PapersEffect of screening on incidence of and mortality from cancer of cervix in England: evaluation based on routinely collected statistics

Editor - We note with interest the statistician's assessment of the
incidence and mortality from cervical cancer in England1 which claims that
the success in reduction of mortality rate since 1990 was due to the
introduction of national call and recall in 1988 and incentive payments to
general practitioners in 1990 with little apparent effect from the earlier
national screening programme which began in the mid-1960s.

At that time one of us (OANH) was invited by Sir George Godber, the
then Chief Medical Officer, to join the newly formed Committee on
Gynaecological Cytology (CGC) and served on it for 18 years. The National
Policy was to screen all women over the age of 35 every 5 years which was
not a bad policy with our, then, limited resources of expert Cytologists.
We soon found that there was a maximal response from younger women as 55%
of cervical smears were taken from women under 352 . It was obvious we
could not reach older, more at risk women, without an age/sex register as
existed in many of the successful Scandinavian countries.
We asked, from the inception of the CGC, for such a Register but were
told that it was not in the Committee's remit but that the whole
population was being registered for preventive health from birth onwards
and that we would get it by 1968. As it happened we got it in 1988 some
20 years later and then only because of the Breast Screening programme.

We did however have the means of improving the response rate from
older women by virtue of the Women's National Cancer Control Campaign -
formed just before the national screening programme began. With up to
nine mobile clinics and a lot of pre-publicity the WNCCC mobile clinics
attracted nearly a half more women in high risk groups (over 35, social
classes 4 and 5, and first smear over 35) compared to the attendance at
statutory clinics in the locality3 , through contracts with Health
Authorities and Workplaces throughout England, Wales and Scotland .
Much has been written about the results of screening programmes since the
first massive and successful one in British Columbia where it was
demonstrated in the Walton report4 that the differential rates of
reduction in cervical cancer deaths was directly related to the percentage
of population covered.

In the U.K. age-specific incidence rates 1963-1980, published by Cook
and Draper in 1984, showed a marked fall in the 45-54 cohort by 1980, who
would have been under 35 and the most intensively screened in earlier
years 5 .
Whatever changes are occurring in the national history of cervical cancer,
and the rise in glandular cancer brings a further complexity, there is
good reason to continue to screen for it by cytology, or the relevant wart
virus strains or by a number of new and upcoming techniques. Quality
practice however, as in all things must be maximally achieved.

O A N Husain
Consultant Pathologist
Charing Cross & St Stephen's Hospital (Rtd)

E Blanche Butler
Reader in Cytopathology
University of Manchester (Rtd)

References

1 Quinn M, Babb P, Jones J, Allen E. Effect of screening on incidence of
and mortality from cancer of cervix in England: evaluation based on
routinely collected statistics. BMJ 1999; 318: 904-8 (Full version)

2 Roberts A. Cervical cytology in England and Wales 1965-80. Health
Trends 1982: 14; 41-43

3 Husain OAN Opportunistic smears. J.R.Soc.Med. 1990; 83: 319-21.

4 Task Force. Appointed by the Conference of Deputy Ministers of Health.
Cervical cancer screening programmes. The Walton Report. Can. Med. Assoc.
J. 1976; 114: 1003-1033.

5 Cook GA., Draper GJ Trends in cervical cancer and carcinoma in situ in
Great Britain. Br. J. Cancer 1984; 50: 367-75.