National rollout of HPV testing, as well as the introduction of self-testing, could improve uptake and further reduce the incidence of cervical cancer in the UK.
Although the UK’s cervical screening programme has reduced cervical cancer mortality rates by 60-70% in the last 30 years, screening uptake rates have fallen by 3.1% from 2004/5 to 2014/5, indicating a need to adopt new methods of screening and increase engagement among women, says a new review published today in The Obstetrician and Gynaecologist (TOG).
The review found that despite the programme’s success, take up rates of cervical screening have fallen from 80.3% in 2004/5 to 77.2% a decade later. Worryingly, just 63% of women in the UK aged 25-29 went for a smear test in 2014. Overall, one in five women between the ages of 25 and 64, and one in three aged below 35 are missing the opportunity to avoid this largely preventable disease.
Coinciding with Cervical Screening Awareness Week, this paper reviews all available evidence on the effectiveness of the UK’s cervical screening programme, as well as analysing the role of the human papillomavirus (HPV) as way of further reducing the incidence of cervical cancer.
Just over 3,000 new cases of cervical cancer are diagnosed each year in the UK and there are over 900 deaths. More than half of cervical cancer cases in the UK each year are diagnosed in women under the age of 45. Cervical cancer is the fourth most common cancer in women worldwide with more than 265,000 women dying from the disease each year. As part of the NHS Cervical Screening Programme, women aged 25 to 49 are invited to be screened every three years, and then every five years until they are 65.
Dr Theresa Freeman-Wang, consultant gynaecologist and co-author of the TOG review, said:
“It’s incredibly worrying that so many women are missing out on cervical screening. Young women who’ve been vaccinated against HPV may think that they are not at risk of cervical cancer, however, although the vaccine is effective against the two most common strains of HPV which cause around 70% of cervical cancers, it doesn’t prevent all of them, so it’s essential they go for cervical screening from the age of 25.
“Research shows that inconvenience, a fear of cancer and concerns about the procedure put women off from making an appointment. Ensuring that coverage does not decline any further, remains an important public health issue.”
With more than 99.7% of cervical cancer cases caused by human papillomaviruses (HPV), there is growing support for HPV testing to be incorporated into the cervical screening programme; either as a co-test, or as a stand-alone primary screening test. Evidence shows that HPV testing is better at detecting potentially premalignant abnormal cells compared to current cervical screening, and involves longer screening internals, meaning testing could be reduced from every three years to six.
HPV primary screening is being evaluated in six centres across the UK to consider whether it should be rolled out across the rest of the UK. HPV testing is already being used across England and Northern Ireland to triage women who have had a cervical smear. Those who are HPV-positive and therefore at higher risk are referred for further investigation (colposcopy) while those who are HPV-negative do not need the procedure and go back to being screened every three or five years.
Falling cervical screening rates have also prompted calls for a self-sampling HPV test. Research shows that women who avoid screening due to time pressures, risk perceptions, lack of knowledge and psychological barriers, consider it more acceptable to take a vaginal swab or urine sample by themselves.
The review also confirms the success of the HPV vaccination, predicting that it will ultimately save 400 lives each year. The programme was introduced in the UK in 2008 for girls aged 12-13 years old, with a two year catch-up jab for those 14-18. Research suggests the vaccine is 94% effective in preventing moderately abnormal cells.
HPV vaccination also has a significant role in protecting men against diseases including genital warts and non-cervical cancers caused by HPV, including head, neck, penile and anal cancers. The Joint Committee on Vaccination and Immunisation (JCVI) recommended in November 2015 that all gay and bisexual men up to the age of 45 should receive the vaccine. This month the vaccine is being made available to gay and bisexual men through GUM and HIV clinics as part of a pilot to establish an appropriate and effective way to deliver the vaccination programme across the country at a later date.
Professor Clare McKenzie, consultant gynaecologist and Vice President for Education at the Royal College of Obstetricians and Gynaecologists (RCOG), said:
“Cervical cancer is largely preventable thanks to cervical screening and HPV vaccination. We strongly encourage women to accept their invitation to cervical screening when they receive it. Women who are worried about screening or symptoms of cervical cancer should seek advice from their GP.
“We also welcome further research into the effectiveness of HPV self-testing as this could further increase uptake among women, in particular women aged under 35 who have the lowest attendance for cervical screening.”
Frankie Appleyard – 29 years old, London (case study via Jo's Cervical Cancer Trust)
Frankie Appleyard had delayed her first cervical cancer screening until she was 26, when she was diagnosed with cervical cancer. “I was probably about a year late from taking up my invitation, and after the screening I was called back in because abnormal cells had been detected. After a colposcopy, I was given my diagnosis; stage one cervical cancer. I had to go for an MRI and then a follow up appointment with my consultant. I went on to have a trachelectomy (the surgical removal of the neck of the womb (cervix), some of its surrounding tissue and the lymph nodes from the pelvis). I got the all clear after that.
“I felt very lucky to have caught it early, but it was still in the back of my mind that if I had gone for the test on time, would things have been different? I think it is so easy to find an excuse not to go, and I think a lot of women don’t really understand the importance of it. People think cancer is one of those things that happen to other people, and they don’t necessarily put themselves as being at risk. But cervical screening is so important, so when you do get the invitation, you need to leave your embarrassment at the doorstep and just get it over and done with.”
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Cervical Screening Awareness Week (13-19 June) is a national campaign led by Jo's Cervical Cancer Trust.
Cervical cancer symptoms
There are usually no symptoms with abnormal cervical cells and sometimes there are no symptoms with early stage cervical cancer. However, there are some recognised symptoms associated with cervical cancer. These include;
- Abnormal bleeding: during or after sexual intercourse, or between periods
- Post menopausal bleeding, if you are not on HRT or have stopped it for six weeks
- Unusual and/or unpleasant vaginal discharge
- Discomfort or pain during sex
- Lower back pain.
For more information visit www.cancerresearchuk.org