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OVERVIEW OF THE CERVICAL SCREENING PROGRAMME

OVERVIEW OF THE CERVICAL SCREENING PROGRAMME. November 2005 Guy Hayhurst Consultant in Public Health, Eastern Cheshire PCT. The aim of the NHS Cervical Screening Programme is to reduce the number of women who develop invasive cervical cancer, and the number of women who die from the disease.

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OVERVIEW OF THE CERVICAL SCREENING PROGRAMME

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  1. OVERVIEW OF THE CERVICAL SCREENING PROGRAMME November 2005 Guy Hayhurst Consultant in Public Health, Eastern Cheshire PCT

  2. The aim of the NHS Cervical Screening Programme is to reduce the number of women who develop invasive cervical cancer, and the number of women who die from the disease

  3. Screening for Cervical Cancer – Evolution of National Policy • 1966Population screening introduced. Five yearly tests for women aged 35 and over • 1973Screening extended to women under 35 who have been pregnant on 3 or more occasions • 1984Commence screening when woman first attends for contraceptive advice. Also early in every pregnancy. Screen at five year intervals. Cease at age 64 after 2 negative tests • 1988Implement computerised call and recall systems, inviting women aged 20 to 64. Recall at least every five years • 1993Three to five yearly screening from 20 to 64 • 1997 Quality Assurance arrangements at regional level • 2003Three yearly screening from 25 to 49, five yearly from 50 to 64. Five-year timescale for implementing LBC

  4. Criteria for Screening Programmes • The Condition– should be an important health problem, and the natural history should be known • The Test– simple, safe and acceptable screening test, known distribution and cut-off point for test values, with an agreed policy on further diagnostic investigation • The Treatment– should be effective, leading to better outcomes, there should be evidence-based policies on who should be offered treatment • The Screening Programme– should be shown to be effective in reducing mortality or morbidity

  5. Cancers in England 2001 Prostate 26,027 (23.1%) Lung 18,545 (16.5% Colorectal 14.836 (13.2%)

  6. Cancers in England 2001 Breast 34,347 (30.6%) Colorectal 12,693 (11.3% Lung 11,940 (10.6%)

  7. Risk Factors for Cervical Cancer Risk is closely related to any sexual behaviour that increases transmission of the causal HPV infection High-risk women can be defined as those who are persistent carriers of a high-risk HPV type Factors thatincreaserisk include: • sexually active at an early age (of either partner) • many sexual partners (of either partner) Among women persistently exposed to HPV infection, some additional exposures further increase risk of progression: • cigarette smoking • long-term oral contraceptive use (five or more years) • parity above five full term pregnancies

  8. Exposure must precede disease Reduction in disease following reduction in exposure Strong (& consistent) association in different populations Risk of disease is related to level of exposure Cohort studies of HPV infected women followed up to CIN2/3 Early vaccination trials of women followed up to CIN show high type-specific protection International case-control studies Studies on sexual behaviour and number of sexual partners Causality criteria for the association between HPV DNA and cervical cancer

  9. Estimates of HPV type-specific relative risk from nine case-control studies Current vaccine availability From: The Aetiology of Cervical Cancer. NHSCSP Publication No 22. September 2005

  10. Global Incidence of Cancer of the Cervix From: IARC Handbook of Cancer Prevention. Cervix Cancer Screening. 2005

  11. National call and recall introduced From: Update to Cancer Trends in England and Wales 1950-1999. National Statistics 2005

  12. Previously screened cohorts From: Update to Cancer Trends in England and Wales 1950-1999. National Statistics 2005

  13. From: Cancer Trends in England and Wales 1950-1999. National Statistics 2001

  14. Five-year age-standardised survival (%), Women 1998-2001, England Five-year survival by year of diagnosis 1996-1999 61.3% 1998-2001 63.1% From: Cancer Survival, England, 1998-2003. National Statistics

  15. Influences on Risk in the under 25’s • between 2001-2003, the Manchester ARTISTIC trial found a 33% prevalence of HPV infection in women aged 20-29, with a clearance rate of 59% within 1 year (1) • following HPV infection, around a quarter of young women will develop transient cytological abnormalities (2) • most low-grade changes will regress spontaneously within 36 months (3) • there is some evidence that high-grade intraepithelial lesions will also regress in young women (4) Factors thatincreaserisk include: • HPV infection • sexually active at an early age • many sexual partners • smoking Factors thatreducerisk include: • regular condom use (1) Kitchener H C, et al. 21st Int. Papillomavirus Conf; Feb 2004; Abstract 268 (2) Moscicki A B, et al. JAMA. June 2001; 285; 2995-3002 (3) Moscicki A B; et al. Lancet. Nov 2004; 364; 1678-1683 (4) Szarewski A, Sasieni P. Lancet. Nov 2004; 364; 1642-1644

  16. Prevalence of high-risk HPV by age group, and age-specific cervical cancer incidence From: The Aetiology of Cervical Cancer. NHSCSP Publication No 22. September 2005

  17. Results of GP and community smears screened in Cheshire & Merseyside Laboratories in 2003/04 197 severe and 362 moderate dyskaryosis at ages 20-24 236 severe and 252 moderate dyskaryosis at ages 25-29 2887 abnormal tests in total

  18. Frequency distribution of new cases of invasive cervical cancer diagnosed in England in 2001 Following computerisation of call and recall, new cases have fallen among women in older age groups where there has been high screening uptake. But - screening coverage has fallen in women aged 25 to 49 In 2001 there were 2,418 new cases of invasive cervical cancer (40 under 25), and 1,046 women died from the disease (6 under 25) Death rates in women aged 20-24 have not been affected by computerised call and recall From: National Statistics 2001

  19. Harm versus Benefit in the under 25’s • Harmmay arise from: • abnormal smears are common, with little prognostic value • women are labelled at-risk (minor changes lead to follow-up) • the damage to the cervix that may result from treatment • The Benefitsare unclear: • the UK case-control study (5) looked at screening histories of 1,305 women (all ages) and 2,532 age-matched controls • 26 out of the 34 women with invasive cancer aged 20-24 had a previous negative smear, which suggests that cytology is not very sensitive for these tumours (5) Benefit of cervical screening at different ages. Sasieni P, Adams J, Cuzick J. British Journal of Cancer. July 2003; 89; 88-93

  20. Age 55-59 Age 30-34 Age 60-64 Age 25-29 From: Cervical Screening Programme, England: 2003-04. Department of Health

  21. Changes in Frequency of Screening Benefit of cervical screening at different ages. P Sasieni, J Adams, J Cuzick. Br. J Cancer. 2003

  22. Guidance on Liquid-based Cytology • July 2000 Health Technology Assessment Review LBC likely to be beneficial, but a pilot study is required • Jan 2002 Scottish Pilot StudyTraining of lab staff and smear takers is feasible; also reductions in lab workload and inadequate rates, and an increase in detection of high grade lesions • Dec 2002 English Pilot Study Initial report on effects and costs of introducing LBC describes a clear reduction in the rate of inadequate smear tests • Oct 2003 NICE Guidance on use of LBC for Cervical Screening LBC is an improvement over Pap smears; it reduces the need for repeat smears, improves detection of high grade lesions, increases productivity in laboratories • Dec 2003 Department of Health “Advice to the Service”

  23. It is recommended that liquid-based cytology (LBC) is used as the primary means of processing samples in the cervical screening programme in England and Wales. There is currently insufficient evidence to recommend one LBC product over another. The NHS Cervical Screening Programme and Cervical Screening Wales may wish to consider evaluating further the different products as the method is introduced.

  24. Ceasing Women from Screening Ceasing a woman from the NHS Cervical Screening Programme means she will receive no further invitations and her name will be removed permanently from future prior notification lists There are two main reasons for ceasing a woman. These are 1) age - women aged 60 or over with three consecutive negative tests; and 2) no cervix The following should not automatically be ceased: • women with physical disabilities • women with learning disabilities • for “clinical” or “medical” • reasons alone • terminally ill women • circumcised women • women who have never • had sex with a man

  25. Women ceased from Cervical Screening in North, Central and South Liverpool PCTs in 2003/04 England N.West Liverpool No cervix 8.2% 8.4% 6.0% (8,708) Age reasons 1.4% 1.4% 1.0% (1,298) Other reasons 1.0% 1.4% 1.6% (2,177) 700 429 321 262 220 134 79 6 26 From: Cervical Screening Programme, England: 2003-04. Department of Health

  26. Cervical Screening – Past and Future Age/Interval Changes Liquid Based Cytology Quality Assurance HPV DNA Testing 2004 2005 Computerised Call and Recall 1997 Computer Assisted Reading 1988 GP Contract 1988 Molecular Markers of Progression Extended to Under 35’s 1973 1966 Population Screening Introduced Routine HPV Vaccination

  27. Frequency distribution of new cases of invasive cervical cancer diagnosed in England in 2001 Following computerisation of call and recall, new cases have fallen among women in older age groups where there has been high screening uptake. But screening coverage has fallen in women aged 25 to 49 In 2001 there were 2,418 new cases of invasive cervical cancer (40 under 25), and 1,046 women died from the disease (6 under 25) Death rates in women aged 20-24 have not been affected by computerised call and recall From: National Statistics 2001

  28. Cheshire and Merseyside SHA 108.3, 130.4, 58.2% Cumbria and Lancashire SHA 109.7, 105.3, 62.2% Greater Manchester SHA 136.7, 129.0, 63.8% From: Clinical and Health Outcomes Knowledge Base 2005

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