2018 has officially made its mark on the world, with the year being donned ‘year of the woman’. From Oprah’s undeniably moving speech at this year’s Golden Globes building on the #MeToo campaign to the Jamaican women’s bobsleigh team reaching this year’s Winter Olympics. This year also marks 100 years since women were given the right to vote, but should we be gambling with our health?
The last week has seen the annual #SmearForSmear campaign launch, raising awareness of cervical cancer and encouraging young women to attend their routine cervical screening appointments. Cervical cancer is the most common cancer in women under the age of 35; every day, in the UK nine women are diagnosed with cervical cancer and two women lose their lives. However, in the UK one in four women don’t attend their cervical screening appointment when invited (Jo’s Cervical Cancer Trust, 2017). So, why is it that, in the ‘age of the woman’, we seem to brush off the idea of catching this very feminine cancer early with a simple test?
Could it be as simple as embarrassment, concerns about it being uncomfortable, a few horror stories and the old-fashioned and rather unpleasant name ‘smear’? It’s no surprise that the majority of women aren’t jumping for joy after reaching the country-specific prerequisite age where we can officially be invited. Cervical screening tests prevent 75% of cervical cancers from developing. This is too important to ignore; the reasons why cervical screening appointments are not attended need addressing publicly and vociferously (Jo’s Cervical Cancer Trust, 2017).
From a good idea to bad practice and the evolution of cervical screening
So, we know that cervical cancer is the most common cancer in women under the age of 35 (Jo’s Cervical Cancer Trust, 2017), but how common is common? It’s fair to say that cervical cancer is a worldwide problem, and something that has been dealt with in very different ways. Approximately 84% of global cervical cancer cases are within less developed countries, with the highest rates seen in Eastern Africa. This contrasts with Western Asia and Australia/New Zealand who sit at the opposite end of the scale having the lowest incidence and mortality rates (GLOBOCAN, 2012). Do these differences just boil down to the respective countries socioeconomic status? How much influence does culture have in our approach to healthcare and in particular, women’s health?
During the 1960s higher income countries had similar levels of cervical cancer incidence and mortality as those in less developed countries, but the difference in these rates has dramatically changed within the last 60 years due to effective screening procedures put in place (Elfstrom et al, 2015).
Today, screening programmes vary drastically between countries, even within Europe. There are no standard global procedures for who should be screened, how often it should be repeated and what method should be used. It is very difficult to say what is working well and why, as Elfstrom et al. discovered in an attempt to perform a quality assurance study across Europe. The main consensus to measure the success of these programmes relies on good coverage, e.g. the number of people who attend their screening appointments. According to the quality assurance survey of European countries, Sweden has the highest test coverage with 78% and 84% (the two percentages represent the two different age groups screened) whilst Hungary has the lowest coverage with less than 10% of women attending appointments. Interestingly, it seems that both Sweden and Hungary send out invitations to screening and both countries, in contrast to the vast majority of European states, offer screening outside of the programme. Age has always been a major discussion point for cervical cancer screening, most countries start screening female adults in their mid-20s – Sweden offers screening at 23 years old for example and the Czech Republic offers screening to all adult women. Of note, the quality assurance survey shows us that Hungary along with Czech Republic, Estonia, Iceland, Latvia, Lithuania, and Romania do not test for the HPV virus (Elfstrom et al, 2015). Does good coverage, age, and HPV testing equal lower incidence and mortality rates? The answer – it would seem so from the evidence on offer. Both Hungary and Sweden have just over 4 million women aged 15 or over, in Sweden there are approximately 451 new cases of cervical cancer each year and 187 deaths per year due to the disease. In Hungary, there are approximately 1,178 new cases per year and 461 deaths per year due to the disease (HPV Centre, 2017).
Looking further across the world it’s clear there isn’t a ‘one size fits all’ when it comes to screening programmes. Australia, most notably, have switched from a traditional Pap smear test programme for 18–70 year olds repeating every two years to a HPV screening test from the age of 25 upwards to be repeated every 5 years (Cancer Council Australia, 2017). Australia has one of the lowest incidence rates for cervical cancer in the world, but will this change in age and repeat time see a further improvement in those rates or a decline in early cervical cancer discovery? Only time will tell.
In China, cervical cancer screening is compulsory (Chang et al, 2013). Studies have shown that women there prefer the compulsory screening and check-up system and in line with this approach, China has a crude incidence rate of 9.4 – similar to Sweden with a crude incidence rate of 9.5 (HPV Centre, 2017). The idea of compulsory screening is something India has recently adopted – 2016 saw a mandatory national screening programme for oral, breast and cervical cancer introduced (Bagcchi, 2016).
Cervical screening was introduced in the UK in 1964. Although a step in the right direction, there was a lack of policy/guidelines as to which women should be screened and poor evidence on how often women should be screened. What’s more, those screened and who tested positively were often inadequately followed up. These screening methods had no impact on the then rising numbers of deaths due to cervical cancer in women <35. It wasn’t until 1988 that the UK’s National Health Service (NHS) launched the cervical screening programme which outlined who should be screened and who should be treated; women aged between 20–64 years old, invited for screening every 3–5 years. Even then, there have been issues such as in 1996 when 90,000 samples had to be re-examined due to insufficient training of cytoscreeners (Albrow et al, 2012).
Fast forward to 2018 and what’s changed? In the UK screening ages have changed to women aged between 25–64 and testing is now encouraged every 3 years for those within the 25–49 age bracket and every 5 years for those between the ages of 50–64 (NHS, 2015). The sexually transmitted human papilloma virus (HPV) is not only now tested for but a vaccine for girls between 12–18 years old was introduced in 2008. The HPV virus is thought to be responsible for nearly all cases of cervical cancer with the two strains HPV 16 and HPV 18 causing 70% of cases (Cancer Research UK, 2016).
Sadly, the advances and improvements we have seen in the UK and other higher income countries hasn’t been mirrored in all corners of the world with both Sub-Saharan Africa and Iran lacking screening programmes (Viviano et al, 2017; Nahvijou et al, 2016). Due to the economic status, lack of resources and evidence of the positive impact of cervical cancer screening in Sub-Saharan Africa a traditional Pap smear screening programme hasn’t been implemented. Unfortunately, HIV, which has a high prevalence in many African countries, makes women more susceptible to cervical cancer by reducing their immune response against the HPV virus (Viviano et al, 2017). Current practice in Africa is varied but several studies have tried to implement a visual inspection as an alternative screening method to Pap smear tests as those who test positive can be treated at the same time as inspection, encouraging uptake of treatment (Afzal et al, 2017).
In the Islamic Republic of Iran, the incidence rate of cervical cancer is much lower with approximately 5 cases per 100,000. However, due to this low incidence rate, there is no prevention screening plan in place leading to a poor prognosis for those diagnosed in the later stages of the disease. A cost-effective study to find a screening solution in Iran found the best method would be HPV DNA testing starting with women aged 35 and above, to be repeated every 10 years (Nahvijou et al, 2016). With further studies, a solution, such as this, tailored to the population and relevant socioeconomic issues, could work for other middle to low income countries lacking a screening programme.
We’re ready and waiting for the technology of 2018
Interestingly, the method of how we screen for cervical cancer hasn’t progressed and efforts haven’t been made to implement a non-invasive diagnostic procedure. Whilst the advances in diagnostics have meant more accurate results, earlier treatment and more lives saved, women must still endure the speculum and colposcopy on the doctor’s couch. Recently, there has been more and more talk about self-testing kits and the role they could play in screening. In 2014, Cancer Research UK launched a pilot clinical trial to investigate whether women who were overdue screening appointments would accept a self-screen test they could conduct at home. Of the 652 women who were offered the home screening test, 443 accepted and 292 returned samples. From those home screening samples 13% tested positive for HPV and after further investigation, 2 women were diagnosed with cervical cancer (Cancer Research UK, 2016).
Further studies are needed to confirm these results but having the technology to offer something as simple as a home screening kit, and that women will seemingly undertake this more readily is a positive marker for the future.
Duke University researchers have also developed a handheld device named the “pocket colposcope”. The device has been developed to provide cervical screening, while reducing the cost and discomfort of the traditional screening method. The pocket colposcope can be connected to devices such as laptops and smart phones, offering a much more portable screening and even with a question mark as to whether this could be another form of home screening. The real hope from this fantastic bit of technology is that women in lower socioeconomic countries will see the benefit and that mortality rates due to cervical cancer will decrease as Nimmi Ramanujam said during an interview “The mortality rate of cervical cancer should absolutely be zero percent because we have all the tools to see and treat it” (Science Daily, 2017).
The conclusion of this blog is really quite simple, there are many challenges today that result in women not undertaking something so important as a smear test. These challenges need to be looked at, with a nod to furthering gender equality in medicine, and addressed. However, the importance of a cervical smear test cannot be overlooked, so take control of your health and book your cervical screening appointment today!
Lauren McCracken, DMC
Afzal et al. 2017. Available from: https://www.sciencedirect.com/science/article/pii/S235257891730005X
Albrow et al. 2012. Available from: http://onlinelibrary.wiley.com/doi/10.1002/cncy.20203/full
Bagcchi. 2016. Available from: http://www.bmj.com/content/355/bmj.i5574.full
Cancer Council Australia. 2017. Available from: https://www.cancer.org.au/about-cancer/early-detection/screening-programs/cervical-cancer-screening.html
Cancer Research UK. 2016. Available from: http://www.cancerresearchuk.org/about-cancer/causes-of-cancer/infections-hpv-and-cancer/hpv-and-cancer
Cancer Research UK. 2016. Available from: http://www.cancerresearchuk.org/about-cancer/find-a-clinical-trial/a-study-looking-at-hpv-self-testing-for-women-who-have-not-been-for-cervical-screening#undefined
Chang et al. 2013. Available from: https://www.frontiersin.org/articles/10.3389/fpsyg.2013.00048/full
Elfstrom et al. 2015. Available from: http://www.ejcancer.com/article/S0959-8049(15)00224-5/fulltext
GLOBOCAN. 2012. Available from: http://globocan.iarc.fr/old/FactSheets/cancers/cervix-new.asp
HPV Centre. 2017. Available from: http://www.hpvcentre.net/statistics/reports/CHN_FS.pdf
HPV Centre. 2017. Available from: http://www.hpvcentre.net/statistics/reports/HUN.pdf
HPV Centre. 2017. Available from: http://www.hpvcentre.net/statistics/reports/SWE_FS.pdf
Jo’s Cervical Cancer Trust. 2017. Available from: https://www.jostrust.org.uk/smearforsmear
Nahvijou et al. 2016. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4898767/
NHS. 2015. Available from: https://www.nhs.uk/conditions/cervical-screening/when-its-offered/
Science Daily. 2017. Available from: https://www.sciencedaily.com/releases/2017/05/170531151035.htm
Viviano et al. 2017. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298303/