Cervical Screening Programme March 2019

Why screening is important? There are 11 national screening programmes screening through the whole life course. Screening is a way of finding out if people are at higher risk of a health problem so that early treatment can be offered or information given to help them make informed decisions. Finding out about a problem early can mean that treatment is more effective. The aim is to offer screening to the people who are most likely to benefit from it. For example, some screening tests are only offered to newborn babies, others such as breast screening and abdominal aortic aneurysm screening are only offered to older people.

Relative survival estimates by route of diagnosis for cervical cancer 2006-2013 Source: National Cancer Intelligence Network (NCIN)

Since the national screening programme was introduced in 1988, mortality rates for Cervical cancer have decreased by up to 70%

HPV The Human Papilloma virus causes over 99% of cervical cancers of these 70% are caused by HPV types 16 and 18. Since 2008 all girls have been offered the HPV vaccination in school. The vaccine protects against types 16 and 18 and types 6 and 11 which cause genital warts. The HPV screening tests for all types of HPV that can cause cancer, which is why screening is still needed. It also can detect small cell cancers which are not HPV related. Screening intervals may be extended in the future. Uptake of HPV vaccination in schools has around 90-95% uptake since it’s introduction. Currently looking at models for screening for HPV vaccinated women.

HPV Understanding of HPV screening and what the results mean. The majority of women will come into contact with HPV during their lifetime and will clear the infection, however some women will have persistent infection and this is what causes abnormal cells. Vaccinated women may think they do not need screening. Women get a leaflet to explain HPV testing in the cervical screening programme. Sample takers must ensure the woman understands which test they are having and the reason why. Cytology – only HPV tested if sample is borderline or mild abnormality, moderate or severe will be directly ref to Colp HPV Primary screening – sample HPV tested first. If HPV positive a slide is made and cytology undertaken. Test is more sensitive and picks up persistent HPV infection before it has caused abnormalities in the cells. Women with persistent HPV infection would be referred to colp at an earlier stage than with cytology primary screening. HPV primary screening will be rolled out across the country by the end of 2019.

Key Messages The test doesn’t look for cancer. It looks for a virus/abnormal cells that if left could develop into cancer. Approximately 90% of women attending for screening have a normal result. More than ½ (52%) of cervical cancers in the UK are diagnosed in females under age 45. (2012-2014). This will change as vaccinated women enter the programme. Women age 25-35 are less likely to attend for screening, therefore having missed opportunities to have early abnormalities treated. Important that younger women are encouraged to attend for screening as over ½ of diagnosis is in under 45. This is the group who do not attend and this could explain why the cancer diagnosis are higher. If they attended for screening, early abnormalities would be detected and treated and have less chance of developing into cancer.

The majority of women will have a negative result. Of every 100 women screened 94 will be negative and be recalled in 3 or 5 years. 6 will have abnormal cells. Of those 6 - 4 will require colposcopy referral and may need treatment for those abnormalites. 2 will have no HPV infection and safely returned to routine recall.

There are various groups of women who do not attend for cervical screening. A number of common reasons for non-attendance. 30% of Asian women had not heard of a “smear test”.

National Cervical Screening Campaign

Risks of cervical screening The risks of cervical screening come from removing abnormal cells during a colposcopy and not from the screening test itself. Removing abnormal cells can sometimes cause bleeding or an infection It can also affect future pregnancies Women who get pregnant after having abnormal cells removed are slightly more likely to have their baby 1 to 2 months early. NHS cervical screening Helping you decide NHS | Presentation to practice nurse forum

Symptoms Symptoms of cervical cancer include: bleeding in between periods or after intercourse. Pain during intercourse. Post-menopausal bleeding, unusual vaginal discharge, lower back pain. Anyone with symptoms should seek advice from their GP no matter what age they are. Screening is not appropriate for women with symptoms.

Reducing Risk HPV vaccination for those eligible. Attendance for screening when invited. Higher incidence of cervical cancer in area’s of deprivation – women from lower socio-economic groups are less likely to attend for screening. Smoking is linked to a higher incidence of cervical cancer. Smoking – reduces the ability of the immune system to clear HPV and reduces cell regeneration.

Issues in Practice Disabilities and special circumstances Don’t assume women who are disabled or have learning disabilities are not sexually active. Reasonable adjustments should be made to accommodate screening for these women. Easy read literature is available for use. It is useful if practices know when a woman who may need literature in a different format is due to be invited – check the PNL. Under the mental capacity act it states that people must be assumed to have capacity to make their own decisions unless proved otherwise. Individuals must be given all practicable help to make their own decisions before it is assumed they cannot do so. Good practice guide for cervical screening section 6 has a list of useful points to consider when dealing with patients with learning disabilities. “The smear test” video

Issues in Practice (con’t) Female to male gender reassignment will fall outside normal call recall if they appear as a male on call/recall system. If they have a cervix the GP must act as call/recall. Male to female gender reassignment will not require screening and will need to be ceased as no cervix.

Good Practice If resources are short, concentrate efforts on those women who have never been screened. Regular screening is the best way to reduce risk of developing cervical cancer. A lot of misconceptions exist regarding screening and these can be addressed by health professionals.

Useful Websites www.screening.nhs.uk www.cancerscreening.nhs.uk www.jostrust.org.uk www.gov.uk/government/organisations/public-health-england https://fingertips.phe.org.uk/profile/cancerservices

SIT Team england.lancashiresit@nhs.net