To mark Cervical Cancer Prevention Week – a UK-wide initiative led by Jo's Cervical Cancer Trust – Mr Jullien Brady, Clinical Advisor for Check4Cancer, talks about the importance of screening, HPV and the challenge of getting more women to attend their tests.
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.
Recently, we have seen some very detailed data published on the effectiveness and scope of the national Cervical Screening Programme. Why is this data significant?
It’s one thing we're particularly pleased about with the Cervical Screening Programme (CSP) – the amount of data we produce. At the end of the day, data runs the world. This data is absolutely rock solid, so we can say with complete certainty what is working and where improvements need to be made. Because it was one of the first screening programmes set up, we paved the way for data benchmarking – but also the government put up a huge amount of money and need to be assured that this money is being put to work. Having credible data shows it is actually working.
What does the data reveal?
Perhaps the most significant trend it reveals is that the number of women invited in last couple of years is slowly rising, while the number of women being tested is slowly falling. This is the key issue we need to address: the engagement with the programme.
What are the signs and symptoms that women need to be aware of?
If you experience bleeding between periods, after sex or after menopause, you should see your GP immediately. You may also have other vaginal discharge or pelvic pain – but early stage cervical cancer may have no symptoms at all, which is why screening is so important. The main message here is simple: if you turn up for screening, you will not die of cervical cancer. I can't guarantee you won't get it, but your chances of dying from it are practically zero, because we can detect it and deal with it. Cervical cancer is an almost entirely preventable disease. Part of the reason for this is that we now know that the majority of cervical cancers are caused by certain strains of HPV – human papillomavirus – and can test for presence of that virus. We are also now vaccinating school-age girls against some of the most high-risk strains of the virus, using a vaccine called Gardasil. People are sometimes alarmed to learn that this is due to a sexually transmitted virus, which can have a stigma attached to it, but the important thing to understand about HPV is that it is endemic in the population. Everybody who is sexually active is exposed to it – it is not a sign of promiscuity – but condoms do not protect against it. So, we need to put that stigma aside.
Do the figures show variations in engagement with the programme according to age or location?
Yes – but this also gives us clues as to why it is happening and what we can do about it. Most worrying is the group of very young women the 25-29 year old group, who have some of the lowest coverage in areas of London – only 60% of eligible women of that age are actually being screened there. Some of that cohort of women may have been vaccinated against HPV and feel they don't need to attend because of that, when in fact they have only been vaccinated against the strains that cause 60-70% of cervical cancer. You might think that a metropolis like London with all its facilities would have the highest coverage, but it has the worst figures across the board. It’s a pretty damning statistic. The reason for that is partly because cities tend to have more lower-paid workers who have more difficulties getting time off. The thing to emphasise is that it's not question of the validity of the tests themselves – the tests and treatments we have are fine – it's just about getting patients through the door to get the screening done. But the nature and logistics of the tests may play a part here. It's a situation where women are being asked to take time off work to have a very intimate and invasive test. You only have to have one little thing to make you think 'Actually, I don't think I'll bother today...'
What are the main obstacles?
A smear test is an invasive, uncomfortable procedure, and so many women have had a bad experience that any little thing may push them over the edge and make them not want to do it. As I’ve mentioned, one of the major problems with people wanting to attend is that they often find it difficult to get time off work to go – and that’s an issue whether you're a CEO or working on the checkout at the supermarket. All of my junior staff, who are doctors, find it incredibly difficult to get time off to get their smear tests done! It's an example of what actually happens in the real world. Some women may also have had a bad experience or been scaremongered, or may be a marginalised group, such as those who have been victims of sexual violence. The CSP does try hard to make those tests as tolerable as they can be, but you simply can't get around the fact of where the cervix is. It's a very invasive, personal thing and anything that can make that easier, in terms of logistics or privacy, has to be a good thing.
How can those obstacles be overcome?
I don’t think there is one simple answer to this – it is a combination of raising awareness, making it clear that it's important enough to make the time and the effort, and making it as easy as possible for women. This is where GynaeCheck comes 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 or 2 years, depending on where she is in terms of her personal risk. That one simple test – which is far less invasive, and is done in your own time – eliminates the two key obstacles at a stroke.
Cervical cancer is often seen as a younger woman’s cancer. Is this an accurate view?
There are two peaks with cervical cancer, one in the mid-30s, then another in the mid to late 60s. This is quite unusual for cancer, because most cancers follow a pattern where the older you get, the higher the risk becomes. But because cervical cancer is related to HPV – a sexually transmitted virus – the first peak is on account of what people did in their youth, and the second peak is due to mid-life divorces, second relationships, people being back on the dating market and so on.. The time delay between exposure and getting cancer is about 15-20 years. Most people have most sexual partners early in their sexual career – late teens, early 20s – which means that first peak occurs at 35-40, then second relationships in the mid to late 40s and early 50s create another peak around later. So, that second peak is directly related to women being exposed to a new raft of HPV when they enter second relationships. If they are not exposed to those – if they are not sexually active or are in a stable, monogamous relationship – the risk remains unaffected.
The interesting political argument is that screening stops at 65, but that is before the second peak really arrives. Often there is discussion about whether screening should be done on younger people, but actually the bigger debate is about whether screening should be done for older women. A key reason for the 65 cut-off point being there, however, is that women simply stop going – after about 50 women's engagement with cervical screening drops dramatically, perhaps because they have had a normal test result for a number of years and feel they no longer need to bother but also because the test becomes more painful. This is where GynaeCheck is perfect, because you don't necessarily need the speculum examination. You can continue with GynaeCheck well beyond menopause, when that second peak occurs.
