The question being, is it safe to lengthen the screening process for women when the worry of cervical cancer is already prevalent?
With Public Health.Gov recently announcing changes to their cervical cancer screening, thousands of women have been left with concerns over their personal health as the government announced screening will now be routinely completed every 5 years rather than 3.
Brought to my attention earlier in the month by a social media post from a work colleague and numerous friends feeds and stories about this, I’ve come to work to find discussions between staff over this matter. The question being, is it safe to lengthen the screening process for women when the worry of cervical cancer is already prevalent?
As a male some might feel this may be a strange or a taboo subject to pass comment on, but as a Health Care Professional working in offices which are occupied heavily by women, am I not compelled to investigate this and help to support their concerns, whilst educating them and myself, and raising some awareness for those who feel strongly against these changes?
Re-think!
With a national ‘re-think’ petition campaign via change.org gaining over 1.2million signatures, women have fought back against the changes, expressing concerns that the extra 2 years left unattended between screenings can potentially open their risk of being misdiagnosed.
Cancer Research UK has commented saying that if diagnosed that 99.8% of cases are preventable. So, the initial thought is, why are women not screened yearly? Surely increasing the length of time un-screened will put women’s lives at risk!
What is Cervical Cancer?
The 4th most common type of cancer in females, and the highest of prevalence in under 35’s, cervical cancer is a type of cancer where uncontrolled abnormal cell division occurs in the cervix area, affecting the uterus/womb. Strongly linked to a virus called Human Papillomavirus (HPV), cervical cancer is the most common cancer caused by this virus, with total infection rates contributing to 5% of the worlds cancer diagnosis and 7.5% of all cancer deaths.
Cervical cancer risks can be lowered by routinely testing for cell changes in the cervix and via a vaccine that helps prevent cell abnormalities caused by the virus. Almost all cases of cervical cancer are linked to HPV.
What is HPV?
HPV is a common group of virus’s associated with skin-to-skin contact in the genital area. HPV is a sexually transmitted disease, however, penetrative sex is not required for transmission. Reported to be over 20,000 total cases in the UK and over 500,000 globally each year, the virus has no real symptoms and as well as its risk of cancer cell development, can also cause skin concerns such as common warts, verruca’s and genital warts. HPV is mostly linked to cancer cell development in the genital area due to its sexual transmission orientation and contributes to 99% of cervical cancer cases, as well as associations to cancer in the rectum, anus, throat and mouth.
Women are most at risk of HPV associated cell changes and thus are at a higher risk of cancer cell development. An average of over 3000 cervical cancer cases are diagnosed each year in the UK, contributing to almost 1000 deaths between 2016-2018. Despite these figures, cell changes develop slowly when in contact with HPV, and can take on average of 10 years before showing signs of abnormalities in a healthy population.
How does the NHS routinely test for cervical cancer in women?
Cervical screening started back in the 1960’s via means of the Papanicolaou Test (PAP Smear Test), identifying pre-cancerous cells in the cervix and helped identify women who were at higher risk of cancer development. PAP testing was later stopped when it was realised the method resulted in large quantity of false negatives and misdiagnosis.
In the 1980s it was found that HPV was a key factor in cancer development and the government launched a nationwide campaign introducing a new method looking for specific markers which increased risk. Cytology methods and computerised inputting were introduced, however, despite the government’s best attempts and the strategies becoming much more embedded into routine public health practice, the 1980’s – 1990’s saw numerous failings of the system and almost 100,000 women needing re-examination due to cases being missed.
From 2000 onwards the processes improved and rates have since significantly dropped. Screening was standardised to a 3-year procedure for women between the ages of 25-49, and 5 years for ages above 50+. Cytology screening process replaced its predecessors, via means of a liquid-based cytology (LBC), which subsequently ran alongside the HPV vaccination program which was introduced in 2008. This method continued until 2019 where it was replaced with Hr-HPV DNA testing, where specific high-risk strains of the virus are identified with almost 100% accuracy. Due to this and combined with the already successful vaccine, Hr-HPV screening is now the primary protocol for cervical cancer testing nationwide.
What is the vaccine?
HPV vaccine helps to protect against cancer by stopping viral infection from High-risk HPV strains. The vaccine is given in two doses and has been available to girls aged 12 and above born after 1st Sept 2006, or to women born after 1991 until the age of 25. Over 10 million vaccinations have been administered since 2008 and has reduced pre-cancerous cell changes by over 87%. Due to its success, public health and the NHS decided from 2019 that the vaccine was to be offered to boys to further limit the risk of HPV transmission between sexes.
Public Health England have suggested the vaccine will now prevent over 64,000 cervical related deaths, and 10,000 anal cancer deaths by 2058. Despite these figures and a well-established national vaccination programme against HPV, the vaccine does not protect against all types of Hr-HPV and there is no guarantee it will fully stop cancer development. There is always a risk of virus mutation, cell infection and cancer development despite being vaccinated or not.
My passing professional thoughts…
From reading online, comments seem to be based around the age of which screening starts (25) and the gap of which screening intervals occur (3 or 5 years). Not only is the lengthening of the screening duration from 3 to 5 years concerning, but it seems many feel that the age of which screening can start should be dropped from 25 to the age of 18.
With these comments in mind and the science suggesting that the combined protocols are sufficiently managing cervical cancer diagnosis, public health have subsequently suggested screening does not need to occur as often. The fact that HPV is slow acting on cells, taking up to 10 years to development and that under 25s are extremely unlikely to have any developmental changes, they suggest by inviting women to screening early could result in unnecessary investigations and treatment, with higher NHS costs.
The most recent Hr-HPV screening test is reported to be 98% reliable. This then shows that when HPV testing is completed, if the result is negative there is likely no Hr-HPV in the cervix and therefore minimal risk of cancer. If the first screen was completed and clear, even if the day after HPV was transmitted, the virus could then take up to 10 years to become harmful in cells. Therefore, if testing started at 12 alongside the vaccination programme, this would essentially mean you are safe from HPV related cell changes until the age of 22.
Saying that, there is still margin for error in the testing. HPV is usually contracted at a sexually mature age, and the fact the vaccine is offered at an age where teenagers are sexually active, wouldn’t it seem more sensible to screen at a slightly earlier age? With the average UK woman being sexually active by the age of 15, the current method leaves a gap of 10 years from vaccine to screening! This is the same 10 year period that scientists reports cells being able to change in cancerous ways. So, should we screen for Hr-HPV 10 years after the vaccine?
The Government nonetheless backs its rationale explaining that cervical cancer risk is rare in women under the age of 25 even though Hr-HPV is common in these age groups. The International Agency for Research on Cancer support this explaining these types of cells are usually dealt with via our own immune systems within a young age group, and subsequently they advise that with vaccination that screening doesn’t need to occur before the age of 25, explaining it can cause more damage than benefit.
This all seems ok for the younger age groups. Vaccines successfully prevent the virus and associated cell changes, however, has anyone considered the women who are over 25, but still under the age of 49, and who were born before 1991. Wouldn’t this group of women be exempt from the vaccine? And therefore, the associated potential risks for women aged 32 onwards be higher?
Public Health and the NHS look at stats and listen to health advisors who say research the science, and they feel the science is right. HPV is prevalent in teenage years but the risk of the virus causing irreversible damage is low thanks to the vaccine and more reliable laboratory testing but this isn’t the case with the later age groups. There are hundreds of comments from women raising concerns from being undiagnosed/misdiagnosed due to this rationale.
I might not be a mathematician but as previously mentioned, anyone born before 1991 wasn’t entitled to the vaccine, meaning someone born in 1990 would be 32 years old, and the age group for the new proposed screening spans till the age of 49. Researchers have mentioned risks of HPV are lower in women aged below 25, and this would then otherwise indicate that risks rise after 25. Therefore, there is 17-year age gap/ range of women that are at higher risk and have not had the vaccinations, who are now expected to have the longer screening intervals.
Conclusion…
It’s ok to say that the science says otherwise but if cases are still apparent, then shouldn’t this age range for women in their 30s onwards be screened on a different pathway regardless of how successful the newer Hr-HPV screening is! Considering this, and the fact that we all know the NHS system has been put through excessive stress due to Covid-19, resulting in the likeliness of cases being missed, are the risks not even more of a concern currently?
Granted this is a very tricky subject to comment on and to try and balance out an argument from a neutral perspective. In my opinion I think the vaccination should still occur at the age of 12, and considering the 10-year viral development window, that screening should then commence at the age of 22, or 10 years after the time of being sexual active. Teenagers and women should be able to consent to the screening at their own accord, with the first review interval being at 3 years, and monitoring thereafter at 5-year intervals as long as the test is clear.
Cases are always going to slip through the net, and can be missed due to laboratory error. There is also an element of genetic or family history to be considered where quicker cell deformation can occur and these should be considered on individual bases in these cases.
Considering all this, I see the governments rationale, and it seems from my perspective a largely debatable subject. I think the key closing point here should be science says there isn’t a risk and as a medical professional I believe in science! Yet if there is concern raised by women then shouldn’t we re-consider these protocols? The fact that Change.org has a huge petition campaign behind this already, shows me there is some proof in the comments.
I hope this HotTopix doesn’t cause any controversy, but I hope it does raise some knowledge and awareness. I know I have learnt and become more knowledgable by writing this and hope it can be as useful and informative to the readers.
If you would like to support this cause, then please click on the link below to sign up for the ‘re-think’ campaign.
Petition · Keep cervical screening to 3 years and not extended to 5 years. · Change.org
