norway. Cancer Epidemiol. Biomarkers Prev. 2022, 31, 1812–1822. https://doi.org/10.1158/1055-9965.EPI-22-0340

Bjørge, T.; Engesæter, B.; Skare, G.B.; Tropé, A. CervicalScreen Norway – A Screening Programme in Transition. Norsk Epidemiol. 2022, 30. https://doi.org/10.5324/nje.v30i1-2.4978

Hashim, D.; Engesæter, B.; Baadstrand Skare, G.; Castle, P.E.; Bjørge, T.; Tropé, A.; Nygård, M. Real-World Data on Cervical Cancer Risk Stratification by Cytology and HPV Genotype to Inform the Management of HPV-Positive Women in Routine Cervical Screening. Br. J. Cancer 2020, 122, 1715–1723. https://doi.org/10.1038/s41416-020-0790-1

Andreassen, T.; Hansen, B.T.; Engesæter, B.; Hashim, D.; Støer, N.C.; Tropé, A.; Moen, K.; Ursin, G.; Weiderpass, E. Psychological Effect of Cervical Cancer Screening When Changing Primary Screening Method From Cytology to Human Papillomavirus Testing. Int. J. Cancer 2019, 145, 29–39. https://doi.org/10.1002/ijc.32067

4. The Introduction repeatedly presents co-testing (cytology + HPV testing) as a relevant “screening modality” and highlights women’s preference for co-testing. However, co-testing is not supported as a primary screening strategy in organised population-based programmes because it adds little (if any) sensitivity compared with HPV testing alone while reducing specificity and increasing unnecessary follow-up (e.g., more false positives/colposcopies), thereby worsening the benefit–harm balance. European recommendations explicitly advise against co-testing for primary screening and recommend transitioning existing cytology/co-testing programmes to HPV-based screening.

I suggest that the authors either (i) remove co-testing as a “preferred option” framing in the Introduction, or (ii) clearly distinguish “stated preference” from “evidence-based recommended strategies,” and explicitly note that co-testing is generally not recommended for primary HPV screening implementation. In other words, a preference–policy mismatch is only meaningful if the preferred option is a realistic, evidence-supported policy alternative; co-testing largely is not.

European Commission, Joint Research Centre; European Commission Initiative on Cervical Cancer (EC-CvC). European Guidelines on Cervical Cancer Screening and Diagnosis; European Commission: Brussels, Belgium, 2025.

Kim, J.J.; Burger, E.A.; Regan, C.; Sy, S. Screening for Cervical Cancer in Primary Care: A Decision Analysis for the US Preventive Services Task Force. JAMA 2018, 320, 706–714. doi:10.1001/jama.2017.19872.

Das, S.; Wentzensen, N.; Sawaya, G.F.; Egemen, D.; Locke, A.; Kinney, W.; Lorey, T.; Cheung, L.C. Primary Human Papillomavirus Testing vs Cotesting: Clinical Outcomes in Populations with Different Disease Prevalence. J. Natl. Cancer Inst. 2024, 116, 1525–1529. doi:10.1093/jnci/djae117.

Schiffman, M.; Kinney, W.K.; Cheung, L.C.; Gage, J.C.; Fetterman, B.; Poitras, N.E.; Lorey, T.S.; Wentzensen, N.; Befano, B.; Schussler, J.; Katki, H.A.; Castle, P.E. Relative Performance of HPV and Cytology Components of Cotesting in Cervical Screening. J. Natl. Cancer Inst. 2018, 110, 501–508. doi:10.1093/jnci/djx225.

5. I suggest revising the structure of Section 4.3. The current heading (“Strengths, limitations, and implications”) leads into a mixed paragraph that combines strengths/limitations with broader implementation implications and recommendations. For clarity and conventional manuscript structure, I recommend restricting Section 4.3 to “Strengths and limitations” only, and moving the “implications” content (practice/policy recommendations) to a separate “Implications” subsection or integrating it into the Discussion. In addition, the manuscript would benefit from a short, standalone Conclusions section that succinctly restates the main findings and their relevance to HPV-based screening implementation in Canada.

Minor revisions

Lines 2-4, Title, "Transitioning to Primary HPV-Based Cervical Screening in Canada: A National Survey of Women’s Screening and Communication Preferences"

Lines 23-35, Simple summary, "In Canada, the Pap test, used for decades for cervical screening, is being replaced by primary Human papillomavirus (HPV) testing, which can detect precancer more sensitively and allows longer screening intervals. To support this transition, we conducted a national survey to understand women’s preferences for screening methods, starting age, screening intervals, and how screening information should be communicated. Women in both adequately screened and underscreened groups preferred co-testing (Pap plus HPV testing), starting screening at age 21, and screening every three years rather than every five years. Participants also preferred receiving screening invitations, reminders, and results by email rather than postal mail. Underscreened women expressed relatively higher preference for HPV self-sampling and were more likely to prefer receiving screening from a gynecologist than from a family physician. These findings suggest that successful implementation of HPV-based screening in Canada will require clear, evidence-based information for the public and clinicians, equity-focused options such as self-sampling, and modernized, user-preferred communication channels to support acceptance and participation."

Lines 37-57, Abstract, "Background: Canada’s cervical cancer elimination goals are challenged by suboptimal screening participation and a reported increase in cervical cancer incidence over the past decade. Cytology-based screening is being replaced by primary HPV testing, which has higher sensitivity for detecting precancer and supports later initiation and longer screening intervals. Public knowledge gaps and negative attitudes toward HPV testing may limit acceptance of these changes. Methods: We conducted a national web-based survey using Best–Worst Scaling (trade-off utilities) to quantify preferences for screening test modality, age of initiation, and screening interval, and assessed preferences for information sources, provider type, and communication methods. Underscreened individuals were oversampled. Results: Among adequately screened (N = 1778) and underscreened (N = 1570) participants, preferences favored co-testing (cytology plus HPV testing), initiating screening at age 21, and 3-year rather than 5-year intervals. Underscreened participants showed relatively higher preference for HPV self-sampling and, compared with adequately screened participants, preferred screening by a gynecologist rather than a family physician. Across groups, participants preferred receiving screening-related information and communications by email over postal mail. Conclusions: Women’s stated preferences currently diverge from key elements of planned HPV-based screening implementation (initiation age and interval). Successful transition will likely require clear, evidence-based public and clinician education, equity-focused implementation strategies that support self-sampling where appropriate, and modernized, user-preferred communication channels to promote acceptance and participation."

Lines 464-487, Strengths and limitations, "A key strength of this study is the use of Best–Worst Scaling, which elicits trade-offs and provides a more discriminating assessment of preference strength than conventional single-item or multiple-choice questions. The large, pan-Canadian sample and purposeful oversampling of underscreened individuals strengthen external validity for screening-eligible populations and address an important evidence gap for implementation planning.

Several limitations should be considered. First, the survey was administered online, which may under-represent individuals with limited internet access or lower digital literacy; however, given that 95% of Canadian adults had internet access and over 70% owned smartphones by 2022, the magnitude of this bias is likely modest. Second, despite the large overall sample, the study was underpowered for robust inference within smaller subgroups (e.g., Indigenous and gender-diverse participants), underscoring the need for adequately powered, participatory work with these communities. Third, preferences were elicited without providing detailed information on current guidelines or the evidence base (e.g., rationale for later initiation age and longer screening intervals with HPV testing). While this approach captures “unvarnished” preferences, it also means that responses may partly reflect familiarity with prior cytology-based messaging rather than informed preferences under an HPV-based programme. Finally, stated preferences in a survey context may not fully predict real-world screening behavior once HPV-based screening and communication strategies are implemented and public and clinician education has occurred."

Lines 488, Conclusions, "This national survey shows that Canadian women’s stated preferences for cervical screening currently diverge from key elements of HPV-based screening implementation, particularly regarding later initiation age and longer screening intervals. Preferences were strongest for more frequent screening, earlier initiation, and—among many respondents—co-testing, while underscreened women expressed comparatively greater acceptability of self-sampling and a preference for specialist-based sampling and digital communication. These findings indicate that successful transition to primary HPV screening will require clear, evidence-based public and clinician education, culturally adapted and equity-focused implementation strategies, and modernized, user-preferred communication channels to support acceptance, participation, and sustainable program delivery across Canada."

 

Author Response

Reviewer 2:

The authors have provided adequate proof for their claims, without overselling them. The authors have treated the previous literature fairly. The paper offers enough details of methodology so that the experiments could be reproduced.

Response. We thank the reviewer for their positive feedback on our manuscript.

The wording in the Introduction seems inaccurate/unclear. The manuscript states that “European guidelines recommend HPV testing as the sole primary screening method, starting at age 25 for HPV-positive individuals or 30 for average-risk populations, and explicitly advising against cytology-based programs”. This is internally inconsistent (you cannot define “HPV-positive individuals” before offering HPV-based screening) and misrepresents the guideline logic. If the authors want to argue for starting at 25 years, they should cite the guideline’s conditional recommendation and explicitly describe the need for triage

Response. We thank the reviewer for their careful reading and agree with this concern. The present study does not seek to advocate for a specific screening initiation age. We have revised p. 3, lines 107-108 in the introduction to clarify the European guidelines.

Evidence from highly vaccinated populations suggests that screening before age 30 may be of limited value.

Response.  We thank the reviewer for this suggestion. We have incorporated this evidence on p. 3-4, lines 142-152.

While [highlighting implementation challenges] are relevant, the framing may overemphasize resistance and could be balanced by acknowledging settings where implementation has been largely smooth and widely accepted in routine practice (e.g., Norway).

Response.  We have revised the Introduction to highlight the successful long-term transition and acceptance of HPV-based screening programs in Norway. See p. 3-4 lines 142-152.

A preference–policy mismatch is only meaningful if the preferred option is a realistic, evidence-supported policy alternative; co-testing largely is not.

Response.  We thank the reviewer for this important observation. We have revised the Introduction to explicitly distinguish women’s preferences from evidence-based screening recommendations and to clarify that co-testing is not recommended as a primary screening strategy in organised population-based programs, see p. 4 lines 181-185.

Section 4.3 should be restricted to strengths and limitations, with implications moved elsewhere, and the manuscript would benefit from a standalone Conclusions section that succinctly restates the main findings and their relevance to HPV-based screening implementation in Canada.

Response.  We thank the reviewer for this helpful structural recommendation and have revised the manuscript accordingly. Section 4.3 has been revised to focus exclusively on strengths and limitations. Section 5 Conclusion has been added to include a brief summary of our findings and the implications of the study. See p. 15, lines 519-533.

Minor revisions:

Response. We thank the reviewer for these helpful suggestions. We have incorporated these revisions where feasible in the Simple Summary (p. 1, lines 23–29), Abstract (p. 2, lines 47–66), Strengths and Limitations (p. 15, lines 512-533), and Conclusion (p. 15, lines 535-540), while being mindful of journal word limit constraints.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors,
Your analysis based on a population-based survey of women’s screening and information preferences in Canada is of interest and will undoubtedly be valuable to readers. In my opinion, the manuscript is very well written. I have only a few minor comments for consideration. I also suggest considering whether some sections could be shortened, for example Section 4.1, Preferences for screening modality, interval, and initiation age.

I also recommend adding a brief Conclusion section after the Discussion section. I recommend reconsideration of the manuscript after minor revision.

 

 

Another comments

 

 

Lines 72-73

…. , implement HPV primary screening ….

Comment: You are correct that the term “HPV test” is commonly used. However, it would be more accurate to replace “HPV test” with “high-risk HPV (hrHPV) test.” Alternatively, you should at least clarify what is meant by an HPV test and specify which types of HPV are being tested.

 

Methods

Comment: You could also state in the Methods section that you followed the relevant guidelines. (i.e. name the specific guideline and cite it in your text). 
https://www.equator-network.org/reporting-guidelines/

The checklist from the relevant guideline should also be submitted as supplementary material.

 

 

Results

Comment: You could create and add Figure showing the flowchart of participant enrollment

 

Lines 422-423

Studies, including our own, have found that many women doubt their ability to self-sample (41, 73).

Comment: The results of your questionnaire-based study should be discussed and compared more thoroughly with findings from other studies, rather than being presented using only general statements.

Author Response

Reviewer 3:

Your analysis based on a population-based survey of women’s screening and information preferences in Canada is of interest and will undoubtedly be valuable to readers. In my opinion, the manuscript is very well written.

Response.  We thank the reviewer for their positive feedback on our manuscript.

I also suggest considering whether some sections could be shortened, for example Section 4.1, Preferences for screening modality, interval, and initiation age.

Response.  We thank the reviewer for this observation. Providing additional context enables readers to better understand our study and its findings.

You are correct that the term “HPV test” is commonly used. However, it would be more accurate to replace “HPV test” with “high-risk HPV (hrHPV) test.” Alternatively, you should at least clarify what is meant by an HPV test and specify which types of HPV are being tested.

Response.  We thank the reviewer for this clarification. We have revised the text to specify “high-risk HPV test–based primary screening” and clarified our use of the term “HPV testing” accordingly (p. 2 line 83).

I also recommend adding a brief Conclusion section after the Discussion section.

Response.  We have now included a Conclusion (Section 5). Please see p. 15, lines 535-551.

You could also state in the Methods section that you followed the relevant guidelines. (i.e. name the specific guideline and cite it in your text). 

Response.  We thank the reviewer for this suggestion. We have revised section 2.1 (p. 4 lines 197-198) to state that the study was reported in accordance with the STROBE guidelines for cross-sectional studies, and we have added the completed STROBE checklist as an appendix.

You could create and add Figure showing the flowchart of participant enrollment.

Response.  We thank the reviewer for this suggestion. We have added a flowchart of participant enrollment as Figure 1.

The results of your questionnaire-based study should be discussed and compared more thoroughly with findings from other studies.

Response.  We thank the reviewer for this suggestion. We have revised this statement to reference our previous findings and explicitly compare our previous findings with extant literature. Please see p. 14, lines 467-471.

Reviewer 4 Report

Comments and Suggestions for Authors

This well composed communication study is apparently part of a larger research project aimed at understanding psychosocial correlates of Canadian women’s intentions to participate in HPV test-based primary cervical screening (lines 163-164), ultimately aiming to shape education interventions for cervical screening-eligible individuals in Canada.

Introduction

Lines 99-107: These strikingly different screening algorithms among Canadian provinces outline a complex background, posing per definition several practical and communication issues. Furthermore, Canada has a diverse population, affecting health priorities, perceptions & public awareness.

Lines 108-9: By and large, evidence in HPV primary screening is heavily influenced by cost effectiveness considerations. Eligible citizens’ viewpoints & preferences are crucial to achieving participation. Please do consider that in settings with organized primary HPV screening utilize validated HPV platforms, whereas unfortunately in settings with opportunistic screening, utilization of non-validated HPV assays is commonplace.

Lines 116-118: Very insightful consideration.

Line 143: Preference policy mismatches in cervical screening implementation are evident in several countries globally, not only in Canada. These mismatches are even more pronounced in settings where guidelines are shaped factoring cost-effectiveness priorities.

Materials & Methods

Section 2.1, Line 161: Presumably recruitment by Dynata abided by GDPR considerations.

2.2. Measures: Did any of the question fields diversify on HPV-vaccination status? There is good evidence that vaccinated individuals might warrant less intensive screening; some Italian prefectures are in various states of implementation of different screening algorithms. Furthermore, in several studies non-vaccinated individuals default health care provider cervical screening while showing a preference for vaginal or urine self-sampling approaches.

2.2. Measures & 2.3. Statistical analysis: Well-composed and descriptive, addressing the basic principles of Best-Worst Scaling (BWS) methodology & the concept of utility trade-offs. However, because of the technical complexity and terms, it is possible that some readers will miss full comprehension.

Discussion

Lines 391-3: Apparently, it is not only women’s lack of preparedness, but also physician’s lack of preparedness too, especially in the context of a national setting with different screening algorithms across neighboring provinces. The authors address this concern later, in lines 432-3.

4.1. Preferences for screening modality, interval, and initiation age Line 400; “response rooted in decades of messaging indicating that more frequent screening saves lives”; quite plausible assumption.

4.2. Preferences for information sources, providers, and communication methods: Genuinely interesting findings overall. Lines 447-451: Is there any role for Canadian provincial colposcopy clinics in delivering HPV testing-even in the context of self-sampling?

4.3. Strengths, limitations, and implications Lines 480-483; A very insightful comment and promising strategy.

Hopefully these study’s in-depth findings will help inform policymakers to enhance implementation effectiveness, especially for underscreened women in Canada.

Author Response

Reviewer 4:

These strikingly different screening algorithms among Canadian provinces outline a complex background, posing per definition several practical and communication issues. Furthermore, Canada has a diverse population, affecting health priorities, perceptions & public awareness.

Response. We appreciate the reviewer’s observation. Substantial interprovincial variation in cervical screening programs and diverse population highlights the need for clear and context-specific communication for HPV test-based screening in Canada.

Please do consider that in settings with organized primary HPV screening utilize validated HPV platforms, whereas unfortunately in settings with opportunistic screening, utilization of non-validated HPV assays is commonplace.

Response.  While the distinction between validated and non-validated cervical screening methods is important, our analysis focuses on the transition from cytology-based to HPV-based screening in a country that mostly has organized programs. As such, we believe that issues related to assay validation in opportunistic screening settings fall outside the scope of the present manuscript.

Preference policy mismatches in cervical screening implementation are evident in several countries globally, not only in Canada. These mismatches are even more pronounced in settings where guidelines are shaped factoring cost-effectiveness priorities.

Response.  We agree with this important observation. In the introduction, p. 3 lines 138-140, we describe the challenges that the UK and Australia faced during their transition to HPV test-based screening. We now specify that both “public attitudes and preferences often lag behind evidence-based policy…” (p. 3, line 139). Our team’s pilot work in Canada is presented as a country-specific example that provides the foundation for the present study.

Presumably recruitment by Dynata abided by GDPR considerations.

Response.  We thank the reviewer for this point. As this study was conducted in Canada, recruitment by Dynata complied with applicable Canadian privacy and data protection standards, and ethical approval was obtained from the Research Ethics Board of the CIUSSS West-Central Montreal.

Did any of the question fields diversify on HPV-vaccination status? There is good evidence that vaccinated individuals might warrant less intensive screening

Response.  We thank the reviewer for this observation. HPV vaccination status was not used to stratify analyses in this study because North American cervical screening recommendations do not differentiate screening algorithms based on vaccination status.

Canadian Cancer Society. 2024. When should I be screened for cervical cancer?

https://cancer.ca/en/cancer-information/find-cancer-early/get-screened-for-cervical-cancer/when-should-i-be-screened-for-cervical-cancer

Centers for Disease Control and Prevention. Reducing Risk for Cervical Cancer. https://www.cdc.gov/cervical-cancer/prevention/index.html

2.2. Measures & 2.3. Statistical analysis: Well-composed and descriptive, addressing the basic principles of Best-Worst Scaling (BWS) methodology & the concept of utility trade-offs. However, because of the technical complexity and terms, it is possible that some readers will miss full comprehension.

Response.  We thank the reviewer for this observation. We have provided examples of survey questions and specified the R packages used to support transparency and reproducibility of the study, and we remain available for readers to contact us should further clarification be needed.

The reviewer provides positive feedback on the Discussion and notes that several points are well addressed (lines 391, sections 4.1, 4.3).

Response.  We thank the reviewer for their positive feedback and thoughtful assessment of the Discussion.

Is there any role for Canadian provincial colposcopy clinics in delivering HPV testing-even in the context of self-sampling?

Response.  We appreciate this thoughtful suggestion. We have revised section 4.2 to include colposcopy clinics, see p. 14, lines 497.

Reviewer 5 Report

Comments and Suggestions for Authors

Dear Authors,

this study analyzes women’s preferences regarding available cervical screening methods, the age of screening initiation, and the intervals between screenings in Canada. The current landscape of screening practices in Canada is highly heterogeneous across different districts, and the nation is currently managing the transition to primary HPV screening.

Initially, I questioned the utility of this study. In large-scale public health programs - and cervical cancer screening is certainly one of the most extensive - individual choices and population satisfaction should not necessarily dictate timing, starting age, or the type of methodology used. However, I have come to realize that the ultimate goal is to encourage as many women as possible to participate in screening. Therefore, understanding their preferences is essential for developing carefully designed strategies to communicate more effectively.

The attention paid to "underscreened" women and their specific needs - which often differ from the general population - is particularly interesting and valuable.

The results align with expectations: individual preferences were higher for co-testing (cytology and HPV test), starting at age 21, and three-year intervals (lines 48-50). It must be noted, however, that these preferences remain partially unfeasible from a policy and economic standpoint.

Regarding Table 1, I personally would not have included the option of "Cervical cancer screening with both the Pap test and the HPV test every 10 years." This strikes me as an excessively "cheap" option with an interval that is likely too long to consistently detect high-grade dysplastic lesions. I noted, however, that the participants did not favor this option.

While starting screening at age 21 is highly desired by the respondents, it may be considered excessive by clinical standards; nevertheless, it is a significant finding regarding patient sentiment.

The data showing that underscreened women prefer HPV self-sampling is very compelling (lines 145-146). As it removes key structural and psychosocial barriers, it is highly likely that global health efforts will move in this direction in the future.

While reading the manuscript, I had concerns regarding potential bias in the administration of the online questionnaire. However, the authors' response is convincing: “given that 95% of Canadian adults had internet access and over 70% owned smartphones by 2022, this bias is likely modest (lines 468-469)”.

There appears to be a typo at line 131: "The same studied showed that higher." This should likely be corrected to "The same studies showed..."

In conclusion, the manuscript is useful, well-written, and addresses important questions for the readership. It deserves to be published in its current form.

Author Response

Reviewer 5:

I have come to realize that the ultimate goal is to encourage as many women as possible to participate in screening. Therefore, understanding their preferences is essential for developing carefully designed strategies to communicate more effectively.

Response.  We thank the reviewer for recognizing the importance and goal of our manuscript. 

The results align with expectations: individual preferences were higher for co-testing (cytology and HPV test), starting at age 21, and three-year intervals (lines 48-50). It must be noted, however, that these preferences remain partially unfeasible from a policy and economic standpoint.

Response.  We thank the reviewer for this key observation. We have revised the introduction to explicitly distinguish women’s preferences for co-testing from policy options. See p. 4, lines 181-185.

There appears to be a typo at line 131: "The same studied showed that higher." This should likely be corrected to "The same studies showed..."

Response.  We have corrected this typo on p. 4, line 165.

In conclusion, the manuscript is useful, well-written, and addresses important questions for the readership. It deserves to be published in its current form.

Response.  We thank the reviewer for their very positive evaluation of the manuscript.