Cervical screening

Cervical screening is available to anyone with a cervix between the ages of 25 to 64 in the UK. The screening test facilitates the identification of changes in the cervix which, if left untreated, could develop into cancer.  

Cervical screening saves at least 2,000 lives each year in the UK [1] and we can expect to see some further impact on lives saved where human papillomavirus (HPV) primary testing has been implemented [2]

There are a few key questions or misunderstandings that can arise around who is eligible to take part in cervical screening and to help with this we have updated our section on eligibility in the Cervical Good Practice Guide Feb 22 to help health professionals provide the right information to patients.

References:

  1.  Landy, R., Pesola, F., Castañón, A. et al. Impact of cervical screening on cervical cancer mortality: estimation using stage-specific results from a nested case–control study. Br J Cancer 115, 1140–1146 (2016). https://doi.org/10.1038/bjc.2016.290
  2. Castanon A, Landy R, Sasieni P. By how much could screening by primary human papillomavirus testing reduce cervical cancer incidence in England?. J Med Screen. 2017;24(2):110-112. doi:10.1177/0969141316654197

Cervical screening in Wales extended to every 5 years

CRUK article explaining why Wales have extended their screening intervals.

Read here

Overview of cervical screening programmes

HPV primary screening is now embedded in primary care across England, Scotland and Wales*. This means that instead of taking a sample of cells from the cervix and sending them to a lab for testing, samples will be tested for HPV first. Only those that are HPV positive will be examined for changes in the cervical cells.

*Northern Ireland have committed to the introduction, but at present there’s no clear timescale

Human papillomavirus (HPV) is a common infection. Most sexually active people come into contact with HPV during their lifetime. But for most, the virus causes no harm and the infection clears on its own. However, in some cases, HPV infection can lead to cell changes that can progress into cervical cancer. 99.8% of all cervical cancer cases in the UK are caused by the HPV infection. [1]

 

Diagram showing the results for every 100 people who have cervical screening

Diagram showing the results for every 100 people who have cervical screening https://www.gov.uk/government/publications/cervical-screening-description-in-brief/cervical-screening-helping-you-decide--2

 

You can read more about HPV and the HPV vaccination here.

It has been estimated that HPV primary testing in England could reduce the number of cervical cancers in women aged 25–64 by 23.9%, saving even more lives and helping to avoid unnecessary procedures for women.[2]

 

References

1 Brown, K.F., Rumgay, H., Dunlop, C. et al. The fraction of cancer attributable to modifiable risk factors in England, Wales, Scotland, Northern Ireland, and the United Kingdom in 2015. Br J Cancer 118, 1130–1141 (2018). https://doi. org/10.1038/s41416-018-0

2 Castanon A, Landy R, Sasieni P. By how much could screening by primary human papillomavirus testing reduce cervical cancer incidence in England?. J Med Screen. 2017;24(2):110-112. doi:10.1177/0969141316654197

There has been a decline over the past 10 years in the number of people taking up their offer of cervical screening.  Lower attendance is particularly evident in the youngest as well as the oldest age groups and in under-represented groups such as those from lower socio-economic and ethnic minority communities. [1]

You can find the stats for individual nations here:

References

  1. Marlow, L., McBride, E., Varnes, L. et al. Barriers to cervical screening among older women from hard-to-reach groups: a qualitative study in England. BMC Women’s Health 19, 38 (2019). https://doi.org/10.1186/ s12905-019-0736-z

  

The latest evidence, barriers, and resources to support participation of cervical screening, through informed choice

There are a range of suggested approaches that you could use to help remove any barriers to participation. Although cervical screening is a familiar procedure for primary care staff for most people it is not a routine process, so it is important to consider discussing cervical screening in conversation.

It is useful to find out what other practices in your area may be doing in case there is an opportunity to work together, or to share good practice. Also consider different options for reminding patients of their cervical screening appointment

  • Sending a targeted text message, endorsed by the GP has seen an increase in uptake [1]
  • Making a proactive telephone call
  • Sending a targeted letter to someone who is overdue or who has never attended an appointment.

For some, barriers to participation may be exacerbated by Covid-19 and health professionals may need to consider how they can proactively raise awareness of screening invitations and any new practice processes to encourage informed participation. See CRUK’s screening recovery guide for health professionals, for some useful tips for how you can support people to access cancer screening services.

CRUK explain how health professionals have an important role to play in supporting people to make an informed choice to access cancer screening in a PHE blog. Read more here.

Professor Sir Mike Richards’ screening review (England) recommended that there should be widespread implementation of initiatives which have been shown to improve uptake. This is particularly important for cervical screening, where the evidence base for interventions designed to increase uptake is growing.

Let us know if you are aware of or are involved in projects that could provide further evidence of good practice.

References

1 Marlow, L., McBride, E., Varnes, L. et al. Barriers to cervical screening among older women from hard-to-reach groups: a qualitative study in England. BMC Women’s Health 19, 38 (2019). https://doi.org/10.1186/ s12905-019-0736-z

There are several barriers that may prevent those eligible from engaging with the cervical screening programme.

Understanding who is not attending screening and the barriers preventing them from participating is important when looking at ways to support engagement with the programme. The reasons for non-attendance may be complex and several factors may be at play.  It is important to address the different barriers to enable everyone to attend screening if they want to.

Some of these barriers may include:

  • Feeling of embarrassment
  • Intending to go but not getting around to it
  • Fear of finding the procedure painful (incl. post-menopausal women)6
  • Worry about what the test might find
  • Previous negative screening experience
  • Finding it difficult to arrange a convenient appointment time
  • Perceived low risk of cancer or not needing screening, e.g. not currently sexually active or in a lesbian relationship (1)
  • Lack of awareness and knowledge of the purpose and benefits of the test which can lead to fear or lack of trust (2)
  • Worry about being perceived as promiscuous
  • Fear due to previous assault or abuse
  • Unable to access information due to language or mode of delivery

Some groups with lower participation include (3):

  • those aged 25–29 and those above 50
  • those living in areas of high deprivation
  • those with a learning or physical disability
  • ethnic minority communities – note disparity varies by ethnic minority group
  • lesbian and people who are bisexual (1)
  • the transgender community (4)

You can read more about barriers to cervical screening here.

References

  1.  Saunders CL, Massou E, Waller J, Meads C, Marlow LA, Usher-Smith JA. Cervical screening attendance and cervical cancer risk among women who have sex with women. J Med Screen. 2021 Jan 21:969141320987271.
  2. Waller J, Bartoszek M, Marlow L, Wardle J. Barriers to cervical cancer screening attendance in England: a population-based survey. J Med Screen. 2009;16(4):199-204. doi: 10.1258/jms.2009.009073. PMID: 20054095.
  3. Chorley, A. J., Marlow, L. A. V., Forster, A. S., Haddrell, J. B., and Waller, J. (2017) Experiences of cervical screening and barriers to participation in the context of an organised programme: a systematic review and thematic synthesis. Psycho-Oncology
  4. Berner, A. M., Connolly, D., Pinnell, I., Wolton, A., MacNaughton, A., Challen, C., Nambiar, K. Z., Bayliss, J., Barrett, J. and Richards, C. (2021) Attitudes of Trans Men and Non-binary People to UK Cervical Screening. British Journal of General Practice.

Cancer Research UK have developed a resource to share good practice with health professionals. The guide provides details of tried and tested interventions that could be used in practice, to support people, and provide them with the relevant information for them to make an informed choice about participating in cervical screening. 

Cervical Good Practice Guide Feb 22

To help people understand what happens at a cervical screening appointment you can share this short video found on our about cervical screening page.

Safety netting, quality improvements and future optimisation of cervical screening

Patients and health professionals should be aware that a previous normal cervical screening test result does not rule out cancer.

If a patient has any symptoms or changes that are not normal for them they should contact a health professional.

Being aware of the symptoms of cervical cancer is important as a normal result does not mean the patient does not have and may still develop cervical cancer in the future.

For more information about safety netting see CRUK’s safety netting web content

The recent change in the cervical cancer screening programme to test initially for human papillomavirus (HPV) infection is working well in practice and is more sensitive than cytology (smear) testing. Trials have shown that HPV screening leads to earlier detection of cervical lesions compared to liquid-based cytology [1].

The UK National Screening Committee (NSC) has recommended the extension of the screening intervals from three to five years for individuals aged 25 to 49 who test HPV negative as part of their routine screen test.

Following this recommendation, Scotland and Wales have extended their screening intervals and we are expecting other nations to change theirs too in the future.

A study looking at the acceptability of an increased screening interval, highlighted the need to provide women with information about the safety and rationale for any change [1,3].

Communicating the long timeline from HPV exposure to cervical cancer may reassure women about the safety of any proposed interval change [2].

References:

  1. Rebolj M, Rimmer J, Denton K, Tidy J, Mathews C, Ellis K et al. Primary cervical screening with high risk human papillomavirus testing: observational study BMJ 2019; 364 :l240 doi:10.1136/bmj.l240
  2. Hill E, Nemec M, Marlow L, Sherman SM, Waller J. Maximising the acceptability of extended time intervals between screens in the NHS Cervical Screening Programme: An online experimental study. J Med Screen. 2020 Nov 11:969141320970591. doi: 10.1177/09691413

Self-sampling is not routinely part of the cervical screening programme; however research is ongoing on the accuracy of home-tests and the feasibility of introducing them into the screening programme [3]. A study into self-sampling is being collated and we can expect to see analysis and results published soon.

Studies have shown that self-sampling could support an increase in the number of women taking up the offer of cervical screening. Self-sampling allows women to take a test in the comfort of their own home.

References:

  1. Rebolj M, Rimmer J, Denton K, Tidy J, Mathews C, Ellis K et al. Primary cervical screening with high risk human papillomavirus testing: observational study BMJ 2019; 364 :l240 doi:10.1136/bmj.l240
  2. Hill E, Nemec M, Marlow L, Sherman SM, Waller J. Maximising the acceptability of extended time intervals between screens in the NHS Cervical Screening Programme: An online experimental study. J Med Screen. 2020 Nov 11:969141320970591. doi: 10.1177/09691413
  3. Arbyn M, Smith SB, Temin S, Sultana F, Castle P. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. Bmj. 2018

In England and Northern Ireland, cervical screening uptake is incentivised through the Quality and Outcomes Framework (QOF) – practices need to ensure a high proportion of the target cohort undergo screening regularly to receive payment.

Additionally, in England the QOF Quality Improvement module on the early diagnosis of cancer provides an opportunity for GP practices to develop quality improvement plans for all screening programmes. Given the impact Covid-19 has had on screening programmes, NHS England has now revised this module to focus on restoring uptake of cervical screening and ensure patients are aware they can access primary care safely.

There are currently no other national incentive schemes operating in other parts of the UK, but this may change in the future. Even without such incentive schemes in place, it’s important to remember the valuable role that primary care can play in helping to support informed uptake of screening, removing any barriers and working collaboratively with local partners to reach out to communities.

In England, there is also the Primary Care Network (PCN) GP Contract Requirements for the Early Diagnosis service specification where PCNs are asked to:

Contribute to improving local uptake of National Cancer Screening Programmes by working with local system partners to agree the PCN contribution to local efforts to improve uptake.

For more information see CRUK’s GP contract hub