PapersEffect of screening on incidence of and mortality from cancer of cervix in England: evaluation based on routinely collected statistics
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7188.904 (Published 03 April 1999) Cite this as: BMJ 1999;318:904
All rapid responses
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.
Competing interests: No competing interests
Editor
Quinn, et al's assessment of the effectiveness of cervical cancer
screening(1) is an indictment of the cost effectiveness of this screening
programme.
Cervical cancer is a rare disease that was declining before the
introduction of the screening programme. Quinn, et al say that the £132
million spent each year "might have prevented 800 deaths from cervical
cancer in 1997". That is £165 000 for each death that "might have been
prevented". That money could be better spent.
In 1911 an embryologist, Dr John Beard, published his trophoblastic
theory of cancer's origins(2). This taught that cancers were similar to
pregnancy trophoblast and, in a similar way, caused the production of
human chorionic gonadotrophin (hCG), well known now as the basis of the
urinary diagnostic test for pregnancy. In the middle of the century, H H
Beard (no relation) and colleagues used this principle to detect cancers
at a very early stage with great accuracy(3).
Although these pioneers received little attention, new research by
Acevedo and co-workers at the University of Health Sciences, Pittsburg,
Pennsylvania on cancer cell lines in vitro and in vivo has confirmed their
work(4-7).
The hCG urine test for pregnancy has a retail cost of less than £6.
It is quick and easy to use and accurate for a wide range of cancers. Its
use as a screening tool would not only save a great deal of scarce NHS
resources it would also help patients: detection of malignancies at a much
earlier stage; less anxiety due to long waiting times; a lower incidence
of false negatives and false positives; and no risk of mix-ups in tissue
samples at pathology laboratories.
I have no competeing interests
Yours sincerely
Barry A Groves
Independent research
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
2. Beard J. The Enzyme Treatment of Cancer and its Scientific Basis.
Chatto & Windus, London, 1911.
3. Terrell TC, Beard HH. A biochemical test for chorionic
gonadotrophin in the urine and its value as an aid in the diagnosis of
pregnancy and malignancy. Southern Med J 1955; 49: 1352.
4. Acevedo HF, Kritchevsky A, Campbell-Acevedo EA, Galyon JC, Buffo
MJ, Hartsock RJ. Flow cytometry method for the analysis of membrane
associated chorionic gonadotrophin, its subunits, and fragments on human
cancer cells. Cancer 1992; 69: 1818-28.
5. Acevedo HF, Kritchevsky A, Campbell-Acevedo EA, Galyon JC, Buffo
MJ, Hartsock RJ. Expression of membrane-associated human chorionic
gonadotrophin, its subunits, and fragments by human cancer cells. Cancer
1992; 69: 1829-42.
6. Acevedo HF, Tong JY, Hartsock RJ. Human chorionic gonadotrophin-
beta subunit gene expression in cultured human fetal and cancer cells of
different types and origins. Cancer 1995; 76: 1467-75.
7. Acevedo HF, Hartsock RJ. Metastatic phenotype correlates with high
expression of membrane-associated complete beta-human chorionic
gonadotrophin in vivo. Cancer 1996; 78: 2388-99.
Competing interests: No competing interests
Does screening really reduce mortality?
Editor - We were rather non-plussed to read the conclusion about cervical cancer
screening by Dr. Quinn and colleagues (1) that is not supported by their
data and wonder whether “political correctness” had anything to do with
it. The statement '800 deaths might have been prevented in 1997' is based
on a projected mortality of a completely arbitrarily (alas, not randomly)
selected part of a subset of mortality trend graphs. Using the same
mortality trend graphs it is possible to reach an exactly opposite
conclusion. For example, in the age group 35-44 yrs, mortality fell from
10/100,000 to 5/100,000 in the period 1960 to 1975 and assuming the trend
continued -by 1997 it should have approached zero- Similarly, using the
same age groups as in the original paper, in the group 25-34 yrs,
mortality fell from 2.5/100,000 to 1.1/100,000 in the period 1955 to 1965
-by 1997 it should have again approached zero. Since the only new
intervention has been screening, and the mortality is excessive at
5/100,000 screening may have caused upto 2900 extra deaths in 1997. using
the same logic!
Jayant S Vaidya, MS DNB FRCS
Michael Baum, ChM FRCS FRCR
Reference
1. Quinn M, Babb P, Jones J, Allen E. Effect of screening on incidence of
an d mortality from cancer of cervix in England: evaluation based on
routinely collected statistics. BMJ 1999;318:904-908
Competing interests: No competing interests