1. The NHS Cervical Screening Programme
Kath Bainbridge North West QA Primary Care Development Nurse

2. What We'll cover Aims and Outline of NHS Cervical Screening Programme
Cervical Cancer causes and incidence
Coverage
Quality Assurance
Call and Recall
GP’s Responsibilities and QOF
Women in Special Circumstances

3. Aims of the NHS cervical screening programme
To reduce the number of women who develop invasive cervical cancer and the number who die from it.
Regular screening is offered so that conditions which might develop into cervical cancer can be identified and treated

4. The Cervical Screening Programme
Started in 1960s
1988 – All Health Authorities run a cervical screening programme for women aged 20-64, with call recall system
Liquid based cytology introduced
Lower age increased to 25

5. The Cervical Screening Programme
National HPV vaccination programme introduced for 13 year old girls
HPV triage piloted
Cytology laboratory services move to cover larger areas
HPV Primary testing pilots

6. Elements of the Cervical Screening programme
Sample Taking
Transportation to Laboratory
Laboratory Screening Service
Call and Recall
Colposcopy

7. Risk Factors for Cervical Cancer
Infection with HPV
Co-factors that modify the risk
Smoking
Long term oral contraceptives (> 5 years)
5 + full term pregnancies
Previous exposure to other STIs e.g. chlamydia
Immuno-suppression
Not being screened
- HPV - >80 types
- HPV16 & HPV18 (high risk types) found in >90% cancers
- HPV6 & HPV11 genital warts (but no increase in cervical cancer)
- Maj of sexually active women will have come into contact with high risk HPV, but immune system will get rid of infection
- Smokers - twice as likely to develop Ca Cx. Perhaps because smoking assoc with high risk behaviour, or suppresses immune system. Stopping system helps clinical abnormalities to regress
- Long term OCP increases cancer risk, but benefits outweigh risks
- Late 1st preg lower risk. Risk rises with number of pregnancies
- Many women who develop CA have never been screened, regular screening can prevent around 75% cases

8. Cervical Cancer Trends in incidence and mortality, England 1989 to 2010
Increase in 2009 is related to the death of Jade Goody – an increased number of previously unscreened young women attended for screening leading to an increased rate of diagnosis. Half a million extra attendances in 2008/ % more than expected – many of these in age age group attending late for screening.
Between March 2009 and June 2009 a 58% increase in diagnosis in women age compared to 2008

9. Map of mortality by Cancer Network, 2006-2010
Incidence and mortality rates tend to be lowest in the south and east of England, and highest in the north and the
midlands.
There is evidence that cervical cancer survival is worse in women living in the most deprived
fifth of areas nationally compared with the least deprived fifth. This equates to a 6% gap in
relative survival one‐year after diagnosis and an 11% gap for five‐year relative survival.

10. Age-specific incidence rates and number of cases diagnosed by five year age group, England 2009
The age‐specific incidence rate peaks among women in their early 30s. Following a gradual reduction
in the rate in women in their 40s, rates rise again in women in their 70s and 80s. As a result of the
screening programme many cervical cancers are detected in younger women, with around 60% of
cases occurring in women aged 25‐49. The cessation of screening when women reach 65 may
contribute to the rise in incidence rates after this age; although cervical screening can be very
problematic in older women due to anatomical changes and the hormonal environment.

11. Age-specific relative survival, England 2007-2009 (one-year) and 2003-2005 (five-year)
Survival following a diagnosis of cervical cancer has improved in England since the late
1980s, from 83% to 88% for one‐year relative survival and from 64% to 70% for five‐year
relative sur
There is strong evidence that cervical cancer survival is worse in older women. For example, oneyear
relative survival in those aged 20‐39 is 96.6% compared with 51.9% in those aged 80 or older.
Similarly, five year survival in those aged 20‐39 is 87.2% compared with 27.0% in those aged 80 and
over.
As with many cancers, this marked difference may, in part, be due to difficulties in treating the
disease in older women, particularly women with co‐morbidities. The cessation of screening in
women over the age of 64 may also result in older women presenting later with their disease.
Differences in tumour biology may also be a factor in poorer survival among older womenvival.

12. The Programme aims for 80% coverage
Coverage is the proportion of women eligible for screening who have had a test with a recorded result at least once in the previous 5 years.
Women are eligible between 24yrs and 6 months – 64 yrs.
Screening frequency 3-5 yearly
If overall coverage of 80 per cent can be achieved, the evidence suggests that a reduction in death rates of around 95 per cent is possible in the long term.
AIM for 80% coverage - maximises the impact of the programme and decrease incidence and mortality.
Good progress over the past 30 years as the programme has been pulled together…
Unfortunately now showing downward trend…

16. Quality of Cervical Screening Programme
Overseen by NW QARC
Systematic approach to performance monitoring and addressing underperformance
Sample taker training
Sample taker database
Failsafe mechanisms
Clear process for managing SUI
Access to quality colposcopy service

17. Clinical Issues in Cervical Screening
Sample acceptance policy
Incidents and significant events
High Inadequate Rates
Sampling and accuracy
Pathway for abnormal bleeding in under 25’s

18. The cardinal symptom of cervical cancer in this age group is postcoital bleeding, but persistent intermenstrual bleeding, which is more common also requires attention.

20. Call and Recall
Call and recall or Primary Care Support Services
Contact practice with Prior Notification List (PNL)
Send invitation letters
None Responder cards
Open Exeter
Ceasing
Will always give advice and information on request
contact details: or
PNL is sent to practices 8 weeks before test due date. - Practice have 4 weeks to complete and return.
Options available: Invite. Postpone recall. Cease recall. No reply ?

21. GP Responsibilities Failsafe systems PNL’s and ceasing women
Management of results and referrals
Quality assurance re sample takers – qualifications and update training
QOF – points, exception reporting

22. Failsafes CONSIDER PATIENT PATHWAY
Housekeeping issues -identify patient , paperwork , labels , equipment expiry dates ..
Transport- issues
Who registers all samples sent and checks all results received?
What about non responders?
Who checks abnormal results dealt with?
Who checks histology results in newly hysterectomised patients?
Who responds to failsafe queries from lab and deals with them and deals with critical incidents?
What happens to TR or no address or don’t want correspondence
Non responders 3rd invite is from practice to chase up ??how to get 25 ‘s in
What about giving urgent results if needs referral – who does it?

23. Employment and training issues.
Practices should check staff :
Trained to take cervical samples
Had an update in the previous 3 years
Familiar with Surepath LBC system
Have access to Manchester Cytology Laboratory Guidelines and The NHSCSP Good Practice Guide No 2 (2011)
Manager has completed sample taker spread sheet and informs The CANE Area Team
They are on the Sample Taker Register
Undertake regular audit of sample taking and outcomes

24. Cervical screening QOF points
Indicator
Points
Achievement thresholds
CS001. The contractor has a protocol that is in line with national guidance agreed with NHS CB for the
management of cervical screening, which includes staff
training, management of patient call/recall, exception
reporting and the regular monitoring of inadequate
sample rates 7
CS002. The percentage of women aged 25 or over and who have not attained the age of 65 whose notes record that a cervical screening test has been performed in the preceding 5 years 11
45-80%
CS004. The contractor has a policy for auditing its
cervical screening service and performs an audit of
inadequate cervical screening tests in relation to
individual sample-takers at least every 2 years 2

25. Women in Special Circumstances
Learning Disabilities
Physical disability
Terminal illness
Radiotherapy
Female Genital Mutilation
Pregnant/post natal
Male to Female sex change
Female to male sex change
Lesbian and Bisexual women
Immuno- compromised
Learning Disabilities – understanding, do you know how to link with local disabilities nurses who may give support – Mental Capacity Act
Physical disability – may need a venue with a hoist, different position
Terminal patients are still offered screening but can choose to decline
Radiotherapy – if for cervical cancer not appropriate
FGM – Still at risk of cervical cancer
Pregnancy / post natal- avoid taking samples in pregnancy and not till 12 weeks post natal
Male to female – no cervix – call and recall need to be notified
Female to male – not called as male name but still have cervix so onus on sample taker
Lesbian and Bisexual – still at risk as someone may have had a male partner
Immuno-compromised – renal transplant take before and if no CIN, normal recall – HIV – annual cytology

26. Vault Samples New guidance in 2009 (reinforced in 2011)
Women who have had a total hysterectomy have no cervix therefore not eligible for recall in NHSCSP
All vault samples in the North West should be done in a colposcopy setting

27. The Future…… HPV Immunisation HPV Primary Screening pilots
Evaluations in other countries for HPV Primary Testing are looking positive
6736(13) /abstract
Women who have had a HPV vaccination?

28. Useful Websites www.cancerscreening.nhs.uk www.cancerresearchuk.org
england
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29. Thank you.