Is the cervical cancer screening programme improving outcomes for women?
The cervical cancer screening programme means women aged 25-64 years of age are invited for regular screening under a call and recall method. What this means is that women in this age range are regularly called for cervical testing. Since May 2013, that has also included testing for HPV (Human Papilloma Virus – most usually associated with cold sores on the lips).
If the sample taken from the cervix is HPV negative, the woman concerned is simply recalled for another test in three to five years’ time.
If a sample is found to be HPV positive however, the sample is then examined by a scientist known as a cytologist to see if there are any abnormal cells. If there are, the woman is called back for further investigation. If abnormal cells are treated early enough, they can be prevented from developing into cervical cancer. No abnormalities after a HPV positive screen means that a woman is called back 12 months later for further checking.
The stated aim of cervical screening is to detect abnormalities within the cervix that could, if undetected and untreated, develop into cervical cancer.
So what are the positives of the cervical screening programme as of 2018-19?
The results of the programme showed many positives for women in England. There was a 0.5% increase in the number of women aged 25-64 years old adequately screened, and a 7.7% increase in the number of women aged 25-64 years who were tested. Whilst these may sound like small increases, they represent many thousands if not millions of women who are being screened and tested for cervical cancer on a regular basis.
Not only this, but the “Cervical Screening Saves Lives” campaign, intended to increase the awareness of screening and to encourage women to attend for regular screening, launched in March 2019 and is expected to improve the screening figures in 2019-2020.
Furthermore, the programme saw the following improvements:
- Percentages of the results showing a higher-grade abnormality decreased with age – it was 2.2% for women aged 25-29, falling to 0.3% for women aged 60-64 years;
- The proportion of inadequate samples, resulting in call back of women for that reason alone, has fallen since 2004-2005 from 8.9%-2.3%;
- For women who have abnormal cells which are further investigated, the laboratories reporting upon those further samples are monitored carefully, and where results fall outside of specified ranges reasons for that are investigated;
- 1% of women with abnormal cervical cells which are further investigated, result from the cervical screening programme;
- There was a 1.9% increase in the number of women with suspected high grade abnormal cells, being offered an appointment for further testing and treatment within 2 weeks.
So what are the negatives of the cervical screening programme as at 2018-19?
It’s not all good news though. Whilst there have been some laudable improvements in screening for cervical cancer, there are a number of negatives that have come out of the review of the programme.
First of all, despite an acceptable performance level being 80% coverage, only 72% coverage was achieved in England; the lowest of the four UK nations. In fact, no local authority in the whole of England reached the acceptable level. Coverage was also lowest in the younger age groups, 25-29 year olds had only 62%, and in London it was only 64.6% across all age groups.
Even after the initial screening, the percentage of lab tests completed within two weeks of a sample being taken actually fell to under 62%. Between 2011 and 2017 this level had been above 90%. The reason given was that HPV screening takes more time, reducing capacity for testing.
Furthermore, despite a target of 98%, only 48.4% of women received their results within two weeks of a sample being taken. Not only have they missed the target by a mile, but the percentage actually decreased by 10% compared to the previous year, and since 2015-16 has decreased from 89%. The problem here is a reduced workforce, meaning that there is reduced screening capacity and a subsequent increase in the time it’s taking to produce the results.
Perhaps most worrying, once a referral was deemed necessary there has been a 2.5% decrease in the number of women offered an appointment within two weeks of this happening – down to 38.1%. There was also a 3.7% decrease in the number of women offered an appointment within four weeks of referral – down to 65.6%. More worrying still, in 0.4% of cases, the time from referral to appointment was over 12 weeks.
Worst of all, In 0.5% of cases, women had still not received their test results within 12 weeks.
What does this tell us about the state of cervical screening?
The aims of the cervical screening programme remain as good as they ever were – to try and reduce the number of women who develop cervical cancer. Unfortunately the high point of cervical screening – the “Jade Goody” effect – around 2011-12 is over and, as so often happens, the aims and vision of the screening programme are not matched by appropriate management including funding which has caused a raft of issues.
First of all, it would appear that cervical screening is still something of a “postcode lottery” in screening, and of particular concern is the reduced coverage in London where arguably potentially more high risk, age group women for cervical abnormalities are located. The very low coverage in the very young is also of particular concern.
There has also been a failure of cause and effect planning in the screening programme – the introduction of primary HPV screening, which has put the service under strain, was not matched with increased funding to provide the necessary personnel to overcome that.
Of particular concern is the programme’s failings to achieve its most important goals – namely 80% of all eligible women being tested, and 98% of letters confirming the results of screening being received by women within 14 days. The quality of the programme, and the take up of it regionally, is likely to be linked.
The results are particularly disappointing, given that the HPV primary screening has in fact reduced and streamlined the number of women having to be recalled for treatment sooner than the usual three to five years.
With the ongoing reduction in the efficacy of the programme, in terms of the number of women it is reaching and the efficiency of the service they are receiving, it is time for NHS Improvement to urgently consider the findings of Public Health England and to act decisively to reverse the trend.