MINI-SYMPOSIUM: CERVICAL CYTOLOGY
Call and recall cervical screening programme: Screening interval and age limits

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Summary

The smear test for cervical screening has been around for over 50 years; however, there is still worldwide variation regarding screening age limits and intervals. This article will review the literature and present new analyses of UK Audit data and international cancer registry data to address the issues of when to start and stop screening and how often to screen. A rational approach to determining screening policy should take into account the underlying rate of cervical cancer, the absolute difference in effectiveness of screening at different intervals, and the costs of screening, including side effects of treatment.

Section snippets

Age at first screen

The appropriate age at which to start screening depends on the underlying age-specific incidence of cancer, the (possibly age-specific) sensitivity of the screening test to detect pre-cancer and the effectiveness of treatment of screen-detected neoplasia. In England, the incidence of cervical cancer in women under 25 years of age is low (2.5 per 100 000 women per year),3 but the prevalence of human papillomavirus (HPV) is high4, 5, 6 and one in six smears in this age group is abnormal.3 Collins

Screening interval

In 1986, the IARC1 published a meta-analysis of the effectiveness of cervical screening using data from case–control studies (some of which were nested within cohort studies) from eight countries. In total, they studied 1381 women with squamous cell carcinoma of the cervix and 2259 age-matched controls. They found that the highest impact on incidence rates comes from screening every 3–5 years between the ages of 35 and 64 years. Screening women aged 25–34 years every 3 years or less has a

Screening in women over the age of 50 years

Van Wijngaarden and Duncan34 suggested that screening should stop at 50 years of age in women who had been adequately screened in their 40s. Their study in North-east Scotland found that cervical neoplasia in women over 50 years of age mainly occurred in women who had been inadequately screened. Cruickshank et al.35 calculated that an extra 9000 women who were adequately screened under the age of 50 years underwent screening to detect one case of CIN3. However, Flannelly et al.36 using data on

Screening women over the age of 65 years

Since the 1960s, screening beyond the age of 64 years has been considered unnecessary in most countries, provided that women have had three consecutive negative smear results. This recommendation was based on the low prevalence of pre-invasive disease in this age group. However, there is some controversy regarding when screening can be effectively and securely stopped.

At the beginning of the call–recall cervical screening programme in England, there was concern and debate regarding the

Side effects/barriers to screening

The most important side effect of and barrier to health-seeking behaviours and participation in screening, follow-up or treatment is anxiety and fear.2 In cervical screening, this comes from misunderstanding by women and health providers of the meaning of a positive smear result (specifically pre-cancerous lesions), a negative test result (usually interpreted as no risk instead of low risk) and an inadequate/unsatisfactory result.2

Other hazards of the screening programme are unnecessary

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