National Health Service Cervical Screening Programme Research Articles

A comparison of the carbon footprint of alternative sampling approaches for cervical screening in the UK: A descriptive study.

To understand whether self-sampling can reduce carbon emissions (CO2 e) from the NHS cervical screening programme (NHSCSP) by comparing the carbon footprint of three sampling strategies: routine cervical sampling, vaginal self-sampling and first-void (FV) urine collection. Descriptive study. National Health Service (NHS), United Kingdom (UK). Patients aged 25-64 years eligible for cervical screening in the UK. A carbon footprint analysis was undertaken for three cervical screening sampling approaches, from point of invitation to screening through to preparation for transport to the laboratory for HPV testing. A combination of primary and secondary data were used, with a bottom-up approach applied to collection of primary data. We report CO2 e per sampling approach, which is the unit used to express carbon footprint and harmonise the contributions of greenhouse gases with different global warming potentials. The total carbon footprint of routine cervical sampling is 3670 g CO2 e. By comparison, vaginal self-sampling had a total carbon footprint of 423 g CO2 e, and FV urine sampling 570 g CO2 e. The largest share of emissions for routine sampling was attributable to the carbon footprint associated with an appointment in a primary care setting, which totalled 2768 g CO2 e. Routine cervical sampling is up to 8.7-fold more carbon-intensive than self-sampling approaches with equivalent effectiveness. We found negligible differences in the carbon footprint of alternative self-sampling methods, supporting the need for an informed choice of screening options for participants, which includes sharing information on their environmental impacts.

Two self-sampling strategies for HPV primary cervical cancer screening compared with clinician-collected sampling: an economic evaluation

ObjectiveTo compare the costs and effects of three sampling strategies for human papillomavirus (HPV) primary screening.DesignCost-consequence analysis from a health system perspective using a deterministic decision tree model.SettingEngland.ParticipantsA cohort of...

An audit of liquid-based cytology samples reported as high-risk human papillomavirus and borderline nuclear change in endocervical cells.

Primary human papillomavirus (HPV) screening, testing for the virus responsible for 99% of cervical cancers, was introduced in 2018-2020 in the UK. This was preceded by HPV triage of low-grade cytology from 2012. Much of the evidence incorporated into current National Health Service (NHS) colposcopy guidance assessed outcomes prior to this change in screening. The aim of this paper is to assess adherence to NHS cervical screening programme standards, determine the incidence of cases reported as high-risk HPV plus borderline nuclear change in endocervical cells, to calculate colposcopic accuracy and assess histological outcomes in this cohort. A retrospective audit of women referred to a colposcopy clinic in one NHS trust from 2016 to 2018. Data relating to histological outcomes, cytological follow-up and demographics were collected. Of 2001 referrals, 22 data sets identifying HPV-positive borderline endocervical change were eligible for analysis (1.2% incidence). Median age was 29.5. Two-thirds (68.2%, n = 15) had high-grade dysplasia at diagnostic biopsy. Those women with reassuring histology had normal cytological follow-up. Colposcopic accuracy was moderate (positive predictive value 43.8%, negative predictive value 100%). Borderline nuclear change in endocervical cells is an uncommon condition but should be treated as a high-grade referral. All women should be offered a diagnostic biopsy at the initial colposcopy; if no histopathological abnormality is identified, alternative sources of pathology should be considered. Excisional treatment should be recommended to unreliable attenders, those with a complete family and inadequate colposcopy (TZ3) and considered in younger women with a TZ3.

Rational care or rationing care? The case of cervical screening across the United Kingdom

In 2003, The National Health Service Cervical Screening Programme (NHSCSP) in England modified its recommendation by increasing the age at which to begin screening from 20 to 25. This was on the grounds that normal changes in the cervix before the age of 25 are often identified during screening as being abnormal, resulting in many young women receiving unnecessary treatment at both a significant psychological cost to the patient and a financial cost to the service. In 2011, the cervical screening programme in Northern Ireland was also amended followed closely by Scotland in late 2012. Some 10 years later, Wales finally altered cervical screening policy in January 2013 and now invite women for an initial screen at the age of 25, in line with the rest of the United Kingdom (UK).The withdrawal of cervical screening from 20 to 24 years in England was the first occasion globally, where a population cancer screening programme was withdrawn. Although the changes in England were perceived by some as “rational care” – as they encourage utilisation of beneficial services while discouraging use of those that may lead to more harms than benefits, many people also believe them to be “rationing care”. In fact, even now, a decade on from the policy alterations in England, people are still vociferously exhibiting their discontent at the decision; exacerbated by national media headlines such as: “Denying young women smear tests is a disgrace”. Yet with recent, rather alarming analysis of trends in England suggesting a rise in the incidence of cervical cancer in young women, it seems of great public health interest to consider whether such a rise is attributable to reduced cervical screening activity and reflect on whether the decision to alter cervical screening policy for those under the age of 25 was, in fact, a rational and correct decision

ABC3 Part I: a review of the guidelines for terminology, classification and management of cervical cytology in England

The provision of guidance on cytology reporting and evaluation, first outlined in 1995 with the publication of Achievable Standards, Benchmarks for Reporting, and Criteria for Evaluating Cervical Cytopathology (ABC), and subsequently revised and expanded in a second edition in 2000, has been pivotal to the success of the National Health Service Cervical Screening Programme (NHSCSP), ensuring that standards are upheld, and that rigorous evaluation and quality assurance take place. In the last decade, major changes to the NHSCSP, notably the adoption of revised age ranges and screening intervals for all women in England, implementation of liquid-based cytology and, most recently, the decision to introduce high-risk human papillomavirus (HR-HPV) testing for triage of low-grade and borderline (equivalent to 'atypical') cytological abnormalities and test of cure after treatment of cervical intraepithelial neoplasia (CIN) determined that an updated version of ABC was required. The third edition of ABC recommends adoption, with minor modification, of the revised British Society for Clinical Cytology terminology and provides guidance on the management of abnormal cytology results linked to this terminology taking account of HR-HPV testing. To accommodate these changes, expanded result codes, which are electronic codes used to transfer management information to central computers for follow-up, call and recall of individual women, have been developed. Further guidance on specimen adequacy is also provided. Revised performance indicators are described and explained in a separate article by R. Blanks in this issue of Cytopathology. All the changes in ABC3 are designed to support the mission statement of the NHSCSP that 'the objective of cervical screening is to reduce cervical cancer incidence and mortality by screening with a high sensitivity for the detection of CIN2 or worse, whilst maintaining a high specificity'.

Cervical screening in England: The past, present, and future

Cervical screening in England commenced in a disorganized fashion in 1964. The flaws of this approach became apparent in the mid-1980s and led to the inception of the National Health Service Cervical Screening Programme (NHSCSP). The main features of this program are its population-based registry, accessibility to all women within the screening age range, its systematic process of call and recall, national coordination, and quality assurance. Its success is in part based on its ability to evolve as evidence necessitates, and throughout the period of 2000-2010, it embarked upon a series of developments involving liquid-based cytology, which also provided the means to conduct reflex high-risk human papillomavirus (HR-HPV) testing and the potential to automate the screening process. As a result of evidence acquired since 2000, the NHSCSP is currently based on a system of primary cytology with HPV triage for low-grade abnormalities combined with cytology plus a HR-HPV "test of cure" for women who have received treatment for cervical intraepithelial neoplasia. Future challenges for the program will involve finding solutions to increasing screening uptake among women <30 years of age-a problem that may be exacerbated when vaccinated women reach the screening age, while making plans to accommodate HPV primary screening.

An audit of colposcopy appointment processes in women with abnormal cervical cytology

This study was conducted to audit the waiting times and default rates of colposcopy using the standard requirements of the National Health Service Cervical Screening Programme (NHSCSP) 2004 guidelines. The records of 291 women with abnormal cervical smears referred to the colposcopy clinic between January and December 2008 at Chiang Mai University Hospital, Thailand, were reviewed. The proportion of women with abnormal cervical smears of any grade receiving colposcopy appointments within 8 weeks of referral (96.9%) achieved the minimum requirements (≥ 90%). However, the waiting times for women with high-grade squamous intraepithelial lesion, glandular cell abnormality and invasive lesion smears were longer than recommended by NHSCSP guidelines. The default rate of 15.8% in this study was slightly higher than recommended by the guidelines (< 15%). Having no health insurance, being known to have HIV infection and waiting times longer than 4 weeks were independent predictors of default from an initial colposcopy appointment. The waiting times for colposcopy among women with high-grade smear abnormality and the default rate failed to meet standard requirements. Designing an effective protocol for colposcopy appointment processes is warranted.

An audit of cervical cytology in HIV‐positive women

To investigate whether a cohort of human immunodeficiency virus-positive (HIV+) women were having annual cervical cytology as recommended by the English National Health Service cervical screening programme (NHSCSP) guidelines. An audit of cervical cytology in an HIV+ cohort of 187 women by obtaining their last cervical cytology result and recall from local cytology services. Of the 187 women in the audit, two were ineligible, leaving 185 women, 167 (90.3%) of whom were aged 25-64 years and eligible for screening. Of the 185 women, 126 (68.1%) had a cytology history, 50 (27%) had never had cervical cytology and nine (4.9%) had inadequate details to ascertain whether or not they had a cytology history. Of the 126 with a cytology record, 34 (27%) had a current cytological abnormality, which was low grade in 25 (19.8%) and high grade in nine (7.1%). Among women aged 25-64 years attending the clinic, these percentages were significantly higher than expected for England as a whole (P < 0.001). Of 126 women with a cytology record, 29 (23%) were overdue for their recall date and of these the previous test was abnormal in 14 (48.3%). Cytology tests were taken within the community setting in 61 (48.4%), whereas 65 (51.6%) were seen either at an HIV sexual health clinic or were under colposcopy follow-up. Of 91 women with negative cytology only 50 (54.9%) were recommended for repeat in 12 months. This audit demonstrates a high rate of cytological abnormalities among HIV+ women compared with the screening population at large. Implementation of NHSCSP guidelines has been difficult and requires improved care pathways between HIV clinics, primary care and laboratories.

Colposcopy audit for improving quality of service in areas with a high incidence of cervical cancer

Objective To audit routine colposcopy performance using 8 standard requirements of the National Health Service Cervical Screening Programme (NHSCSP). Methods Records of women who underwent colposcopy for abnormal cervical cytology between January and December 2008 at Chiang Mai University Hospital, Thailand, were reviewed. Results The standard requirements were not achieved in 2 practices: (1) the proportion of women who had recordings of visibility of the transformation zone (96.6%) did not achieve the NHSCSP requirement of 100%; and (2) the rate of excisional biopsy (87.8%) was lower than the 95% minimum required. Conclusion Colposcopic performance at Chiang Mai University Hospital was generally favorable. However, re-audit is necessary to ensure that unmet standards of performance are improved and achieved standards are maintained.

Role of automation in cervical cytology

The introduction of liquid-based cytology (LBC) in UK laboratories has set a platform for automation in the cervical screening process. Currently, machines are used in sample preparation, recording of results and electronic transfer of data to various agencies. The UK government has recently set a turnaround time target by 2010 of 14 days from the sample being taken to the result being received by the woman. This target gives laboratories only 7 days to process and report cervical samples. Currently, two FDA-approved semi-automated machines are available which can expedite the microscopic analysis of the process; however, the available data on effectiveness and cost-effectiveness are not sufficient for the UK screening programme to make a decision regarding their introduction in cytology laboratories. The Health Technology Assessment-funded MAVARIC trial is assessing each system. It is also designed to provide a head-to-head comparison of both systems. The trial is due to report in 2009. If favourable, the UK screening programme will have to look into the detail of the practicality of introducing these technologies in cytology laboratories. This review focuses on the brief history of automation and gives details of the working of the two FDA-approved systems. The points needing to be considered when deciding whether or not to implement these technologies in the National Health Service Cervical Screening Programme (NHSCSP) in the UK will be enumerated.

Cervical surveillance in HIV-positive women: a genitourinary medicine clinic experience

BackgroundThe prevalence of cervical intraepithelial neoplasia (CIN) is increased in HIV infection. The UK National Health Service Cervical Screening Programme (NHSCSP) guidelines therefore provide specific recommendations for HIV-positive women. An...

An audit of standards of the ‘see and treat’ approach in women with a high-grade squamous intraepithelial lesion on Pap smears

SummaryThis study was undertaken to audit the performances of the ‘see and treat’ approach in women with a high-grade squamous intraepithelial lesion (HSIL) cytology at Chiang Mai University Hospital using selective criteria from the National Health Service Cervical Screening Programme (NHSCSP) 2004 guidelines. Women with a HSIL smear, who had undergone colposcopy and immediate loop electrosurgical excision procedure (LEEP) during June 2006 and September 2008, were reviewed. The standard measurement was determined by the following criteria: (1) the proportion of women treated at the first visit who have evidence of cervical intraepithelial neoplasia (CIN) on histology to be >90%; (2) the primary haemorrhage must be <5%; (3) the proportion of patients admitted as inpatients owing to treatment complication to be <2%. Of 247 women in this study, the histopathological results were as follows: CIN II–III, 188 (76.1%); cancer, 31 (12.6%); adenocarcinoma in situ, 5 (2.0%); CIN I, 5 (2.0%); and no CIN, 18 (7.3%). The prevalence of CIN I or higher was 92.7%. Primary haemorrhage was observed in 13 (5.3%) women. Four (1.6%) women were admitted as inpatients because of LEEP-related complications. In conclusion, the ‘see and treat’ approach in our institute has acceptable overtreatment and complication rates.

Cervical screening: why young women should be encouraged to be screened

BackgroundThe English National Health Service Cervical Screening Programme (NHSCSP) recommendation not to offer cervical screening to women aged 20–24 years is considered in the context of national rates of cervical...

Identifying the performance criteria for appraisal of colposcopists: benchmarking Delphi

Colposcopy forms an essential part of National Health Service Cervical Screening Programme (NHSCSP). With an increased emphasis on accountability and improved performance, there is a need to identify the performance criteria that are essential to be satisfied by the colposcopists at the time of appraisal. To identify the performance criteria essential for appraisal of colposcopists by two-generational Delphi survey. Delphi survey. Annual British Society for Colposcopy and Cervical Pathology conference (BSCCP 2005, Edinburgh, UK). Four hundred and ninety-nine delegates attending the above conference. A two-generational Delphi survey was undertaken to identify the criteria needed for appraisal. The participants were asked to rate the relevance of quality items that might be considered necessary for appraisal of performance of colposcopists. After the first round, the results were presented, and the respondents were given the chance to reflect on their response and change it if necessary. Criteria considered to be essential for appraisal of colposcopists in areas of training, diagnostic and therapeutic aspects and communication. In the first round, 306/499 (61%) participants returned the completed questionnaire. Sixty percent (187/306) of participants returned their questionnaire in the second round. In addition to BSCCP certification, four other criteria were identified, which were quality of recorded findings, biopsy rate when atypia noted, proportion of biopsies histologically adequate and proportion of normal initial posttreatment follow-up smears. This Delphi survey has been the first to identify criteria to be used in the annual appraisal of professionals. It has resulted in a number of criteria that could be considered for the appraisal and possible revalidation of colposcopists practising in UK.

Cervical cancer in women aged less than 25: East Kent experience

SummaryThe National Health Service Cervical Screening Programme (NHSCSP) guidelines raised the initiation of screening age from 20 to 25 years of age in 2004, on the basis that only 1.3% of cervical cancers occur in this age group. Between 2003 and 2005, cervical cancer was diagnosed in six women under 25 years in East Kent, 6.25% of 96 cervical cancers cases. All except one patient in our series presented with a cervical smear abnormality. High-grade cervical smear abnormalities were identified and treated in 187 women under 25 years during this period. Adoption of the guidelines may increase the incidence of invasive disease in young women, the stage at diagnosis and radicality of treatment required.

The number of dyskaryotic cells on an initial ThinPrep® cervical sample showing mild dyskaryosis has predictive value

Recent National Health Service Cervical Screening Programme (NHSCSP) guidelines suggest referral for colposcopy following an initial result of mild dyskaryosis. The aim of this study was to investigate if the number of dyskaryotic cells counted on an initial ThinPrep cervical sample showing mild dyskaryosis has predictive value. Cases of mild dyskaryosis on ThinPrep cervical samples from 2002 were retrieved from the cytology department records of St Luke's Hospital. A total of 123 sequential cases with a first-time result of mild dyskaryosis on ThinPrep slides with follow-up cytology available in the same institution were identified. While blinded to outcome, the number of dyskaryotic cells was counted in each case. Follow-up colposcopy/histology information was retrieved where indicated. The number of dyskaryotic cells counted on each slide was collated with outcome data. Of the 123 cases, six women were lost to follow-up. Seventy-three had a negative outcome, 27 had a low-grade outcome and 17 had a high-grade outcome. Only one of 17 high-grade outcome cases had < or = 15 dyskaryotic cells on the initial slide. The distribution of women with a negative/low-grade outcome and those with a high-grade outcome with >15 and < or = 15 dyskaryotic cells on the initial slide was tested using a chi-square test (P = 0.008). The negative predictive value for a high-grade outcome when < or = 15 dyskaryotic cells were present on the initial slide was 97.7%. The number of dyskaryotic cells on ThinPrep slides showing mild cervical dyskaryosis has predictive value. The number of dyskaryotic cells may be used to select women suitable for cytological rather than colposcopic follow-up.

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.

The predicted effect of changes in cervical screening practice in the UK: results from a modelling study.

In 2003, the National Health Service Cervical Screening Programme (NHSCSP) announced that its screening interval would be reduced to 3 years in women aged 25–49 and fixed at 5 years in those aged 50–64, and that women under 25 years will no longer be invited for screening. In order to assess these and possible further changes to cervical screening practice in the UK, we constructed a mathematical model of cervical HPV infection, cervical intraepithelial neoplasia and invasive cervical cancer, and of UK age-specific screening coverage rates, screening intervals and treatment efficacy. The predicted cumulative lifetime incidence of invasive cervical cancer in the UK is 1.70% in the absence of screening and 0.77% with pre-2003 screening practice. A reduction in lifetime incidence to 0.63% is predicted following the implementation of the 2003 NHSCSP recommendations, which represents a 63% reduction compared to incidence rates in the UK population if it were unscreened. The model suggests that, after the implementation of the 2003 recommendations, increasing the sensitivity of the screening test regime from its current average value of 56 to 90% would further reduce the cumulative lifetime incidence of invasive cervical cancer to 0.46%. Alternatively, extending screening to women aged 65–79 years would further reduce the lifetime incidence to 0.56%. Screening women aged 20–25 years would have minimal impact, with the cumulative lifetime incidence decreasing from 0.63 to 0.61%. In conclusion, the study supports the 2003 recommendations for changes to cervical screening intervals.

Quality in colposcopy.

This article analyses the colposcopy service, which is a crucial part of the National Health Service Cervical Screening Programme (NHSCSP), to assess how quality is measured and delivered. It highlights the role of the nurse colposcopist and discusses where improvements to the service could be made.

Proffered Papers 10.30–11.15 Monday 15 September 2003 4 An audit of the positive predictive value of high‐grade dyskaryosis for CIN 2 or worse on histology

The positive predictive value (PPV) of high‐grade dyskaryosis for CIN2 or worse on histology is published annually for the laboratories in the UK National Health Service Cervical Screening Programme (NHSCSP). The laboratories collect this data every year for a 3‐month period from April to June as part of the KC61 return. The laboratory PPV is expected to fall between 65% to 85% and provides an inter‐laboratory comparison figure for the specificity of the laboratory reporting. The PPV of individual consultants reporting the smears is monitored internally.The RVI the PPV fell from 84.9% in 2000–2001 to 78.71% in 2001–2002. PPV for individual consultants showed a drop for four of the five consultants, including a fall from 91.6% to 77.94%. The reasons for the fall were investigated by pursuing data rechecking, accuracy of reporting, cyto‐histological correlation, histology and colposcopy factors and follow‐up cytology. The main cause of the fall lay outside the laboratory in the type of biopsy taken at colposcopy.We conclude that the type of biopsy taken at colposcopy influences the PPV calculation. Informal discussions with others suggest comparison between laboratories is not reliable as departments vary in how the KC61 data is collected. As the type of data effects the correlation results, we conclude that caution must be exercised in inter‐laboratory comparisons until more standardization is introduced in histology data collection for PPV for the KC61. It is suggested that other laboratories view their PPV data with our findings in mind.