The age of cervical screening should be reduced: FOR: Invite them all by 25; use clinical judgement rather than refusing them below that age.

Abstract

Should the lower age limit of 25 for cervical screening be reduced? Or is it too late, now that 80% of women aged 20–24 will have been vaccinated by 2016? My answers to these questions are, respectively, yes and no. CIN3 and the less frequent CGIN are the lesions at greatest risk of progression to invasion. CIN3 spreads laterally and into crypts before invasion develops (Tidbury et al. BJOG 1992;99:853–6) at a rate estimated as ~1% per year. The risk of preterm delivery is related to depth of excision (Castanon et al. 2014;349:g6223). Small lesions are more likely to be treated adequately by a <10-mm-deep LLETZ (with no significant risk) than are larger lesions left untreated for several years. In 2003, 4000 cases of CIN3 (20% of all cases) were detected at age 20–24 and registrations in that age band were increasing. Increases in the same birth cohorts 5 years later (age 25–29) suggest a higher risk of disease in women born since about 1975 (Herbert et al. reply to Castanon et al. Br J Cancer 2013; 109:35–41). Recent figures do not suggest regression of untreated CIN3 in women aged 20–24; rather they suggest rates of progression greater than estimated because registrations of cancer below 30 years of age have increased proportionately more than CIN3 (100% compared with 50%). The downside of screening women aged 20–24 is the potential unnecessary treatment of CIN2: although progression to CIN3 takes place in 20–25%, around half regress spontaneously (Holowaty et al. 1999. J Natl Cancer Inst 91:252–8; Castle et al. Obstet Gynecol 2009; 113:18–25). Protocols for selective treatment of CIN2 could be implemented, equally relevant at age 25–29, which is the peak age band for CIN3. Uptake of young women for cervical screening has fallen during the last decade and less than two-thirds of women aged 25-29 are now screened (http://www.hscic.gov.uk/catalogue/PUB15968/cerv-scre-prog-eng-2013-14-rep.pdf). Abandoning the conflicting message that screening is harmful below 25 but essential above that age might help reverse this trend. There is little excuse for cancer developing in a young woman, who may have been sexually active since before the age of consent and who has been refused screening in an overly restrictive programme. Doctors should be allowed to use their clinical judgement when carrying out cervical cytology tests in women below 25 years of age – by which age all women should at least have been invited. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.