The challenges of NHS Cervical Cancer Screening

22-28th January marks Cervical Cancer Prevention Week, whereby charities and professional bodies campaign to raise awareness of the importance of cervical cancer screening.

Statistics from Cancer Research UK state that over 3000 new cases of cervical cancer were diagnosed in 2015. Yet when one in four women who are invited for a cervical smear test do not attend, this indicates a growing public health problem.

Is it an issue of perception? A recent BBC news story suggests some women may feel embarrassed about their bodies and be hesitant to attend what may be seen as an invasive procedure, whilst others might be unaware of the need for a test.

Members of the IBMS Cytopathology Advisory Panel are biomedical scientists who are specialists in cytology and advise the IBMS on policy, quality, safety, set exam papers and help develop professional qualifications, were asked to comment.

Kirstie Rice, a Consultant Biomedical Scientist in cervical cytology at New Cross Hospital, explained

“During the last 15 years there has been a gradual decrease in the uptake of cervical screening for the eligible population (25-64) but this has been particularly noticeable in the younger age group (25-49), where the incidence rate of cervical cancer cases is highest. There was a brief period during 2009 where uptake rose dramatically causing laboratory backlogs in reporting samples following the diagnosis and subsequent death of Jade Goody from cervical cancer.

This, however, hasn’t been sustained. Local, national and charity campaigns have all attempted to raise awareness of the importance of cervical screening in women’s health. However, the decline continues. The cervical cancer awareness charity Jo’s Trust report that many young women don’t attend for cervical screening due to being embarrassed of their bodies. 

Could this largely be due to the increasing presentation of images of ‘perfect bodies’ which are unrealistic and not truly representative of many if not any woman’s body in reality?  Lack of education on the importance of cervical screening and perceived discomfort of the procedure are also likely to play a role.

Younger women who have been vaccinated may be even less likely to attend as they may incorrectly perceive the vaccination provides 100% protection from the risk of cervical cancer.”    

Allan Wilson, Senior Chief Biomedical Scientist and Advanced Practitioner in cervical cytology at Monklands Hospital, added:

“There is evidence which shows the high uptake of the HPV vaccine has helped lower the levels of cancer-causing HPV in young women in Scotland by 90%.”

The issues surrounding cervical cancer screening are not only with public perception but also affect laboratory staff conducting the testing in laboratories.

Members of the IBMS Cytopathology Advisory Panel commented on the challenges facing pathologists with cervical cancer screening.

The challenges ahead  

Sue Vryenhoef, a Consultant Biomedical Scientist and Hospital Based Programme Coordinator for cervical screening at Leicester Royal Infirmary, stated:

“Over the next two years the national cervical cytology screening programme will see one of the biggest changes to cervical screening that has occurred since organised screening began in the 1980s. This will be extremely challenging. 

Six laboratories in England have been piloting primary HPV testing since 2013 on some of their population to determine if it should be adopted by the NHS Cervical Cancer Screening Programme (NHSCSP) as the way forward for the programme.

In July 2016 following a review of the available evidence, the UK National Screening Committee recommended that HPV testing should replace cytology as the first stage in cervical screening and NHS England took the decision to implement Primary HPV testing by the end of 2019.

An option appraisal led by Public Health England (PHE) was undertaken to assess how the service change could be delivered safely, effectively and sustainably across England. A number of options were considered and two were recommended, both utilising centralised testing but with different numbers of laboratories. In November 2017 it was announced that there would be 10-13 laboratories for England providing primary HPV testing and cytology screening that will be operational by the end of 2019.”

Allan added that

“A similar process is being undertaken for Wales and Scotland. Wales will be the first of the four nations to change to HPV primary screening in September 2018. Scotland will move from seven laboratories to two by January 2020. All parts of the UK are experiencing similar pressures on staffing levels and turnaround times.

Sue continued:

“There are approximately 50 laboratories in England; therefore 37-40 laboratories will cease to be part of the screening programme by the end of 2019. One of the major challenges in the next two years is how to continue to provide a quality service to the women of England whilst this change is implemented.

Currently many areas of England are not achieving the 14 day national turnaround time and women are experiencing significant delays for their results. The laboratories and PHE are working to try and reduce the waiting times for results but this is difficult and may not be achievable. Maintaining staffing levels will undoubtedly be a challenge because of the uncertainty around which laboratories will be undertaking HPV primary testing.

Every effort will be made during this period to ensure that a quality service is provided and that staff are well supported. To achieve this there may be delays in women receiving results.”

Kirstie concluded,

“There is a huge team of dedicated professionals involved in the provision of cervical screening in the UK from call/recall, primary care, screening laboratories, colposcopy and commissioners all working together with the aim of providing a world-class screening service for women. 

The NHS cervical screening programmes throughout the UK has faced many challenges since 2004 with the introduction of Liquid Based Cytology, HPV vaccination, HPV Triage and test of cure testing, which has resulted in laboratory mergers and a consequential loss of experienced staff.   The move towards roll-out of HPV primary screening has impacted on turn-around times for results due to an accelerated loss of staff from the service and difficulty in recruiting qualified replacement staff. Eighty percent of laboratories in England are now struggling to achieve turnaround time targets.” 

The importance of cervical cancer screening 

It is clear that even with the campaigns to raise awareness of the value of cervical smear testing, more work is required. There is still a pressing need for women aged 25-64 to be made aware of the importance of attending cervical smear tests and to know that the HPV vaccine does not guarantee 100% protection. Equally, the decision to limit the number of laboratories conducting cervical cancer testing means that test result delays may become a regular occurrence, which could further delay diagnoses of female patients with cervical cancer.

Sue said,

“The importance of regular cytology screening is well documented and the delays in getting results back to women should not deter anyone from having a cytology test. Better to have a test and wait for a result than not to participate in the screening programme at all.”

Kirstie added,

“This continuing decline in uptake is a major concern for all involved in this highly effective screening programme which can only continue to be effective if women take up the invitation for screening.”

As a final point, Allan commented,

“There is no doubt that the UK cervical screening programmes are the envy of many countries with their focus on quality standards. The programmes have directly led to a steady decline in incidence and deaths from cervical cancer. This success can only continue if women attend for smears. It is not a coincidence that the most significant risk factor in women who develop cervical cancer is that they have not attended regularly for screening.”

As more women are diagnosed with cervical cancer each year, it is vital to raise awareness of the importance of cervical cancer screening and to encourage women to get tested.

If you are interested in taking part in this campaign, the charity Jo’s Trust has a series of infographics, posters and fact sheets available to download. You can also follow the campaign on Twitter using the hashtag #SmearForSmear.