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

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

Screening for Cervical Cancer – Evolution of National Policy 1966 Population screening introduced. Five yearly tests for women aged 35 and over 1973 Screening extended to women under 35 who have been pregnant on 3 or more occasions 1984 Commence 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 1988 Implement computerised call and recall systems, inviting women aged 20 to 64. Recall at least every five years 1993 Three to five yearly screening from 20 to Quality Assurance arrangements at regional level 2003 Three yearly screening from 25 to 49, five yearly from 50 to 64. Five-year timescale for implementing LBC

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

Cancers in England 2001 Prostate26,027 (23.1%) Lung18,545 (16.5% Colorectal (13.2%)

Cancers in England 2001 Breast34,347 (30.6%) Colorectal12,693 (11.3% Lung11,940 (10.6%)

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 that increase risk 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

Causality criteria for the association between HPV DNA and cervical cancer 1.Exposure must precede disease 2.Reduction in disease following reduction in exposure 3.Strong (& consistent) association in different populations 4.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

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

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

National call and recall introduced From: Update to Cancer Trends in England and Wales National Statistics 2005

Previously screened cohorts From: Update to Cancer Trends in England and Wales National Statistics 2005

From: Cancer Trends in England and Wales National Statistics 2001

From: Cancer Survival, England, National Statistics Five-year age-standardised survival (%), Women , England Five-year survival by year of diagnosis % %

Influences on Risk in the under 25’s Factors that increase risk include: HPV infection sexually active at an early age many sexual partners smoking Factors that reduce risk include: regular condom use between , 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) (1) Kitchener H C, et al. 21st Int. Papillomavirus Conf; Feb 2004; Abstract 268 (2) Moscicki A B, et al. JAMA. June 2001; 285; (3) Moscicki A B; et al. Lancet. Nov 2004; 364; (4) Szarewski A, Sasieni P. Lancet. Nov 2004; 364;

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

Results of GP and community smears screened in Cheshire & Merseyside Laboratories in 2003/ severe and 362 moderate dyskaryosis at ages severe and 252 moderate dyskaryosis at ages abnormal tests in total

From: National Statistics 2001 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) 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 Death rates in women aged have not been affected by computerised call and recall

Harm versus Benefit in the under 25’s Harm may 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 Benefits are 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 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

Age Age Age Age From: Cervical Screening Programme, England: Department of Health

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

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 Study Training 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”

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.

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

Women ceased from Cervical Screening in North, Central and South Liverpool PCTs in 2003/04 From: Cervical Screening Programme, England: Department of Health England N.WestLiverpool No cervix8.2%8.4%6.0% (8,708) Age reasons1.4%1.4%1.0% (1,298) Other reasons1.0%1.4%1.6% (2,177)

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

From: National Statistics 2001 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) 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 Death rates in women aged have not been affected by computerised call and recall

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