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Reducing mortality from cervical cancer

14 May, 2012

Reducing mortality from cervical cancer

Senior midwifery lecturer Aine Kothari explains how the NHS Cervical Screening Programme has been remarkably successful in saving women's lives.
Midwives magazine: Issue 3 :: 2012

Senior midwifery lecturer Aine Kothari explains how the NHS Cervical Screening Programme has been remarkably successful in saving women’s lives.

Cervical cancer incidence has fallen by 42% since the establishment of the NHS Cervical Screening Programme (NHSCSP) in 1988 (Peto et al, 2004). However, in 2008, 759 women died from cervical cancer in England (ONS, 2008). Despite this comprehensive screening programme, women die from the disease and those most at risk are women who have not been regularly screened.

In a study of 180,000 women aged 25 to 64 in the South London borough of Lambeth and Southwark, of the 133 women who had invasive cancer diagnosed between 1999 and 2007, almost 31% had no record of previous cytology and a further 15.8% had not had screening for more than five years (Herbert et al, 2010). Overall, women living in the most deprived areas have cervical cancer rates three times as high as those in the least deprived areas (Cancer Research UK, 2011).

The proportion of eligible women who take up their invitation for screening has fallen over the last 10 years from 82.3% to 78.9% in 2010 (NHSCSP, 2010). This downward trend has been greatest in younger women (Poole, 2011). Coverage in women aged 25 to 39 is currently only 74% (NHSCSP, 2010).

Any opportunities health professionals have to promote the benefits of cervical screening should be utilised. Midwives have such an opportunity and can advise women in their care of the benefits of the screening programme. Guidance from the NHSCSP (2004) advises that routine screening is postponed during pregnancy and details of the woman’s expected date of delivery are communicated by the woman’s GP to the call/recall department. This ensures that women who are due to be screened receive an invitation around three months following the birth. In women where there has been a previous history of abnormal cell changes, or who have had previous treatment, guidance should be sought from the colposcopy clinic regarding management during pregnancy.  

The question regarding cervical screening history is routinely asked at the antenatal booking appointment. If cervical screening is overdue, this information is recorded in the woman’s notes. On discharge from midwifery care, the woman is reminded of the need to attend for screening. In many areas, this information is contained in the discharge letter sent to GPs and health visiting services.

At the six- to eight-week postnatal check, the need for cervical screening is reiterated and the woman is advised to make an appointment; cervical screening can resume three months following the birth. This coincides with a very busy time in a woman’s life when making time to attend a screening appointment may be low on her list of priorities. The antenatal appointment or postnatal discharge visit is a good opportunity for ascertaining the woman’s cervical screening history and, when necessary, providing information so that women are aware of the simplicity and benefits of attending screening, and that it should be undertaken three months following the birth (if a sample has not been taken in the previous three years) and certainly before embarking on their next pregnancy.

Providing information about screening at this time in a woman’s life could contribute to increasing uptake and reduce the incidence of morbidity and mortality from cervical cancer.
In order to answer any questions the woman might have about the screening programme, it is useful to be aware of how cervical cancer develops, what risk factors are known and how the process of cervical screening works.

In 1988, the NHSCSP established a call/recall system, which coordinates the invitation for screening and results process. All women registered with a GP in the UK receive a written invitation for screening at three- or five-year intervals, depending on age. From 25 to 49, the screening interval is three years; from 50 to 64, it’s five years. Screening begins at age 20 in Scotland, Wales and Northern Ireland.

Prior to the invitation, the call/recall department forwards a prior notification list to GP surgeries, providing an opportunity for surgeries to verify the appropriateness of the proposed invitation. An invitation letter is subsequently sent to the woman’s home address, in which the woman is asked to contact her surgery to make an appointment. The screening test is undertaken at the GP surgery and, in many areas across the UK, contraception and sexual health clinics offer a drop-in service.

The test takes, on average, 20 minutes and involves a vaginal speculum examination undertaken by a nurse or doctor, in order to visualise the cervix and specifically the squamo-columnar junction. A sample of cells is obtained using a soft-bristled cervex-brush and the sample is saved in a liquid solution – this is referred to a liquid-based cytology. The sample is appropriately labelled and dispatched to a cytology laboratory for analysis. Bioscientists analyse and report. The results are sent to both the GP and the call/recall department who forward the results to the woman’s home address within 14 days. In the event of abnormalities (referred to as dyskaryosis) that require further investigation, the woman is referred to colposcopy, where further tests may be undertaken to determine the extent of the development of cervical intraepithelial neoplasia and treatment initiated if indicated. 

The risk factors for developing cervical cancer include human papilloma virus (HPV). Our knowledge of the link between HPV and the development of cervical cancer is continuing to grow. HPV is generally sexually transmitted and about 50% to 70% of young people will acquire a genital HPV infection at some point, with the peak incidence being when they become sexually active (Bosch and Iftner, 2002). However, 70% of the initial infections disappear within a year and 90% within two years. It is the persistent infections that predispose to cancer (Bosch and Iftner, 2002).

A HPV vaccination programme was introduced in September 2008 and the vaccine is given to girls aged 12 to 13 (year 8) and a subsequent catch-up programme for girls aged 14 to 17 was undertaken. The vaccine immunises against HPV strains 16 and 18, which pose the greatest risk and account for 70% of cervical cancer cases (Bosch and Iftner, 2002). New understanding of the role of HPV in the genesis of cervical cancer has led to the incorporation of HPV testing in the national cervical screening programme in England. From April 2011, samples from women, which contain cells with low-grade abnormalities (borderline or mild dyskaryosis) are tested for high-risk HPV strains and, if positive, the women are referred to colposcopy (Szarewski, 2011).

Midwives have an opportunity to remind women about the importance of the cervical screening programme and to encourage them to attend when invited. This health promotion activity has the potential to reduce mortality from this preventable and curable condition.

Aine Kothari
Senior midwifery lecturer at Anglia Ruskin University, Chelmsford

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Additional information is available at: cancerscreening.nhs.uk

Bosch FX, Iftner T. (2002) The causal relationship between human pappilomavirus and cervical cancer. Journal of Clinical Pathology 55(4): 244-65.

Cancer Research UK. (2011) Cervical cancer – risk factors. See: info.cancerresearchuk.org/cancerstats/types/cervix/riskfactors (accessed 15 May 2012).

Herbert A, Anshu A, Culora G, Dunsmore H, Gupta S, Holdsworth G, Kubba A, Mclean E, Sim J, Raju KS. (2010) Cervical cancer audit: why cancers developed in a high-risk population with an organised screening. BJOG 117: 736-45.

NHSCSP. (2004) Cervical screening call and recall: guide to administrative good practice. See: cancerscreening.nhs.uk//cervical/publications/nhscsp18.pdf (accessed 15 May 2012).

NHSCSP. (2010) NHS cervical screening 2010 review. See:
cancerscreening.nhs.uk/cervical/publications/2010review.html (accessed 15 May 2012).

Office of National Statistics. (2008) Cervical cancer – UK incidence statistics. See:
info.cancerresearchuk.org/cancerstats/types/cervix/incidence (accessed 14 May 2012).

Peto J, Gilham C, Fletcher O, Matthews F. (2004) The cervical cancer epidemic that screening has prevented in the UK. The Lancet 364: 249-56.

Poole J. (2011) Cervical cancer incidence and screening coverage: an age-related
: In: NHSCSP. NHS cervical screening 2011 review. See:
cancerscreening.nhs.uk/cervical/publications/2011review.html (accessed 15 May 2012).

Szarewski A. (2011) Ushering in a new era: human papillomavirus (HPV) testing comes to the NHS Cervical Screening Programme. Journal of Family Planning and Reproductive Health Care 37: 64-7.

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