Evidence on increasing cervical screening uptake

Coronavirus (COVID-19)

We know that this is an especially worrying time so we have created a key messages document for Health Professionals focussed on safety netting patients presenting with symptoms during the coronavirus outbreak. We have also created a page on the subject specifically for patients on our about cancer hub. We will update that information as guidance changes.

Safety netting patients during covid-19

image of health professional holding a cervical screening test
Image Point Fr/Shutterstock.com

How we can help

Contact the Early Diagnosis with any questions about evidence or resources

Email us

Cervical screening is offered to women in the UK between the ages of 25 to 64 and involves checking samples collected from the cervix for abnormal changes or, increasingly, the presence of HPV (human papilloma virus), which increases the risk of cervical cancer. The ultimate intent is to prevent cervical cancer from developing, by detecting and treating changes early.

Up until 2018/2019, liquid cytology was used in the NHS Cervical Screening Programme. This involved looking at cervical samples under a microscope to check for any abnormal cell changes. But the way that samples are processed has changed. In 2016 the UK National Screening Committee (UK NSC) made a recommendation that the Cervical Screening Programme should incorporate human papillomavirus (HPV) testing as the first stage in processing samples.

What this means is that after a cervical sample has been taken, it will be sent to the lab and the samples will be first tested for HPV. Only samples that are HPV positive will undergo liquid-based cytology.

The change to HPV primary testing has happened to the Cervical Screening Programme in Wales (September 2018) and since then across England and Scotland, with the latter using it as an opportunity to increase the screening interval for all HPV negative women to 5 years. Northern Ireland has yet to introduce HPV as the primary test in its cervical screening programme.

HPV is a common infection which most sexually active people come into contact with in their lifetime. In most people, HPV doesn’t cause harm and the infection clears on its own. But in some cases, HPV infection can lead to cell changes that can progress into cervical cancer. You can read more about HPV and the HPV vaccine here.

99.8% of all cases of cervical cancer in the UK are linked to the HPV infection [1]. It has been estimated that the introduction of HPV primary testing in England could reduce the number of cervical cancers in women aged 25-64 by 23.9%, saving even more lives than the current test [2].

References

[1] https://www.cancerresearchuk.org/health-professional/cancer-statistics/s...

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5490776/

Because of the way that cervical screening programmes operate, it is more usual to see coverage data reported, than uptake. Uptake and coverage of cervical screening has been falling and is lower in specific groups of people. For example, uptake is lowest among participants aged 25-29 and coverage is particularly low in deprived populations and those with high proportions of ethnic minority communities [1].

You can find the stats for individual nations here:

Scotland

Wales

England

Northern Ireland

References

[1] https://www.england.nhs.uk/wp-content/uploads/2019/02/report-of-the-inde...

There has been growing interest in understanding the barriers to cervical screening. A study looking at non-participation in cervical screening found that approximately half of non-attenders did intend to be screened, but had just not actually made it [1]. The reasons for people not attending cervical screening are complex and may be different among different groups of people. There isn’t one solution to increase uptake and it’s important to address different barriers to enable everyone to attend screening if they want to. You can read more about barriers to cervical screening here.

References

[1] Marlow et al - Understanding the heterogeneity of cervical cancer screening non-participants: Data from a national sample of British women.

Interventions

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.

Improved acceptability of a screening test is one of the things linked to improved uptake [1]. Within cervical screening, there is a lot of interest in self-sampling as an example of this. The premise is usually that a participant takes a vaginal swab, often at home and then sends it off to be tested, in this case for HPV.  Women who test positive for HPV would be invited to have a sample taken by a health professional for cytology screening.

Evidence suggests that this could be an effective way of increasing uptake [2-4] and that many women who are overdue, or actively choose not to attend cervical screening, would be interested in HPV self-sampling.

There is a pilot taking place in parts of London to see whether HPV self-sampling kits should be offered to women who don’t attend their screening appointments. And screening programmes across the UK nations are interested in exploring this area too. We will update our information as more detail becomes available.

References

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5542134/

[2] Cadman L, Wilkes S, Mansour D, et al. A randomized controlled trial in non-responders from Newcastle upon Tyne invited to return a self-sample for Human Papillomavirus testing versus repeat invitation for cervical screening. J Med Screen 2015:22(1), 28–37.

[3] Kitchener, HC, Gittins M, Rivero-Arias O, et al. A cluster randomised trial of strategies to increase cervical screening uptake at first invitation (STRATEGIC). Health Technol Assess. 2016:20(68):1-138

[4] Szarewski A, Cadman L, Mesher D, et al. HPV self-sampling as an alternative strategy in non-attenders for cervical screening – a randomised controlled trial. BJC 2011:104(6), 915–920.

 

Pre-screening reminders have been found to support improved screening uptake [1], and as an example of this approach, text message reminders may be an effective way at increasing cervical screening attendance. A randomised control trial was carried out in a London borough to see how text messaging affected the proportion of women being screened. This trial showed a significant increase in uptake when a simple or GP-endorsed text message reminder was sent to women [2]. You can read more about the research in this blog post.

Public Health England (PHE) have announced that they’re working up some principles on the use of text messages for screening reminders, and we’ll share more on this when it’s ready.

References

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5542134/

[2] Behavioural text message reminders to improve participation. Huf et al. 2017

CRUK’s good practice guide resource is to support health professionals, mainly in primary care, who want to be more proactive. It provides information on some of the barriers to participation in the cervical screening programme and the details of tried and tested interventions that could be used in practice to encourage participation (through informed choice).

Engaging primary care in cervical screening good practice guide

We’re now on twitter.
Join the conversation and follow @CRUKHCPs for news, updates and opinion.

@CRUKHCPs

Last reviewed

Trans or non-binary?

A transgender man

Being trans or non-binary should not affect diagnosis or treatment of cancer, but sex assigned at birth, hormones or surgeries, will be relevant for some types of cancer screening.