Taking cervical cancer screening to the next level

To mark Cervical Screening Awareness Week – a UK-wide initiative led by Jo's Cervical Cancer Trust – Mr Jullien Brady, Clinical Advisor - GYN Check4Cancer, talks about the importance of screening, and how the latest developments can help save more lives.

First of all, can you tell us why the UK cervical screening programme is so important?

Gynaecologists are particularly proud of the cervical screening programme; it was one of the very first, national call and recall systems introduced in the world, and it’s considered a benchmark screening programme. When it was introduced in 1988, the programme set out to try and reduce the number of new cases of cancer by half by the year 2000. It was incredibly successful; within four years incidence had dropped by 50%, and within six it had dropped by about two thirds – from about 6,000 cases to around 2,000. In terms of the number of lives saved, it was calculated in 2012 that it had saved about 100,000 lives by that point. The processes we use now – with a combination of testing for HPV, which is the virus that causes abnormal smear results, and the smear tests themselves – mean that if a woman attends the regular screening when she’s invited, her chances of dying from cervical cancer are almost zero. It is an almost entirely preventable disease.

How has this been achieved?

We now know how the disease is acquired, who is at risk and that in the vast majority of cases it is a fairly slow growing cancer. It also has very easily identifiable pre-cancerous stages, which allows you to treat it very simply and effectively, potentially years before it becomes cancerous. It’s an ideal disease to tackle through screening, because it ticks all the boxes for that process. The sad thing, though, is that since the 1990s we haven’t been able to get the incidence of cervical cancer any lower than around 1,500-2,000 cases a year, and that’s really where Check4Cancer and GynaeCheck come in, helping to tackle the difficulties some women have attending their smear tests. A cervical smear is not a particularly pleasant test because of the very invasive nature of it, and this is the issue we now wish to tackle.

What makes cervical cancer so easily identifiable, and so treatable?

Cervical cancer is effectively a sexually transmitted disease. It’s caused by exposure to the human papillomavirus, or HPV, and everybody who is sexually active has been exposed to HPV. It is endemic within the human population, and even if you use a condom you will be exposed. There are also lots of types – over a hundred strains – but only a few that are high risk. They’re given numbers, and 16, 18 and 45 are the main culprits, responsible for 70% of cervical cancer. When the cervical screening programme was first set up, we didn’t know the true causal link between HPV and abnormal changes on the cervix. The traditional pap or smear test looks for the abnormal changes in the cells of cervix, but we now know those changes can only be caused by certain types of high-risk HPV, so we’re now able to test for those high risk strains. Over the past few years there has also been available a very effective vaccine called Gardasil, which has been given to school-age girls nationally. This protects them against the main high-risk strains of HPV. We are just beginning to see the first women who were vaccinated coming for smear tests, and we’re very hopeful that there will be a significant drop-off as a result of those vaccinations. We do however already know that Gardasil will only cover 70% of cervical cancer incidence. At present though, in the NHS, the smear test remains the main screening method, although women can be tested for HPV at the same appointment.

Why is this a problem?

We believe there are around 900,000 eligible women who do not attend smear tests. This is where GynaeCheck and Check4Cancer come in. Our checks are a two-stage process, with GynaeCheck or Check4Cancer providing the initial part of the test, to establish first whether the woman has the presence of the high-risk HPV virus. The advantage of this is that the test can be administered by the woman herself in the privacy her own home. She doesn’t need to make an appointment, the instrument is no bigger than a super-size tampon, and feedback on early use of it has been very positive. The sample is then sent away, and they are then told whether or not they are high-risk HPV positive. If they are, only then will they need a smear test, which they can still get under the NHS. And if it’s negative, great – the woman is happy and just needs to repeat the test in 1-2 years’ time, depending on where she is in terms of her personal risk.

How are you aiming to get the message across?

We are launching Project 100,000, and the challenge is whether we, along with Jo’s Cervical Cancer Trust and all the partners we work with, can re-engage 100,000 women in an 18-month period. The aim is to show all those women who previously would not have gone for a smear test this new piece of kit and get them back into the process. If we do manage to re-engage that number of women, it will literally save thousands of lives, and would be the biggest advance in cervical screening in the last quarter century.

Is this why companies are introducing GynaeCheck – and other cancer checks – as potential benefits for employees?

The smart companies with good HR systems are realising that if they invest a little bit of money in this at the start, they can actually save lives down the line. And employees find it really positive as well, because they feel they are being very much looked after. It’s a hugely powerful message for the employer, and this approach may mean very early intervention in the disease can potentially save an employee’s life. It’s all about choices. GynaeCheck is about giving women a different way of taking an autonomous lead with their healthcare. As healthcare evolves, people are becoming more savvy about their choices. And what you are effectively saying to women with the HPV test is “Here is a test that gives you an 80-90% chance of not having a speculum examination ever again.”

Mr Jullien Brady is a Consultant Obstetrician and Gynaecologist at Bedford Hospital, with extensive experience in the UK cervical screening programme. He is one of the National Quality Assurance Directors and Lead Colposcopist representing the East of England for both of these roles, and a member of the Executive Committee of the BSCCP, the governing body of Colposcopy.