183 General discussion The story of the Janssens family – The Answers In his search for answers the GP found that it would still be wise for Sarah to participate in the cervical cancer screening programme (CSP). Furthermore, he understands that participating in a CSP can also have some potential harms. He learns that deciding on participation in a CSP is not always an easy choice, and that some people are not capable of deciding on participation, because they lack certain knowledge, or experience certain kinds of (access)barriers. The GP experiences that his role is different between the different programmes and varied over the course of preceding years. The GP’s quest for information yields the following results. For many people cervical cancer is linked to being sexually active. While this is not completely untrue, prominent and persistent misinterpretation of the association may discourage people from attending the cervical CSP.1 Regarding the human papillomavirus (HPV) vaccination campaign, similar effects have been described.2 To a certain extent, Sarah is right that she is less likely to be infected with HPV if she has had one and the same boyfriend for a long time. Nevertheless, the virus may be contracted by her boyfriend long before or during their relationship, wherefore it still would be best for Sarah to get screened on HPV.3 Even if Sarah was vaccinated for HPV, it would be wise for her to participate in the CSP, since vaccinating is not 100% effective.3 Luckily HPV-testing can be done easy and quick via a self-sampling test, which has been validated to be used by every woman and nowadays is seen as an equal alternative,4 or by getting a Pap-smear done at a GP-practice.5 Earlier the Dutch Health Council advised to send the HPV self-sampling test along with the invitation as standard.6 Recently this advice was adopted by the minister of Health. These days only women who are invited for the very first time (at 30 years of age) receive a self-sampling test immediately with the invitation. From the second invitation onwards, women can ask for the self-sampling test, or it will be sent along with the reminder letter after 12 weeks.7 The rationale behind the CSPs is that participation will lead to overall early-stage cancer diagnoses, better treatment options and a better outcomes. The harms of the CSPs are however lesser known; not only by the public, but also by some healthcare providers. 8, 9 Potential harms of attending the CSPs can be best summarized as: (I) overdiagnosis and overtreatment; (II) false-positive screening results; (III) underdiagnosis and undertreatment, caused by a false-negative screening result, and (IV) causing certain physical and psychological side-effects, due to the used screening test(s).10 7
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