Cervical Cancer In England Research Articles

Trends in incidence of cervical cancer in England, 1985-2019

Abstract Background Worldwide, cervical cancer is the 4th most common cancer in women. The highest incidence is observed in Africa (25.6/100,000) and the lowest in North America (6.1/100,000). Over 99% of cases are caused by human papillomavirus (HPV). In the UK, HPV vaccination has been offered to school children aged 12-13 years since 2008. We conducted a retrospective population-based cohort study to examine whether there have been changes in the incidence of cervical cancer in England during the past four decades. Methods Individual level data for women diagnosed with cervical cancer in England during 1985-2019 were obtained from the Office for National Statistics/Public Health England. Average annual incidence rates were calculated by two age categories (0-49, 50+ years) and all ages combined during the seven five-year time periods (1985-89 to 2015-19). The percentage change in incidence was calculated as change in the average annual incidence rate from the first (1985-89) to the last time period (2015-19). Index of Multiple Deprivation (IMD) quintiles (2015-19) were examined to determine the social gradient of the disease. Results During the 35-year study period, a total of 100,303 women with cervical cancer were registered in England. In women aged 0-49 years, the average annual incidence rates declined by about 20% (from 11.6/100,000 in 1985-89 to 9.3/100,000 in 2015-19), and in women aged 50+ years, the rates declined by about 64% (from 26.1/100,000 in 1985-89 to 9.5/100,000 in 2015-19). At all ages combined, the rate declined by 43%. With regard to the social gradient, about half of the cases occurred in women in the most deprived quintiles. Conclusions There has been a steady decline in the incidence of cervical cancer in England over the past four decades. These findings are consistent with reports from other Western countries. The finding of relatively increased risk of cervical cancer among women from most deprived communities needs further investigation. Key messages • Considering that over 99% of cervical cancers are potentially preventable, there is an urgent need to support low- and middle-income countries to roll out HPV vaccination programme. • The difference in risk of cervical cancer by social gradient highlights the importance of reducing health and social inequalities.

Cervical cancer and COVID-an assessment of the initial effect of the pandemic and subsequent projection of impact for women in England: A cohort study.

ObjectiveTo review the effect of the COVID‐19 pandemic on the diagnosis of cervical cancer and model the impact on workload over the next 3 years.DesignA retrospective, control, cohort study.SettingSix cancer centres in the North of England representing a combined population of 11.5 million.MethodsData were collected retrospectively for all diagnoses of cervical cancer during May–October 2019 (Pre‐COVID cohort) and May–October 2020 (COVID cohort). Data were used to generate tools to forecast case numbers for the next 3 years.Main outcome measuresHistology, stage, presentation, onset of symptoms, investigation and type of treatment. Patients with recurrent disease were excluded.Results406 patients were registered across the study periods; 233 in 2019 and 173 in 2020, representing a 25.7% (n = 60) reduction in absolute numbers of diagnoses. This was accounted for by a reduction in the number of low stage cases (104 in 2019 to 77 in 2020). Adding these data to the additional cases associated with a temporary cessation in screening during the pandemic allowed development of forecasts, suggesting that over the next 3 years there would be 586, 228 and 105 extra cases of local, regional and distant disease, respectively, throughout England. Projection tools suggest that increasing surgical capacity by two or three cases per month per centre would eradicate this excess by 12 months and 7 months, respectively.ConclusionsThere is likely to be a significant increase in cervical cancer cases presenting over the next 3 years. Increased surgical capacity could mitigate this with little increase in morbidity or mortality.Tweetable Covid will result in 919 extra cases of cervical cancer in England alone. Effects can be mitigated by increasing surgical capacity.

Impact of screening between the ages of 60 and 64 on cumulative rates of cervical cancer to age 84y by screening history at ages 50 to 59: A population-based case-control study

There is little empirical data on the absolute benefit of cervical screening between ages 60-64y on subsequent cancer risk. We estimate the incidence of cervical cancer up to age 84y in women with and without a cervical cytology test at age 60-64y, by screening histories aged 50-59y. The current study is a population based case-control study of women born between 1928 and 1956 and aged 60-84y between 2007 and 2018. We included all such women diagnosed with cervical cancer in England and an aged-matched random sample without cancer. Women with a hysterectomy were excluded. Exposure was cervical cytology between ages 50–64y. The main outcome was 25y cumulative risk of cervical cancer between ages 60-84y. We found that eight in every 1000 (8.40, 95%CI: 7.78 to 9.07) women without a screening test between age 50‐64y develop cervical cancer between the ages of 60-84y. The risk is half: 3.46 per 1000 (95%CI: 2.75 to 4.36) among women with a test between age 60-64y but no cervical screening test at age 50-59y. The absolute difference in risk is equivalent to one fewer cancer for every 202 such women screened. The highest risk (10.01, 95%CI:6.70 to 14.95) was among women with abnormal screening at ages 50-59y and no tests 60-64y. 25y risk among women with a screening test every five years between age 50–64y was just under two in a 1000 (1.59, 95%CI:1.42 to 1.78). Results suggest the upper age of screening should be dependent on previous screening participation and results.

Prediction of cervical cancer incidence in England, UK, up to 2040, under four scenarios: a modelling study

SummaryBackgroundIn the next 25 years, the epidemiology of cervical cancer in England, UK, will change: human papillomavirus (HPV) screening will be the primary test for cervical cancer. Additionally, the proportion of women screened regularly is decreasing and women who received the HPV vaccine are due to attend screening for the first time. Therefore, we aimed to estimate how vaccination against HPV, changes to the screening test, and falling screening coverage will affect cervical cancer incidence in England up to 2040.MethodsWe did a data modelling study that combined results from population modelling of incidence trends, observable data from the individual level with use of a generalised linear model, and microsimulation of unobservable disease states. We estimated age-specific absolute risks of cervical cancer in the absence of screening (derived from individual level data). We used an age period cohort model to estimate birth cohort effects. We multiplied the absolute risks by the age cohort effects to provide absolute risks of cervical cancer for unscreened women in different birth cohorts. We obtained relative risks (RRs) of cervical cancer by screening history (never screened, regularly screened, or lapsed attender) using data from a population-based case-control study for unvaccinated women, and using a microsimulation model for vaccinated women. RRs of primary HPV screening were relative to cytology. We used the proportion of women in each 5-year age group (25–29 years to 75–79 years) and 5-year period (2016–20 to 2036–40) who have a combination of screening and vaccination history, and weighted to estimate the population incidence. The primary outcome was the number of cases and rates per 100 000 women under four scenarios: no changes to current screening coverage or vaccine uptake and HPV primary testing from 2019 (status quo), changing the year in which HPV primary testing is introduced, introduction of the nine-valent vaccine, and changes to cervical screening coverage.FindingsThe status quo scenario estimated that the peak age of cancer diagnosis will shift from the ages of 25–29 years in 2011–15 to 55–59 years in 2036–40. Unvaccinated women born between 1975 and 1990 were predicted to have a relatively high risk of cervical cancer throughout their lives. Introduction of primary HPV screening from 2019 could reduce age-standardised rates of cervical cancer at ages 25–64 years by 19%, from 15·1 in 2016 to 12·2 per 100 000 women as soon as 2028. Vaccination against HPV types 16 and 18 (HPV 16/18) could see cervical cancer rates in women aged 25–29 years decrease by 55% (from 20·9 in 2011–15 to 9·5 per 100 000 women by 2036–40), and introduction of nine-valent vaccination from 2019 compared with continuing vaccination against HPV 16/18 will reduce rates by a further 36% (from 9·5 to 6·1 per 100 000 women) by 2036–40. Women born before 1991 will not benefit directly from vaccination; therefore, despite vaccination and primary HPV screening with current screening coverage, European age-standardised rates of cervical cancer at ages 25–79 years will decrease by only 10% (from 12·8 in 2011–15 to 11·5 per 100 000 women in 2036–40). If screening coverage fell to 50%, European age-standardised rates could increase by 27% (from 12·8 to 16·3 per 100 000 by 2036–40).InterpretationGoing forward, focus should be placed on scenarios that offer less intensive screening for vaccinated women and more on increasing coverage and incorporation of new technologies to enhance current cervical screening among unvaccinated women.FundingJo's Cervical Cancer Trust and Cancer Research UK.

By how much could screening by primary human papillomavirus testing reduce cervical cancer incidence in England?

ObjectiveThe replacement of cytology with human papillomavirus testing as the primary cervical screening test in England is imminent. In light of newly available evidence, we revised our previous estimates of the likely impact of primary human papillomavirus testing on incidence of cervical cancer.Method and resultsUsing screening data on women aged 25–64 diagnosed with cervical cancer in England between 1988 and 2012, we previously reported that 38.8% had a negative test six months to six years prior to diagnosis. However, not all of these cancers would be prevented by human papillomavirus testing: for 1.0% the human papillomavirus positive test would come too late (within 18 months of diagnosis) to make a difference; 7.6% will have a negative human papillomavirus test (based on 79.9% sensitivity of human papillomavirus testing in cytology negative women); and 2.0% will develop cancer despite a positive human papillomavirus test. Additionally, we estimate that some women (equivalent to 4.3% of current incidence) whose cancers are currently prevented by cytology-based screening will have a false-negative human papillomavirus test.ConclusionOverall, we estimate that 23.9% (95% CI: 19.3–27.6%) of current cases in women invited for screening could be prevented. Based on 2013 cancer incidence statistics, absolute numbers could be reduced by 487 (95% CI 394 to 563) or 3.4 (95% CI 2.8 to 4.0) per 100,000 women per year.

Delays in diagnosis of young females with symptomatic cervical cancer in England: an interview-based study.

BackgroundDiagnosis may be delayed in young females with cervical cancer because of a failure to recognise symptoms.AimTo examine the extent and determinants of delays in diagnosis of young females with symptomatic cervical cancer.Design and settingA national descriptive study of time from symptoms to diagnosis of cervical cancer and risk factors for delay in diagnosis at all hospitals diagnosing cervical cancer in England.MethodOne-hundred and twenty-eight patients <30 years with a recent diagnosis of cervical cancer were interviewed. Patient delay was defined as ≥3 months from symptom onset to first presentation and provider delay as ≥ 3 months from first presentation to diagnosis.ResultsForty (31%) patients had presented symptomatically: 11 (28%) delayed presentation. Patient delay was more common in patients <25 than patients aged 25–29 (40% versus 15%, P = 0.16). Vaginal discharge was more common among patients who delayed presentation than those who did not; many reported not recognising this as a possible cancer symptom. Provider delay was reported by 24/40 (60%); in some no report was found in primary care records of a visual inspection of the cervix and some did not re-attend after the first presentation for several months. Gynaecological symptoms were common (84%) among patients who presented via screening.ConclusionsYoung females with cervical cancer frequently delay presentation, and not recognising symptoms as serious may increase the risk of delay. Delay in diagnosis after first presentation is also common. There is some evidence that UK guidelines for managing young females with abnormal bleeding are not being followed.

How much could primary human papillomavirus testing reduce cervical cancer incidence and morbidity?

Human papillomavirus (HPV) testing is being considered as the primary screening test for cervical cancer in England, rather than the currently used cytology test. We aimed to estimate the impact of primary HPV testing on incidence and morbidity of cervical cancer in England by estimating the proportion of cervical cancer diagnosed within 6 years of a negative cytology. We used a population-based case-control study of prospectively recorded data on cervical screening in England between 1988 and 2012, including 8774 women with invasive cervical cancer aged 25 to 64 and 17,341 controls. We used incidence rates in 2010 to estimate absolute risks. We found that 38.8% of all women with cervical cancer had a negative test within 6 years of diagnosis. Assuming HPV testing is 95% sensitive for cancers that would develop over the next 6 years but were missed by cytology, and that 4.3% of those diagnosed by cytology would be missed by HPV testing, we estimate that a maximum of 32.6% of current cases in women invited for screening aged 25 to 64 could be prevented. This translates to a reduction in the rate of cervical cancer in this age group of 4.2 per 100,000 women per year in England, equivalent to 587 cancers.

Dramatic increase in cervical cancer registrations in young women in 2009 in England unlikely to be due to the new policy not to screen women aged 20–24

To explore whether the 17% increase in cervical cancer in England in 2009 was due to the change in cervical screening policy. Trends in incidence of cervical cancer and of cervical intraepithelial neoplasia grade 3 (CIN3) were analysed for England, Wales and Scotland. Invasive cervical cancer data on 4079 cancers in women aged 20-39 diagnosed between April 2007 and August 2011 in England were analysed by single year of age. In England there was a 38% (95% confidence intervals [CI] 18-62%) increase in cervical cancer incidence rates in women aged 25-29 in 2009 relative to 2008, and a 30% (11-51%) increase in women aged 35-39. Compared rates in 2010 are similar to those in 2008. The average increase between 2000 and 2010 in women aged 25-29 was no greater in England than in Scotland and Wales (relative risk 0.98, 95% CI 0.69-1.39). In England there has been a gradual increase in CIN3 (particularly for ages 25-29) since 2003, with a more dramatic increase in 2009, but a fall in 2010. Audit data showed an increase in cancers diagnosed at age 25 in 2009/2010 and 2010/2011 (P ≤ 0.0004). No increase was observed at age 26. For ages 27-29 an increase in cancer was observed for 2008/2009-2009/2010 when compared with 2007/2008-2010/2011 (P < 0.00001), but linear trends were not significant. The increase in cervical cancer in England in 2009 cannot be attributed to the lack of screening of women aged 20-24, or to a general decrease in the coverage or quality of cervical screening.

Primary care factors associated with cervical screening coverage in England

The National Health Service Cervical Screening Programme was established to decrease the incidence and mortality of cervical cancer in England. To identify socioeconomic and general practice factors associated with cervical screening coverage in England, a national cross-sectional study was conducted using data on 26 497 476 female patients registered with 7970 practices in 152 English primary care trusts (PCTs). The 2008-09 data on cervical screening coverage rates from the quality and outcomes framework (QOF) database were used with data on QOF indicators, staffing levels and socioeconomic status. The mean cervical screening coverage rate was 78.5% at the PCT level and 83.5% at the practice level. At both levels, cervical screening coverage was significantly negatively associated with the index of multiple deprivation score, percentage of female patients aged 25-49 years and percentage of ethnic minority patients. Also, at the practice level, the percentage of female patients aged 50-64 years, overall QOF score and records and information score were significantly positively associated with cervical screening coverage. Cervical screening coverage was significantly lower in PCTs and practices serving higher percentages of younger-aged women, non-Caucasian individuals and those living in socioeconomic deprivation. It is therefore important to adopt strategies to improve cervical screening coverage in these groups.

The impact of policy and screening on cervical cancer in England

The impact of policy and screening on cervical cancer in England

The impact of policy and screening on cervical cancer in England

There has been a significant statistical decrease in the incidence of cervical cancer since screening programmes have been introduced. This article will explore and evaluate the impact of the Cancer Reform Strategy on cervical screening in England, which preceded the Government's policy for cancer care announced in January 2011. The Strategy raised the initial age of screening from 20 to 25 years of age. This left a group of the population who could not access screening while also not being eligible for vaccines against cervical cancer. Although this caused concern for many people, the media coverage and reaction to the human papilloma virus (HPV) vaccine and the death of Jade Goody, for example, encouraged women to consider cervical screening. The barriers to screening have been identified but overall the Cancer Reform Strategy was found have a positive impact both economically and socially. The Strategy has led the way for the Government's policy for cancer care, which needs to continue achieving the same positive outcomes.

Increasing rates of cervical cancer in young women in England: an analysis of national data 1982–2006

Background:In England, cervical cancer is the second most common cancer in women aged under 35 years. Overall incidence of cervical cancer has decreased since the introduction of the national screening programme in 1988 but recent trends of incidence in young women have not been studied in detail.Methods:Information on 71 511 incident cases of cervical cancer in England, 1982–2006, in 20–79-year-olds was extracted from a national cancer registration database. Changes in incidence were analysed by age group, time period and birth cohort. Poisson regression was used to estimate annual percentage change (APC).Results:Overall incidence, during 1982–2006, fell significantly from 213 to 112 per million person years. However, in 20–29-year-olds, after an initial fall, incidence increased significantly during 1992–2006, (APC 2.16). In 30–39-year-olds incidence stabilised during the latter part of the study period. The pattern was most marked in the North East, Yorkshire and the Humber and East Midlands regions. Birth cohorts that were initially called for screening between 60–64 and 35–39 years of age show an incidence peak soon after the age of presumed first screen, whereas younger birth cohorts show a peak at about 35 years of age. Incidence in the 1977–1981 birth cohort has increased relative to that among women born between 1962 and 1976.Conclusion:These results have implications for cervical screening, human papilloma virus vaccination and other public health interventions targeting young people.

Survival from cancer of the uterine cervix in England and Wales up to 2001

Cervical cancer is the third most common cancer in women worldwide, after cancers of the breast and large bowel, with approximately 470 000 new cases a year in 2000, some 10% of all cancers in women (Ferlay et al, 2001). Approximately 80% of all cases occur in developing countries, where cervical cancer is often the most common cancer in women, whereas in developed countries, cervical cancer only accounts for about 5% of all cancers in women. It has been known for 30 years from observational data that cervical cancer is likely to have an infectious component (Beral, 1974), subsequently confirmed as HPV (Bosch et al, 1994). Trials of vaccination already appear promising for primary prevention (Gravitt and Shah, 2005; Mao et al, 2006). In England and Wales, the age-standardised incidence of cervical cancer in the 1970s and 1980s remained between 14 and 16 per 100 000, although age-specific rates were influenced by strong cohort effects (those women born in the 1890s were at high risk, those born in the mid-1930s at low risk). The cervical screening programme began in the 1960s, offering cervical smear tests to detect premalignant lesions in women aged 25–64 years on a 5-yearly basis, but it was largely ineffective until the late 1980s (Murphy et al, 1988). In 1988, a national call and re-call system was established and coverage rose rapidly to approximately 85% (Quinn et al, 1999). As a result of these improvements, the incidence of invasive malignancy fell continuously after 1990 to below 9 per 100 000 in 2000 (Quinn et al, 2001; Office for National Statistics, 2003a). Mortality from cervical cancer in England and Wales had been declining steadily at approximately 1.5% each year from the early 1950s to the late 1980s. This long-term decline began before the introduction of screening. From 1990, the rate of decline in mortality increased three-fold, and by 2002 the age-standardised death rate had fallen to 29 per 100 000, barely one-third of the death rate in 1971 (83 per 100 000) (Office for National Statistics, 1999, 2003b). Only 1000 deaths were attributed to cervical cancer in 2002, and the screening programme has been credited with preventing 800 or more deaths a year (Quinn et al, 1999; Peto et al, 2004). We analysed the data for 44 090 women diagnosed with invasive cancer of the uterine cervix in England and Wales during the 14-year period 1986–1999, some 90% of those eligible for inclusion in the analyses. Approximately 4% of women otherwise eligible for analysis were excluded with zero recorded survival (date of diagnosis same as date of death). The proportion of women for whom recorded survival was zero did not vary between socioeconomic groups, however, and it was stable throughout the 1990s (data not shown). Therefore, these exclusions are unlikely to have had any substantial impact on socioeconomic gradients in survival, or on trends in the gradient. A further 3% of women with cervical cancer were excluded because it was not their first primary malignancy, and 2% because their vital status was unknown on 5 November 2002, the date when the data were extracted for analysis. Some two-thirds (67%) of cervical cancers were squamous carcinomas, and a further 16% were adenocarcinomas: both proportions were similar throughout the 1990s. Other morphological types were individually rare, but cancers with poorly specified morphology accounted for about 10%. Annual incidence rates for invasive cervical cancer in the late 1990s were 50% higher among the most deprived women (12.8 per 100 000) than among the most affluent (8.5 per 100 000), but this difference was less marked than in the early 1990s (63%). This is because incidence declined more among the most deprived women over this period (18%) than among the most affluent (11%) (Figure 1). Figure 1 Trends in the age-standardised incidence of cervical cancer in women aged 15–99 years, by deprivation group: England and Wales, 1986–1999.

Cervical screening in England and Wales: an update

The National Health Service Cervical Screening Programme (NHSCSP) has played a major role in reducing the mortality from cervical cancer in England and Wales. However, the current system has numerous shortcomings and it is likely that its success has reached a plateau. In light of this, significant changes have recently been made to the programme. These alterations, as well as further potential developments, are considered here. The aim of any change to the programme is to improve its sensitivity and specificity whilst reducing patient morbidity and maintaining cost-effectiveness. Alterations to NHSCSP guidelines include the replacement of the Papanicolau smear with liquid-based cytology, the referral for colposcopy of women with a single dyskaryotic cytology result and the commencement of screening at the later age of 25. These changes appear to be beneficial overall. The role of newer technologies in the programme is being clarified and it is likely that human papillomavirus testing will be incorporated in the near future. Progress is being made in the field of human papillomavirus vaccines, particularly prophylactic, which may go on to have the most profound impact on the incidence of cervical cancer. The disease is now largely a burden of the developing world, where the use of these technologies is considered. Changes currently being instituted in the NHSCSP should go some way towards improving the service. The importance of increasing coverage rates, reducing patient waiting times and the associated anxiety must not be overlooked.

Cervical cancer screening in England and Wales: an update

The National Health Service Cervical Screening Programme in England and Wales has been a significant factor in the fall of mortality in cervical cancer in England and Wales. This improvement is likely to reach a plateau. There appear to be two approaches to combat this. Firstly, and most importantly, coverage rates need to be improved. Secondly, the method of screening can be improved. This review article aims to look at changes that are currently being considered in order to further improve the Programme, whilst keeping it as cost-effective as possible. From a technical point of view, these include the introduction of liquid-based cytology and human papilloma virus (HPV) testing as well as other new technologies. Also discussed are the issues of the management of mildly dyskaryotic smears by cytological surveillance or immediate colposcopy, the auditing of all previous smears of patients with cancer of the cervix, and a possible change in the nomenclature used in England and Wales towards the Bethesda system (TBS). The psychological morbidity of screening is also considered as reducing this may improve coverage.

Analysis of Cervical Cancer Mortality and Incidence Data from England and Wales: Evidence of a Beneficial Effect of Screening

Summary Incidence and mortality rates for invasive cervical cancer in England and Wales have changed considerably since records began in 1950s. It is well known that cervical cancer rates show substantial birth cohort effects and these make the interpretation of secular trends difficult. Here the incidence data (from 1971) and mortality data (from 1950) are analysed by using generalized additive models. The goodness of fit is evaluated by using residual plots and scaled changes in deviance. The incidence of squamous cell and adenocarcinoma of the cervix were analysed separately after making an adjustment for those with unknown histology. Although the age and cohort model provides an adequate description of the data up to the mid-1980s, additional terms are required to model the more recent data. Reasonable fits are obtained by adding functions of calendar year since 1978 in each of three age bands. Estimates of the cohort effects obtained from the incidence of squamous cancer and mortality data are remarkably similar and fit with hypothesized effects of changing sexual norms on cervical cancer rates. Secular trends suggest that cervical screening had little effect on cervical cancer rates before the mid-1980s and that since then the effect on mortality and incidence of squamous cell carcinoma of the cervix has been substantial whereas the effect on the incidence of adenocarcinoma of the cervix has been modest. Secular trends are greatest in younger women. They are minimal in women aged 70 years and over. If the secular trends are attributed to cervical screening, the models estimate that, as a result of screening, approximately 6000 fewer deaths occurred between 1991 and 1997 and that approximately 4000 fewer squamous cancers were diagnosed between 1989 and 1992.

An evaluation of screening policies for cervical cancer in England and Wales using a computer simulation model.

Several screening policies have been recommended for implementation in England and Wales in the last 20 years, although no evidence as to their relative effectiveness or efficiency has been provided. Using a computer simulation model, the outcomes expected from those policies had they been implemented over a 30 year period (1961-90) have been examined. The original policies based on five-yearly testing of women aged over 35 appear to be the most cost-effective, and extension of screening to younger age groups leads to loss of efficiency. Attempts to use non-screening health care contacts in order to take cervical smears (eg, during pregnancy, family planning, at gynaecology clinics) produce few advantages and considerably complicate the establishment of regular testing for the individual. The achievement of higher attendance rates is as important to the outcome of screening as concentration on more intensive or complex policies.

The impact of screening on the incidence of cervical cancer in England and Wales.

Age-specific incidence curves for clinical cancer of the cervix in England and Wales show progressive changes over the period 1963-1978; in particular, a large reduction in incidence is seen in the age group 35-54. Since screening on any scale began in the early 1960s, we have investigated how much of this reduction in incidence in the middle age range can be attributed to detection of pre-invasive disease. Data on registrations of in-situ cancer have been used to estimate the patterns that might have been observed in the absence of screening. The results indicate clear cohort effects on incidence, with rising rates in the generations born 1906-1921 and since 1931, with a fall in the decade between. In addition to this, screening has probably led to a substantial reduction in the number of cases of clinical cancer in women aged 35-54, but has had little effect over the age of 60 where virtually no screening has been performed. Below age 35 the observed increase in incidence may be considerably less than it would have been in the absence of screening.

MORTALITY FROM CARCINOMA OF CERVIX UTERI IN BRITAIN

A review of age-specific mortality-rates from cervical cancer in England and Wales and in Scotland in 1968-76 shows a decline, striking at some ages. In England and Wales, however, there has been an increase at ages 25-34 and, possibly, at 15-24. Signs of such an increase are also seen in Scotland for the age-groups 25-34 when figures for two regions with well-established screening programmes are removed. Indeed trends in these regions compared with those for the rest of Scotland support the benefit of cervical screening.