NHS Cervical Screening Programme Research Articles

The invasive cervical cancer review: psychological issues surrounding disclosure

An audit of the screening history of all new cervical cancer cases has been a requirement since April 2007. While NHS cervical screening programmes (NHSCSP) guidance requires that women diagnosed with cervical cancer are offered the findings of the audit, as yet there has been no research to investigate the psychological impact that meeting to discuss the findings might have on patients. This is in spite of the fact that cytological under-call may play a role in as many as 20% of cervical cancer cases. This review draws on the literature concerning breaking bad news, discussing cancer and disclosing medical errors, in order to gain insight into both the negative and positive consequences that may accompany a cervical screening review meeting. We conclude that while patients are likely to experience some distress at disclosure, there are also likely to be positive aspects, such as greater trust and improved perception of care.

Adjunctive colposcopy technologies for examination of the uterine cervix--DySIS, LuViva Advanced Cervical Scan and Niris Imaging System: a systematic review and economic evaluation.

Women in England (aged 25-64 years) are invited for cervical screening every 3-5 years to assess for cervical intraepithelial neoplasia (CIN) or cancer. CIN is a term describing abnormal changes in the cells of the cervix, ranging from CIN1 to CIN3, which is precancerous. Colposcopy is used to visualise the cervix. Three adjunctive colposcopy technologies for examination of the cervix have been included in this assessment: Dynamic Spectral Imaging System (DySIS), the LuViva Advanced Cervical Scan and the Niris Imaging System. To determine the clinical effectiveness and cost-effectiveness of adjunctive colposcopy technologies for examination of the uterine cervix for patients referred for colposcopy through the NHS Cervical Screening Programme. Sixteen electronic databases [Allied and Complementary Medicine Database (AMED), BIOSIS Previews, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Database of Abstracts of Reviews of Effects (DARE), EMBASE, Health Management Information Consortium (HMIC), Health Technology Assessment (HTA) database; Inspec, Inside Conferences, MEDLINE, NHS Economic Evaluation Database (NHS EED), PASCAL, Science Citation Index Expanded (SCIE) and Science Citation Index (SCI) - Conference Proceedings], and two clinical trial registries [ClinicalTrials.gov and Current Controlled Trials (CCT)] were searched to September-October 2011. Studies comparing DySIS, LuViva or Niris with conventional colposcopy were sought; a narrative synthesis was undertaken. A decision-analytic model was developed, which measured outcomes in terms of quality-adjusted life-years (QALYs) and costs were evaluated from the perspective of the NHS and Personal Social Services with a time horizon of 50 years. Six studies were included: two studies of DySIS, one study of LuViva and three studies of Niris. The DySIS studies were well reported and had a low risk of bias; they found higher sensitivity with DySIS (both the DySISmap alone and in combination with colposcopy) than colposcopy alone for identifying CIN2+ disease, although specificity was lower with DySIS. The studies of LuViva and Niris were poorly reported and had limitations, which indicated that their results were subject to a high risk of bias; the results of these studies cannot be considered reliable. The base-case cost-effectiveness analysis suggests that both DySIS treatment options are less costly and more effective than colposcopy alone in the overall weighted population; these results were robust to the ranges tested in the sensitivity analysis. DySISmap alone was more costly and more effective in several of the referral groups but the incremental cost-effectiveness ratio (ICER) was never higher than £1687 per QALY. DySIS plus colposcopy was less costly and more effective in all reasons for referral. Only indicative analyses were carried out on Niris and LuViva and no conclusions could be made on their cost-effectiveness. The assessment is limited by the available evidence on the new technologies, natural history of the disease area and current treatment patterns. DySIS, particularly in combination with colposcopy, has higher sensitivity than colposcopy alone. There is no reliable evidence on the clinical effectiveness of LuViva and Niris. DySIS plus colposcopy appears to be less costly and more effective than both the DySISmap alone and colposcopy alone; these results were robust to the sensitivity analyses undertaken. Given the lack of reliable evidence on LuViva and Niris, no conclusions on their potential cost-effectiveness can be drawn. There is some uncertainty about how generalisable these findings will be to the population of women referred for colposcopy in the future, owing to the introduction of the human papillomavirus (HPV) triage test and uptake of the HPV vaccine.

The NHS Cervical Screening Programme criteria for evaluating cervical cytology: comparison of the new with the old

The NHS Cervical Screening Programme criteria for evaluating cervical cytology: comparison of the new with the old

The NHS Cervical Screening Programme

Cervical cancer is the 11th most common cancer in women. Cervical screening aims to reduce the number of women who develop invasive cervical cancer and, consequently, the number of deaths caused by cervical cancer, by regularly screening women so that cervical abnormalities that might otherwise develop into invasive cancer can be identified and treated. GPs play an important role in raising awareness of cervical cancer and ensuring that women are provided with the necessary information and advice to assist them in making an informed choice about attending cervical screening appointments.

Cost effectiveness of human papillomavirus test of cure after treatment for cervical intraepithelial neoplasia in England: economic analysis from NHS Sentinel Sites Study

Objectives To evaluate the cost effectiveness of human papillomavirus testing after treatment for cervical intraepithelial neoplasia (CIN).Design Economic analysis using a Markov modelling approach to combine cost and epidemiological data...

Who defaults from colposcopy? A multi-centre, population-based, prospective cohort study of predictors of non-attendance for follow-up among women with low-grade abnormal cervical cytology

The success of cervical screening relies on women with abnormal cervical cytology attending for follow-up by colposcopy and related procedures. Failure to attend for colposcopy, however, is a common problem in many countries. The objective of this study was to identify factors associated with non-attendance at an initial colposcopy examination among women with low-grade abnormal cervical cytology. A cohort study was conducted within one arm of a multi-centre population-based randomised controlled trial nested within the UK NHS Cervical Screening Programmes. The trial recruited women aged 20-59 years with recent low-grade cervical cytology; women randomised to immediate referral for colposcopy were included in the current analysis (n=2213). At trial recruitment, women completed a socio-demographic and lifestyle questionnaire; 1693 women in the colposcopy arm were also invited to complete a psychosocial questionnaire, including the Hospital Anxiety and Depression Scale. Women were sent up to two colposcopy appointments. A telephone number was provided to reschedule if necessary. Defaulters were defined as those who failed to attend after two appointments. Logistic regression methods were used to compute multivariate odds ratios (OR) to identify variables significantly associated with default. 148 women defaulted (6.7%, 95%CI 5.7-7.8%). In multivariate analysis, risk of default was significantly raised in those not in paid employment (OR=2.70, 95%CI 1.64-4.43) and current smokers (OR=1.62, 95%CI 1.12-2.34). Default risk deceased with increasing age and level of post-school education/training and was lower in women with children (OR=0.59, 95%CI 0.35-0.98). Among the sub-group invited to complete psychosocial questionnaires, women who were not worried about having cervical cancer were significantly more likely to default (multivariate OR=1.56, 95%CI 1.04-2.35). Anxiety and depression were not significantly associated with default. Women at highest risk of default from colposcopy are younger, not in paid employment, smoke, lack post-school education, have not had children and are not worried about having cervical cancer. Findings such as these could inform the development of tools to predict the likelihood that an individual woman will default from follow-up. Interventions to minimise default also deserve consideration, but a better understanding of reasons for default is needed to inform intervention development.

British HIV Association guidelines for the management ofHIVinfection in pregnant women 2012

British HIV Association guidelines for the management of<scp>HIV</scp>infection in pregnant women 2012

4.0 Screening and monitoring of HIV‐positive pregnant women

4.0 Screening and monitoring of <scp>HIV</scp>‐positive pregnant women

The impact of Jade Goody's diagnosis and death on the NHS Cervical Screening Programme

ObjectivesIn August 2008 the British reality TV star Jade Goody made public her diagnosis of cervical cancer. In February 2009 it was announced that she was terminally ill and she died a few weeks later. A surge in cervical screening attendances associated with these events was widely reported. This paper aims to quantify the size of that effect across England, its duration, and whether it affected some groups of women more than others.SettingThe Cervical Screening Programme in England.MethodsRoutinely collected statistics for the months around Jade Goody's diagnosis and death were compared with those for other periods.ResultsAbout half a million extra cervical screening attendances occurred in England between mid-2008 and mid-2009, the period during which Jade Goody was diagnosed and died; among these were 370 attendances where the test result was suspected neoplasia. At its peak in March 2009, attendance was 70% higher than expected. Increases were seen in both initial and follow-up screening attendances and in colposcopy attendances, and at all ages, though the magnitude was greater for women aged under 50. A substantially greater proportion of the extra attendances of women aged 25–49 on routine recall occurred in women whose attendance was overdue (28% occurred at 60 months or more) and relatively little represented over-screening (8% had been screened within the last 30 months).ConclusionsThe pattern of increased attendance mirrored the pattern of media coverage of Jade Goody's diagnosis and death. It is likely that the increased screening resulted in a number of lives saved.

A comparative study of efficacy and outcomes of large loop excision of the transformation zone procedure performed under general anaesthesia versus local anaesthesia

Although Australian National Health and Medical Research Council (NHMRC) guidelines do not specify targets for mode of anaesthesia for large loop excision of the transformation zone (LLETZ) procedures, UK NHS Cervical Screening Programme (NHSCSP) guidelines recommend that >80% of LLETZ procedures be performed under local anaesthesia. There is a paucity of clinical data regarding both the proportion of women receiving general anaesthesia for treatment, factors underpinning this choice and the impact of mode of anaesthesia on treatment outcomes. To identify the proportion of women who have a LLETZ under general anaesthesia and to establish the impact of mode of anaesthesia on outcomes including treatment efficacy, overtreatment (negative histology), short-term morbidity and attendance for follow-up. Single-centre retrospective analysis of all women treated with LLETZ for suspected cervical dysplasia between 1, May 2005 and 1, May 2009. Thirty-three percent of a total 465 LLETZ procedures were carried out under general anaesthesia, although the reason for anaesthesia choice was not recorded in 52% of cases. There were no significant differences in the primary outcomes of unclear LLETZ margins or negative LLETZ histology, or in the secondary outcomes of depth and surface area of LLETZ specimen, short-term morbidity or rates of incomplete follow-up. Although reasons underpinning selection of anaesthesia mode remain elusive, at this centre, outcomes following LLETZ procedure for the management of suspected cervical dysplasia are not affected by the mode of anaesthesia used.

Review of cytology and histopathology as part of the NHS Cervical Screening Programme audit of invasive cervical cancers

To audit pathology slide reporting in the Cervical Screening Programme in England by reviewing cytology and histology slides from women subsequently diagnosed with invasive cervical cancer. Between April 2007 and March 2010, 6113 women diagnosed with cervical cancer were identified. Cervical cytology and histology slides taken within 10 years of diagnosis were identified and where possible reviewed after a nationally agreed protocol. Reviewers were not blinded to the original reading of each sample. Most cytology samples before 2005 were conventional, most after 2007 liquid based. Of 13,745 cytology results from women developing cervical cancer, 55% were reviewed. The review result was identical for 55% of slides. Of 3759 originally normal slides, only 45% were normal on review: 11% were inadequate, 21% low grade (borderline or mild dyskaryosis) and 23% high grade (moderate dyskaryosis or worse). Of tests originally normal taken over 5.5 years before diagnosis, 14% were upgraded to high grade compared with 37% within 3.5 years of diagnosis. Of 5159 histology specimens recorded within 10 years of diagnosis of a cancer, 3895 were reviewed. Overall, 94% of samples reviewed retained the original diagnosis. One per cent (33/3012) of cancers were downgraded and 5% (6/112) of negative samples were upgraded to cancer upon review (four of which were taken within 2 months of diagnosis). In comparison, 15% (14/91) of cervical glandular intraepithelial neoplasia (CGIN) and 12% (38/314) of cervical intraepithelial neoplasia grade 3 (CIN3) were upgraded to cancer. In spite of the excellent quality of cytology in England, a high proportion of negative cytology taken up to three and a half years before diagnosis were considered to contain abnormal cells by reviewers informed of the subsequent cancer. Continuing these reviews, with a strong focus on education, will ensure a clear understanding of these slides and further reduce the risk of developing cervical cancer.

The NHS cervical screening programme audit of invasive cervical cancers: who benefits?

Please cite this paper as: Moss E, Sherman S, Pearmain P, Redman C. The NHS cervical screening programme audit of invasive cervical cancers: who benefits? BJOG 2012;119:1–4.

Incidence of cervical intraepithelial neoplasia grade 2 or worse in colposcopy‐negative/human papillomavirus‐positive women with low‐grade cytological abnormalities

To determine the risk of incident high-grade cervical intraepithelial neoplasia (CIN) in human papillomavirus (HPV) -positive women with low-grade cytological abnormalities who had a satisfactory normal colposcopy. A retrospective follow-up study within the NHS HPV/LBC pilot studies. The NHS Cervical Screening Programme in England. A total of 1063 HPV-positive women with borderline or mild dyskaryosis who were negative at colposcopy from three sites within the NHS HPV/liquid-based cytology (LBC) pilot studies. HPV triage took place in 2001/02. In 2009 all information on additional management on HPV-positive/colposcopy-negative women was requested. The rate of disease following a negative colposcopy was calculated, and survival analysis was used to determine whether the grade of referral cytology impacted on risk of subsequent disease. Results were compared with those in women from the same population who had not been HPV triaged. Incident CIN2 or worse during follow up. Of 1063 eligible women 965 had documented follow up. The cumulative rate of CIN2+ at 3 years in these women was 4.4% (95% CI 4.0-7.0%); the median time from normal colposcopy to final result was 27 months. There was no significant increase in the risk of future disease associated with age or initial cytology result. The rate of subsequent high-grade CIN among colposcopically negative triaged women was sufficiently low to justify return to routine recall.

Which women default from follow‐up cervical cytology tests? A cohort study within the TOMBOLA trial

To identify factors associated with default from follow-up cervical cytology tests. A cohort study was conducted involving 2166 women, aged 20-59, with recent low-grade cervical cytology taken within the NHS Cervical Screening Programmes in Scotland and England, and managed by 6-monthly cytology in primary care. For the first (6-month) and second (12-month) surveillance cytology tests separately, women were categorized as 'on-time attendees' (attended ≤6 months of test being due), 'late attendees' (attended greater than 6 months after test was due) or 'non-attendees' (failed to attend). Multivariate odds ratios (ORs) were computed for factors associated with late and non-attendance. For the first surveillance test, risk of non-attendance was significantly higher in younger women, those without post-secondary education, and non-users of prescribed contraception. Factors significantly associated with late attendance for the first test were the same as for non-attendance, plus current smoking and having children. The most important predictor of non-attendance for the second surveillance test was late attendance for the first test (OR = 9.65; 95% CI, 6.60-16.62). Non-attendance for the second test was also significantly higher among women who were younger, smokers and had negative cytology on the first surveillance test. Late attendance for the second surveillance test was higher in women who were younger, smokers, had children and attended late for the first test. Women at highest risk of default from follow-up cytology tend to be young, smoke, lack post-secondary education, and have defaulted from a previous surveillance appointment. Tackling default will require development of targeted strategies to encourage attendance and research to better understand the reasons underpinning default.

‘A False Sense of Security’? Understanding the Role of the Hpv Vaccine on Future Cervical Screening Behaviour: A Qualitative Study of Uk Parents and Girls of Vaccination Age

ObjectivesThe UK Human Papillomavirus (HPV) vaccination programme was introduced in 2008 for girls aged 12–13. The vaccine offers protection against HPV types 16 and 18, which together cause about 70% of cervical cancers. Vaccinated girls will receive future invitations to the NHS Cervical Screening Programme, to prevent cancers associated with HPV types not included in the vaccine, and in case of prior infection with HPV 16 or 18. Little is known about parents' and girls' understandings of the protection offered by the vaccine, or the need for future screening.DesignQualitative interviews with twenty-six parents, and nine girls aged 12–13 who were offered HPV vaccination through a Primary Care Trust (PCT) in the South-east of England, UK.SettingThirty-nine schools, and four general practices.ResultsUncertainty about the level of protection offered by the HPV vaccine was evident among parents, and to a lesser extent among vaccination-aged girls. There was a lack of understanding among parents and girls that cervical screening would be required irrespective of vaccination status; some parental decisions to accept the vaccine were made on the misunderstanding that vaccination provided complete protection against cervical cancer.ConclusionsSufficient awareness of the issues related to screening is necessary for informed decision-making about whether or not to accept the HPV vaccine. Clearer information is needed concerning the incomplete protection offered by the vaccine, and that cervical screening will still be required. Future invitations for cervical screening should stress the necessity to attend regardless of HPV vaccination status, to ensure that high levels of prevention of cervical cancer through screening are maintained.

Implementing the national invasive cervical cancer audit: correlation between local and regional classification

To determine the accuracy of information recorded regionally and locally on the screening classification of cervical cancer cases using the national invasive cervical cancer audit categories. Comparison of the audit categorization of all cervical cancer cases diagnosed at the University Hospital of North Staffordshire (UHNS) between January 2003 and December 2006 with the classification assigned by the West Midlands Cervical Screening Quality Assurance Reference Centre (WMQARC). Eighty-seven cases of cervical cancer were diagnosed during the three-year study period. There was agreement between the UHNS and WMQARC classification of cases in 52 cases (59.7%), moderate agreement κ = 0.51 (95% CI 0.39-0.63). The greatest disparity was seen in the classification of lapsed attenders, with nine of the 26 cases categorized as 'lapsed' by the UHNS being assigned to the 'lost to follow-up' category by WMQARC. Three cases were deemed unclassifiable by WMQARC using the national classification since the women were over the age of 70 years but had previously been enrolled in the screening programme, and currently there is no national category for these women. Accurate and consistent classification of invasive cervical cancer cases is essential in order to obtain useful information on the efficiency of the national screening programme at a local, regional and national level. The use of a national algorithm would provide reassurance that all data used in the national evaluation of the NHS Cervical Screening Programme are consistent, meaning that robust conclusions could then be drawn from the data.

Age Criteria for Cervical Screening in England: Qualitative Study of Women’s Views

The age criteria applied in the NHS Cervical Screening Programme have been much debated at policy and professional levels, but little is known about women’s views on appropriate age criteria. Our objective is to provide insight into women’s views on age criteria for the NHS Cervical Screening Programme in England. We present data collected as part of a qualitative interview study conducted in the East Midlands of England. Thirty-five women, representing a range of ages and ethnic groups, were interviewed. Analysis was based on the constant comparative method. Women’s views about the age criteria that should appropriately be applied to cervical cancer screening diverged considerably from the technical principles and criteria upon which policy decisions are based. Women called for screening to be extended at both the upper and the lower ends of the age range. However, there was little explicit acknowledgment in women’s accounts of the risks posed by screening or of the relative effectiveness and cost-effectiveness of screening in women of different ages. Policy decisions about screening programmes often face problems of legitimacy and acceptability. There is an increasingly pressing need to ensure that the criteria used to make decisions about who will be offered screening are made explicit and communicated effectively, so that people’s views can be well-informed.

Estimation of disease severity in the NHS cervical screening programme. Part II: quantitative methods of estimating disease severity and progression potential

This is the second of a two-part paper exploring the use of a more quantitative approach to both cytology and histology disease severity measurements. In Part I the problem of artificial cut-off points was discussed and a semi-quantitative solution to the problem proposed. In Part II quantitative methods are proposed that are used to predict the estimated progression probability (EPP) to invasive cancer. Based on models derived from published data the grade number (GN) is related to the EPP to invasive cancer over the next 10 years for both cytology (CEPP) and histology (HEPP) using a look-up table. CEPP and HEPP are then adjusted by other factors such as age, persistence, HPV result, number of cells and lesion size to obtain the adjusted CEPP and HEPP (ACEPP and (AHEPP). The two factors can be combined to produce an adjusted weighted estimated progression potential using the formula AWEPP √((ACEPP + AHEPP)/2) × AHEPP) using a two to one bias in favour of the histology. As an example of the methodology consider a slide estimated as showing a 60% probability of moderate dyskaryosis (HSIL favouring CIN2) and 40% probability of mild dyskaryosis (LSIL favouring CIN1). The GN number would be 1.6 (as described in Part I) and the EPP over the next 10 years 0.78%. For a woman aged 52 years (correction factor ×2.0) with a second mildly dyskaryotic smear (correction factor ×1.25) and >50 dyskaryotic cells (correction factor 1.5) the ACEPP would be 0.78 × 2.00 × 1.25 × 1.5 = 2.9%. If the HEPP on histology was 50:50 between CIN1 and CIN2, the AHEPP can be calculated as 1.4%. The AWEPP would be √((2.9 + 1.4)/2 × 1.4) = 1.7%. The final estimate of disease progression potential based on both cytology and histology is 1.7% over 10 years. These quantitative approaches based on adjusted and weighted EPP provide a framework suitable for research, audit and comparison between screening centres, and for tailoring criteria for colposcopy referral and treatment. Further research is required to improve the estimates given in the paper.

Estimation of disease severity in the NHS cervical screening programme. Part I: artificial cut-off points and semi-quantitative solutions

Current cytology and histology classifications are based on ordered categories and have a strong emphasis on providing information that decides a woman's management rather than the best estimate of disease severity. This two-part paper explores the use of a quantitative approach to both cytology and histology disease severity measurements. In Part I the problem of artificial cut-off points is discussed and a simple semi-quantitative solution to the problem is proposed. This closely relates to the revised British Society for Clinical Cytology (BSCC) terminology. The estimates of disease severity are designed as extensions of the existing methods, with an emphasis on probability rather than certainty, as a more natural way of approaching the problem. Borderline changes are treated as categorical variables, but koilocytosis, mild, moderate and severe dyskaryosis, and ?invasive as quasi-continuous and the disease severity estimated as a grade number (GN) with any value between 0-4 and the margin of error as a calculated grade range (CGR). As an example, if the reader is unsure between moderate dyskaryosis (HSIL favouring CIN2) and mild dyskaryosis (LSIL favouring CIN1) they can register this uncertainty as a probability, such as 60%/40% moderate/mild. With 2 and 1 as the mid-points of the grade numbers for moderate and mild dyskaryosis the GN value is ((60 × 2)+(40 × 1))/100 = 1.6. The CGR is 1.5 - 0.4 to 1.5 + 0.6 = 1.1 to 2.1. The GN (CGR) estimate of disease severity is therefore 1.6 (1.1-2.1). In a similar manner the disease severity from all slides showing koilocytosis or dyskaryosis can be estimated as a number between 0 and 4 with an associated error. Histology can be treated in a similar way. This semi-quantitative approach provides a framework more suitable for research and audit of disease severity estimates. It avoids the paradox inherent in the current systems using artificial cut-points to produce categories whereby increasing agreement can only be achieved by losing information.

The multidisciplinary colposcopy meeting: recommendations for future service provision and an analysis of clinical decision making

In 2004 the NHS Cervical Screening Programme (NHSCSP) recommended that multidisciplinary meetings should be incorporated into patient management. No data has been provided since then regarding its functionality or benefits. We aim to address this issue. Retrospective review. Jessop Wing colposcopy multidisciplinary meeting (MDM), Sheffield, UK. All women referred to the MDM from September 2003 to September 2009. Retrospective review of the colposcopy database (Sept 2003-Sept 2009), cross-referenced with multidisciplinary team (MDT) letters, patient notes and the hospital results reporting system. Baseline statistics were used for data analysis. Indications for MDT referral; concordance rates from cytopathology and histopathology review; concordance rates between MDT treatment decisions and final patient management. A total of 535 cases were discussed at 62 MDT meetings during the allocated study period. Discrepancy between referral cytology and cervix punch biopsy was the most common referral (49%). Cytology and histology review concurred with the initial reports in 75.8 and 97.8% of cases, respectively; the MDT decision was concordant with the final patient management in 97% of cases. The main reason for discordance (67%) resulted from patient factors. When significant discrepancies exist between colposcopy, cytology and histopathology, then MDT discussion seems pertinent as MDT discussion can lead to the avoidance of over-treatment. To improve timeliness of treatment, MDT meetings should occur at least monthly. The results of each case discussion should be recorded in the patient case notes, the minutes of each meeting should be circulated to all MDT members and a letter describing MDT recommendations must be sent to the colposcopist responsible for patient care.