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Cervical Cancer – should the age for cervical screening be lowered?

Rebecca Drew
Each year in the UK around 250,000 people are diagnosed with cancer with 13,000 losing their lives to the disease. Statistically, more than one in three people will develop cancer at some point in their lifetime, with one in four dying from the condition. In 2013, around 29% of deaths in the UK were as a result of cancer. The outcomes for patients in the UK are drastically poor compared to those in other parts of Europe. When the coalition government produced their budget in January 2011, they introduced 'Improving Outcomes – a strategy for cancer'. Ultimately, it was the government's ambition to drive up England's cancer survival rate. At the time, it was proposed the strategy would work towards saving an extra 5000 lives every year by beating cancer. The government backed the strategy with £750 million of funding to be spread over four years. It set out plans such as:
  • Increasing early diagnosis (of which £450 million would be used to improve this)
  • Increasing the uptake of cancer screening by introducing new programmes but also enhancing prior versions
  • Ensuring all patients have access to the best possible treatment, care and support
Sadly, recent headlines bring this ambition into question; particularly given the fact that for the third consecutive quarter in a row, NHS England missed key targets for treating cancer patients. The NHS currently works towards a 62 day target by which time when cancer is suspected, treatment should be commenced. Between July and September this year just 83.5% of cases were treated within time, the target is 85%. The failure of 1.5% appears small, but in reality means that more than 5,500 of the 33,404 people who began treatment during this time were not provided with early treatment. Many patients saw their waiting time prolonged by two or three months before treatment was commenced.

'Improving Outcomes – a strategy for cancer' stresses early diagnosis is essential in trying to beat cancer; the government were upfront in their views that this needed improving within the NHS.

While there are many types of cancer where earlier diagnosis requires a review, I have focused on the issues surrounding the diagnosis of cervical cancer.

Cervical Cancer

Cervical cancer is a relatively uncommon cancer that often has no symptoms. In the UK roughly 3000 women are diagnosed with cervical cancer every year, which amounts to 2% of all types of cancer diagnosed.  Cervical cancer is diagnosed following a cervical smear test. Currently, cervical screening is available every three years for women between the ages of 25 - 49 and every five years for women between 50 – 64.   The smear test does not check for cervical cancer directly; rather it tests the health of cervical cells. The results can indicate 'abnormal' changes that may be present within the cervical cells.  To be precise, a medical instrument called a spectrum is inserted into the vagina, holding the walls of the vagina open so that the cervix is visible. Cells are then taken from the surface of the cervix using a small brush. Around 1 in 20 women will receive results that show some abnormal changes in their smear test. Most changes will not lead to cervical cancer and cells will revert to normal on their own. Over three quarters of all new cases are diagnosed in women aged 25 – 64 and cervical cancer is now the most common cancer in women under 35. Research states that cervical screening prevents around 45% of cervical cancer cases in women in their 30's, read more here.

There are several factors that can lead to the presence of abnormalities in the cervix, however, a significant number of the changes are caused by the Human papilloma viruses (HPV). HPV is a virus that affects the skin and moist membranes that line parts of the body including the vulva, cervix and vagina. HPV can be passed on by skin contact and most commonly through sexual intercourse. There are more than 100 different types of the HPV virus and most people will have the virus at some time during their life. HPV often causes no symptoms and resolves itself. However, some strains of the virus such as types 16, 18, 31, 33 and 45 increase the risk of developing cervical cancer. In particular, types 16 and 18 cause about 70% of cervical cancers. The remaining 30% are caused by the majority of the remaining strains. Recently the NHS has started to offer a test to check for HPV for those women who were found to have borderline or mild cell changes. Women who test positive for high-risk HPV are referred for a colposcopy (a close examination and biopsy of the cervix) straight away.

Additionally, in 2008, the NHS began providing girls between the ages of 12 – 13 with a vaccine against HPV. While on the surface it may seem that these are both positive changes that are working towards providing an earlier diagnosis, I am plagued by the following questions.
  1. What is being done to support young women that do not qualify for the vaccine?

  2. Why is the current age for compulsory cervical screening 25?
My questions are raised by much of what is portrayed by today's media. Firstly, there are often articles that focus on the fact that the age of young adults becoming sexually active has significantly lowered in recent years. It is known that HPV is a high risk cause of cervical cancer and often passed on through sexual intercourse, therefore, I question why women are only offered a cervical smear test when they reach the age of 25 and not when they reach the consensual age of 16?

When questioning this I highlight the following articles:
  • In 2013, Dawn Western attended her GP surgery with crippling back pain (a symptom of cervical cancer); she was refused a smear test on numerous occasions because she was only 24. A month after her initial complaint she finally received a smear test, her results were abnormal and she was referred for a biopsy. In December 2013, Dawn was told her cervical cancer was incurable and given months to live. She passed away just months later at the age of 26. Insultingly, one day after her death, Dawn's family received a letter inviting Dawn to attend her GP surgery for her first routine smear test. The full article can be read here.
  • In January 2013, 23 year old Keely Devine had attended her GP six times complaining of symptoms of cervical cancer. She too was refused a smear test due to her age; her diagnosis on several occasions even following several internal examinations was an inflamed cervix. Eventually having seen a registrar, she was told she needed a colposcopy and was diagnosed with cervical cancer. By the time she was referred for treatment her cancer was too advanced and she passed away in September 2013 Kelly's story can be read here and here.
  • In April 2013, Jess Evans was diagnosed with advanced cervical cancer. She repeatedly complained of abnormal bleeding and bloating. Due to her age, she was turned down for a smear test nine times. She passed away in February 2014. She was only 22.
  • In May this year, Labour MP Alison McGovern said that the death of Sophie Jones in March 2014, aged only 19, demonstrates that 'culture change is needed within the NHS'. Sophie presented to her doctors with many of the symptoms associated with cervical cancer, but was refused a smear test due to her age. Read more here
  • Most recently, Aimee Willet, aged 25 was diagnosed with cervical cancer following her first cervical smear. Aimee has been told that her cancer is inoperable and has been warned she is unlikely to survive until 2016. You can read more about Aimee's case here

In 2004, following a review by the 'Advisory Committee on Cervical Screening' regarding the age that cervical screening should start, the age was raised from 20, to 25. A review of cervical screening in 2012 confirmed that a policy of not screening under the age of 25 has little or no impact on the rates of cervical cancer in young women. One in three women under 25 would have an abnormal result, as opposed to one in fourteen for all women screened.  While I acknowledge that research shows routine screening of women under 25 may have little or no impact, I do not agree that it can be justified that a women under 25 is refused the right to a cervical smear test solely due to her age. Research may show it has little impact, but evidently cervical cancer is becoming increasingly common in women in their early 20's and only diagnosed following cervical screening! Late diagnosis affects over ¼ of patients every year and I would argue that access to a smear test under the age of 25 could drastically lower this figure.

The five cases I have outlined above are in reality only a very small number of the cases that are diagnosed each year affecting women in their early 20's. Unsurprisingly, the families of these young women are all campaigning for the age of cervical screening to be lowered.  The family of Sophie Jones have set up a campaign titled 'Sophie's Choice'. It requests for all young women who have symptoms and want a smear test to be automatically given one regardless of their age. The campaign is backed by MPs and has over 225,000 signatures for the minimum age for automatic tests to be lowered to 16. I agree and have backed this campaign myself.

While I acknowledge that enduring a cervical smear is embarrassing, uncomfortable and somewhat painful, these articles emphasise the necessity for the age of cervical screening to be lowered, or at the very least be available to women under the age of 25 when requested. A smear test would indicate abnormal changes within the cervix, lead to earlier diagnosis and therefore earlier treatment.  Evidently, Alison McGovern MP is correct in her view that a culture change is needed within the NHS and I believe that the only way to succeed in ensuring earlier diagnosis and treatment in relation to cervical cancer is to lower the age of cervical screening. It brings me to question the amount of harm that a test under the age of 25 could do, when it could potentially save someone's life.

Final thoughts

While I have focused on the issues concerning the diagnosis of cervical cancer and the fact that I believe it is vital the age of cervical screening is lowered, I cannot end this article without recognising that with regards to all types of cancer, more than a third of all NHS trusts in England have breached the '62 day target' for treatment.  This is wholly unacceptable. Cancer wards in NHS hospitals are rapidly expanding the number of patients they treat each year and recent publications suggest that by 2016 the NHS will be pushed to the limit due to the ever rising number of cancer patients.  Yet regardless of this, between 2009 /2010 and 2013 /2014 when the disease has been growing most rapidly (with the number of cancer patients up by 51%), the government spending has decreased by £200 million.  With a backing of £750 million to 'beat' cancer, it begs the question where this money has actually been used. Given this, unless there is culture change within the NHS and the government fulfil their funding specifications, it seems that the NHS is likely not only to fail in its target for the final quarter, but unless changes are implemented, enforced and continued almost immediately, they will do so for the foreseeable future.

Rebecca Drew, Paralegal to Mark Bowman

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