Views & Reviews From the Frontline

Cervical screening: a smear campaign

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c4640 (Published 25 August 2010) Cite this as: BMJ 2010;341:c4640
  1. Des Spence, general practitioner, Glasgow
  1. destwo{at}yahoo.co.uk
    Figure1

    I once worked in Norfolk; but when my wife fell pregnant she choked, “I want to go home.” Concrete tower blocks, Irish tricolours, Union Jacks, and red hair flashed through my mind. “To Glasgow!” I said. But Scotland has enduring qualities: humour, respectful irreverence, directness, pragmatism, swearing, and a national mantra, “Life is for living.” We may have some of the worst health statistics in the Western world, but we are a country of the unworried unwell. It is odd that there is a current anomaly in screening policy in the UK countries. Cervical screening in Scotland (and Wales and Northern Ireland) starts at the age of 20, not 25 as in England. Last year after the death of Jade Goody there were emotional calls to lower the screening age in England to 20 in line with rest of the UK. These calls came not merely from the tabloid press, which unquestioningly considers all screening a good thing, but also from many in the BMA.

    The incidence of cervical cancer in women younger than 25 is low: perhaps some 40 cases a year in the UK. Some people argue that screening could prevent half of these. But, as ever, theory is not the same as practice. A recent review of screening in women under 25 showed little or no benefit on rates of invasive cancer up the age of 30, so these cases may not be preventable by screening (BMJ 2009;339:b2968, doi:10.1136/bmj.b2968). Screening is also associated with harm. Some 40% of women will have a false positive result of cervical smear testing, representing non-progressive and reversible changes, during their lifetime (BMJ 2003;326:901, doi:10.1136/bmj.326.7395.901). These false positives don’t just cause considerable psychological angst but also lead to referral for colposcopy and treatments that remove part of the cervix—treatments associated with real and lasting harm. With even the least problematic treatment, large loop diathermy, the numbers needed to harm are 250 for preterm labour before 28 weeks and 500 for perinatal mortality (BMJ 2008;337:a1284, doi:10.1136/bmj.a1284).

    Even in the land of the far-from-free, irrational, unregulated, and financially driven screening, the United States, it has been recommended to raise the age at which screening starts to 21. This is at long last a recognition of the harms of overtreatment when screening young people. Also, the recent introduction of vaccination against human papillomavirus will see a decline in cervical dysplasia, so soon the absolute benefit of screening will be reduced greatly. Generally the cervical screening programme is a success story, but we should recognise its limitations. So, rather than England changing its policy, it is the devolved health departments in the rest of the UK that should raise the screening age to 25. For this is the pragmatic and simply the Celtic thing to do.

    Notes

    Cite this as: BMJ 2010;341:c4640

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