Cervical screening
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7451.1272 (Published 27 May 2004) Cite this as: BMJ 2004;328:1272All rapid responses
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Dr Raffle’s editorial describes a lamentable lack of ability to
harness information in the huge natural experiment that is the national
cervical screening programme. Differences in effectiveness in disease
prevention may be too small to measure but differences in scale of worry
from abnormal cytology reports and rates of colposcopy referral are huge
and easily estimated from published figures.
I drew attention to massively different rates between similar
population bases in 1996[1] and these differences have persisted.
Cervical cancer is perceived as a pressing problem in Wales and three
yearly screening from 20 to 65 is the current standard. I have studied the
figures of both Wales and individual components of the system. Current
Laboratory rates of abnormality extrapolate to cumulative lifetime rates
of abnormality exceeding total participating population coverage in nearly
half the Principality. This is not a sustainable or stable system. An
alternative screen, such as colposcopy without prior cytology should be
considered. This approach would remove “waiting worried” and the stigma of
referral to hospital following abnormal results which can cause life
insurance problems.
Cytology Screening Wales has given me suspend code data for the Local
Health Board of Merthyr Tydfil, a high cervical cancer incidence area
served by a “high reporting” laboratory, Prince Charles Hospital, Merthyr
Tydfil. Suspend codes indicate colposcopy referral. There is one
colposcopy referral per 45 year woman/lifetime screened, so three
colposcopy clinic attendances and associated smears and biopsies have to
be added to the cost of about 15 screening smears in any calculation of
current costs. Cutting out the smear tests would free up considerable
funds. The high rates are perceived as of the highest quality in a high
incidence area. These rates are not a flash in the pan; they have been
sustained for over a decade, so most participating women can expect to be
worried by an abnormal result.
Some women will have 45 years of screening without referral, but for
every one of these at least one woman will be referred to colposcopy
twice. Examination of suspend code rates over five and ten years suggests
a three way split in the population, about a third not referred, a third
referred once and the remainder having multiple referrals. Cervical cancer
incidence rates for Merthyr Tydfil have fallen less than the Welsh or UK
National trend in the five year time shift between the 1989-1998 and 1992-
2001 statistical reports [2, 3].
Merthyr Tydfil has the highest all causes mortality in the UK. There
are plenty of people of both sexes who could be helped by measures
suggested as appropriate by Dr Raffle. She asks for comments what would
her readers choose. I support her choices.
Dr Raffle’s Welsh colleagues and their paymasters have already chosen
and prioritised three yearly screening from ages 20 to 65. In Merthyr 22%
of the 25-35 years old screened population have visited the colposcopy
clinic in the last decade; many more have a single abnormal smear on file.
In public health terms is this a forgivable error?
If pre-malignant cervical intraepithelial neoplasia (CIN) really is
this prevalent, with cytological changes the norm and “biopsy proved” high
grade (CIN 2 or CIN 3) dysplasia afflicting a quarter of the population
then cervical screening cannot be abandoned. In areas such as Merthyr a
trial offering women entry to regular three yearly screening at 25 versus
appointments for colposcopy at thirty and forty as an alternative should
be considered.
Women are told “about 1 in 10 results show changes in the cells.”[4]
The reality is they are consenting to colposcopy via an anxiety generating
smear test lottery of uncertain validity.
1. Jones, Judy, Doubt cast on smear test results, The Observer,
London 7 January 1996
2. Page44, Cancer Incidence in Wales 1989-1998 Welsh Cancer Intelligence
and Surveillance Unit, Cardiff.
3. Page 97, Cancer Incidence in Wales 1992-2001 Welsh Cancer Intelligence
and Surveillance Unit, Cardiff.
4. Cervical Screening – The Facts, Cervical Screening Wales Cardiff August
2003
Competing interests:
Former Consultant Pathologist at Prince Charles Hospital, Merthyr Tydfil. See Reference 1 or search BMJ.Com for background information.
Competing interests: No competing interests
We were disappointed to read Angela Raffle’s editorial on cervical
screening [1]. The article was entrenched in the hypothesis that the only
outcome to assess the validity of cervical screening is death from
cervical cancer.
In 2000 there were 2424 newly registered cervical cancer diagnoses
but only 1035 deaths [2]. Most women are cured of their disease but the
morbidity from treatment is substantial unless the disease is detected in
it’s very early or pre-invasive stages. The standard treatment for
cervical cancer (Stage 1a2 to 4) is either radical hysterectomy or chemo-
radiotherapy. The former is associated with lymphocyst formation and
infertility. Furthermore, the incidence of bowel, bladder and sexual
dysfunction is substantial. Chemo-radiotherapy also causes infertility,
bowel dysfunction, urinary symptoms, and apareunia. Most women who receive
these treatments survive their disease yet at a great expense.
More frequent screening from the age of 20 is likely to detect
cervical dysplasia before invasion occurs but has been shown to have
little effect on mortality. Treatment for pre-invasive lesions is not
associated with so many complications and preserves fertility. It can
normally occur in the outpatient setting under local anaesthetic. Less
advanced cancers can also be treated by cone biopsy or radical
trachelectomy that does not result in infertility or sexual dysfunction.
It is time for public health physicians to look beyond mortality as
an outcome for cervical cancer screening and to look at other important
markers of health such as fertility, morbidity, and quality of life.
1 Raffle AE. Cervical screening. BMJ 2004; 328; 272 –1273.
2 Department of Health Statistical Bulletin, Cervical Screening
Programme, England: 2001-2002.
Competing interests:
None declared
Competing interests: No competing interests
Dr Raffle[1] works in one of the few areas in England that has
enforced a 5-yearly screening interval, and for which the new guidelines
will result in more rather than less screening. It is correct to point out
that decisions regarding at what ages and how often to offer screening
rely on a cost-benefit analysis taking into account available resources.
Unfortunately some of her estimates of the benefits of screening are
wrong. Our study[2] found that in women aged under 40 the risk of
cervical cancer 3-5 years after a negative smear is as great as in
unscreened women. Thus the cost per cancer prevented is the same using 3-
or 5-yearly screening in younger women. (The total cost and the total
number of cancers prevented are both greater with more frequent
screening).
Of greater importance is the dangerous suggestion to stop routine
screening beyond age 50. After at least three rounds of well organised
screening, nationally more than 1 in 200 screened women aged 50-64 have
moderate dyskaryosis or worse on their smear[3]; and in a multi-centre
study, 1.8% of over 30,000 women with a negative screening history before
age 50 had subsequent dyskaryosis[4]. These figures are in stark contrast
to 1 in 17,793 with a high-grade abnormality cited by Dr Raffle. Further,
there is no study showing that Pap screening offers protection for as much
as 10 years in older women, let alone 20 years. Our best estimate is that
one cancer is prevented for every 1000 screens when offered 5-yearly to
previously screened women aged 50-64. At a cost of about £25,000 per
cancer prevented, we would say that this is money well spent.
Peter Sasieni
Jack Cuzick
1. Raffle AE. Cervical screening. BMJ. 2004 May 29;328(7451):1272-
3.
2. Sasieni P, Adams J, Cuzick J. Benefit of cervical screening at
different ages: evidence from the UK audit of screening histories. Br J
Cancer. 2003 Jul 7;89(1):88-93.
3. Department of Health. Cervical screening programme, England: 2002-
03. Statistical Bulletin 2003/24. National Statistics 2003.
4. Flannelly G, Monaghan J, Cruickshank M, Duncan I, Johnson J,
Jordan J, Campbell M, Patnick J. Cervical screening in women over the age
of 50: results of a population-based multicentre study.BJOG. 2004
Apr;111(4):362-8.
Competing interests:
Peter Sasieni has a grant from the NHS Cervical Screening Programme to evaluate the effectiveness of screening
Competing interests: No competing interests
Sir
in the Wessex region in 1998 (unpublished data I obtained from public
health consultant) for every woman who died from cervical carcinoma 2
women and a man died from malignant melanoma.
Nationally, around twice as many people die from melanoma as from
cervical cancer, and the incidence is increasing.
There are 100 unfilled consultant dermatology posts in the UK, GPs
are not as well trained in melanoma recognition as they should be.
Although there is a lack of evidence that melanoma screening saves
lives (just as there was no evidence for the introduction of breast or
cervical screening when they were brought in)it is clear that melanoma is
a health emergency to which disproportionately few resources are being
devoted.
Dr Raffle has done a service by raising this question, better earlier
diagnosis of melanoma is just one of the areas of medicine where probably
more lives could be saved for the pound, but it is likely that the answer
will come from the powerful gender and defensive medicine lobbies
Competing interests:
None declared
Competing interests: No competing interests
The answer- but not the solution- to Dr Raffles’ question about how
one should spend government money is to insist that any body issuing new
guidelines should first have to identify what services are to be
sacrificed to fund the changes and then get agreement on this being done.
This is no new idea: it was standard policy up to the 1960’s, when the
Plowden report insisted that changes had to occur at whatever cost. “Power
without responsibility has been the prerogative of the harlot through the
ages”- only now it is the blinkered attitude of those who can see only the
needs of their special pleading groups.
No mechanism exists which can enumerate and evaluate the various
demands on a tax funded health service. Without that superficial policies
lurch to and fro in response to the latest fashions and politically
rewarding initiatives. Meanwhile the lumbering Leviathan blunders on with
self preservation as its only principle.
Having taken your (tax) money, is it right for government to decide that
money should be spent on someone else’s illness rather than yours? This is
the real cost of the NHS and will spell its downfall. It is time for Adam
Smith’s “Invisible Hand” to be given a chance.
Competing interests:
None declared
Competing interests: No competing interests
Daily Mail, July 15, 2012:
Cancer death grandmother
Grieving widower, Brian Cathcart, 57, told how his wife and
grandmother of seven, Julie, had been denied cervival screening when she
went to her GP. Their GP said, "We aren't allowed to screen anyone aged
over 50 any more."
Just four years later, Julie was found to have cervical cancer. "It
had spread", said Brian, "and there was nothing they could do. She was
dead in 6 months."
Now Brian is aiming to sue the NHS for denying his wife the right to
life............
*********
False positives are too easily regarded as "better safe than sorry";
false negatives are "blunders". It's very difficult to deny that "a stitch
in time saves nine", even though Angela Raffle shows quite clearly that
the stitch is expensive and more likely to damage the fabric than repair
it.
It's not evidence that drives screening programmes; it's politics.
Competing interests:
None declared
Competing interests: No competing interests
Editor,
In my opinion, expensive healthcare practices in cancer screening (1) will
continue all around the world as far as Oncological Terrain will be
overlooked or ignored in primary prevention of malignancy. Although cancer
screening is not at all the same as “Cancer Primary Prevention”, both
continuing to invite women over 50 for cervical screening and shortening
the screening interval from five years to three for “all” younger women,
is a real nonsense, beside an useless expensive healthcare practice. In
fact, only individual with Oncological Terrain as well as oncological
“real risk” can be involved by malignancy (2) (See website HONCode
233736, www.semeioticabiofisica.it). Doctors and health authorities
must fortunately take into account the existence of Single Patient Based
Medicine (3) beside EBM (See the above-cited website: Constitutions and
SPBM), as E.U. Competent Authorities suggest wisely (Network of Competent
Authorities Health Europe: website http://www.epha.org/a/355
URL:
http://europa.eu.int/comm/health/ph_information/documents/ev_20030710_co...
), referring to my former Rapid Response to BMJ.com. (2003) (4) about
SPBM, which is based on numerous biophysical-semeiotic constitutions
(diabetic, dyslipidemic, hypertensive, oncological, osteoporotic,
rheumatic, lythiasic, a.s.o.). After recognizing rationally “all”
individual with oncological terrain AND “real risk” of malignancy,
evaluated in a quantitative way, we can surely initiate the best of
malignancy primary prevention, as I suggest in my very recent book (2).
1) Raffle A.E.Cervical screening
BMJ 2004;328:1272-1273 (29 May), doi:10.1136/bmj.328.7451.1272
2) Stagnaro-Neri Marina, Stagnaro Sergio. Introduzione alla Semeiotica
Biofisica. Il Terreno oncologico”. Travel Factory SRL., Roma, 2004.
http://www.travelfactory.it/semeiotica_biofisica.htm
3) Stagnaro S. Single Patient Based Medicine against Health Care
Disparities.
(21 May 2004) http://bmj.bmjjournals.com/cgi/eletters/328/7450/1213
4) Stagnaro S
“Single Patient Based Medicine” versus EBM.
(16 May 2003) . http://bmj.com/cgi/eletters/326/7398/1048#32299
Competing interests:
None declared
Competing interests: No competing interests
An example of what not to do....
In Australia our screening program is aimed at all sexually active
women from teens to 70.
Basically the recommendation is you start screening a couple of years
after you become sexually active and present every 2 years.
This program GUARANTEES we harm as many women as possible.
Of course, absolutely no criticism of the screening program is tolerated.
There is very little discussion here about the risks and limitations of
screening and the need for doctors to obtain informed consent.
It seems that it doesn't matter how many women are put through the ordeal
of a false positive and biopsies, as long as we show a reduction in the
death rate from this cancer.
I recently saw a TV interview with a 21 year old woman unlucky enough
to have cervical cancer. Her smear (six months earlier) was normal...yet
the opportunity was taken to impress on all young women to rush out and
have their smears.
I cringed, knowing the damage that would be done...physically and
mentally, to these young women.
It's always a tragedy when a young person gets cancer, but rare cases
should never shape health care policy.
In that case, the young woman may have received a diagnosis and treatment
earlier, if she hadn't been screened...
I'm sure a "Normal" test result would reassure many symptomatic women.
I read recently that almost 78% of screened Australian women will
face a colposcopy (and usually some form of biopsy) in her lifetime, but
only a very small number will have any sign of malignancy. (Laura Koutsky,
Cancer Prevention, Fall 2004, Issue 4)
I think that figure is just shocking....but it's a figure that is
never mentioned to women.
The information women receive on cervical and breast cancer screening
is IMO, misleading and grossly inadequate.
I cannot believe we treat our healthy women this way.
The States is even worse...ANNUAL screening starting 3 years after
you become sexually active or from age 21...which seems to suggest that
all women should start screening by age 21 - even virgins!
I think the interval moves to 2 or 3 years after you've reached 30 and
have had three normal test results.
I've read that approx. 95% of women having annual screening will face
colposcopy (and usually biopsies)in her lifetime, with only a very small
number having any sign of malignancy. (RMDeMay, "Should we abandon pap
smear testing", Jnl of Cl Pathology, 2000)
These are very unpleasant and possibly, harmful procedures.
Some women are left with psychological/psychosexual issues, some have
damage that may cause infertility or problems during pregnancy and even
pre-term delivery.
Almost all doctors in the States also make full annual gynaecological
exams and smears a pre-requisite for contraceptive pills.
I'm not sure how that can be justified medically or ethically...
In Australia it seems that the need for doctors to obtain informed
consent and consider the welfare of their patients is largely ignored in
favour of reaching high screening targets and collecting financial
incentives from the Government.
It seems politics and money drive many of these cancer screening
programs and the health and safety of patients comes a very poor third....
Competing interests:
None declared
Competing interests: No competing interests