Cervical Cancer Screening

Jane Ellison Excerpts

Thursday 1st May 2014 Commons Chamber

[Mr Baron]

The hon. Lady makes an excellent point, which leads me neatly on to the report that the all-party group produced back in 2009 on reducing cancer inequalities—I should perhaps declare an interest as the chairman of the group. The report, which was extensive and took in much written and oral evidence, found that this country’s health care system stood as much chance as any other of getting patients from the one-year point to the five-year point after diagnosis. However, where we fell down was on getting them to the one-year point in the first place. That suggests that the NHS is as good as any other health care system at treating cancer once it is detected, but very poor at detecting it. That underperformance in diagnosing cancer means that we trail other health care systems. We never catch up from that original loss.

Comparisons are always dangerous. When we compare our system with that in France, for example, we are comparing it with centres of excellence, so we have to be careful in our comparisons. However, the figures of 5,000 lives a year that could be saved if we matched European averages and 10,000 that could be saved if we met international averages are generally accepted. They can largely be accounted for by the early phase, when we fail to pick up cancer early enough and so do not get enough people to the one-year point after diagnosis.

The all-party group therefore decided to ask how we could focus the NHS on earlier diagnosis. We have been laser-like and dogged in our campaign on that front.

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

indicated assent.

[Mr Baron]

The Minister is nodding—kindly, I think. I thank her for that in one respect.

The solution that the all-party group came up with was to focus on outcomes. We could bombard the NHS with a lot of targets to try to encourage earlier diagnosis, but instead we decided to focus on one outcome measure—the one-year survival rate, broken down by CCG—as a driver towards earlier diagnosis.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

I congratulate the hon. Members for Wirral South (Alison McGovern) and for Liverpool, Walton (Steve Rotheram) on securing and leading this debate. We all wish that we were not debating this issue, important though it is, against such a tragic backdrop. I share the view of the hon. Member for Wirral South that it is a great innovation that, through e-petitions and the Backbench Business Committee—she knows that I used to serve on that Committee—we can now bring issues of such huge public concern swiftly to the House for debate.

This has been an excellent debate, and I thank all Members for their contributions. Depending on how tolerant Mr Deputy Speaker is feeling, I may not get the chance to address all the points that have been raised, but I hope Members know that I will, as I always commit to, respond to them after the debate.

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

Order. The Deputy Speaker is always generous in the time that he gives but, recognising that there are constraints, I welcome those comments.

--- Later in debate ---

[Jane Ellison]

Indeed, and I will be guided by you, Mr Deputy Speaker.

Like others, I start by paying tribute to Sophie Jones and her brave battle against cervical cancer. I also offer my sincere condolences to her family who have conducted themselves with such dignity in recent weeks and months. I assure all Members that I will try to address the important issues that they have raised. There is a lot to say, so if I do not get through it all, I will respond to them afterwards.

Although I am not able to comment in detail on individual clinical cases, we understand that Sophie’s case was one of misdiagnosis rather than of screening, to which the hon. Member for Liverpool, Walton alluded. Thankfully, cases of cervical cancer in her age group are extremely rare. I understand that the medical director for the Cheshire, Warrington and Wirral area team has requested that the GP practice undertake a significant event analysis to review the case, and ensure that all appropriate procedures are followed and that any lessons learned are put into practice. Once that is completed, it will be agreed with the practice how that will be shared. I can assure the House that I fully expect NHS England to keep the family and local MP fully informed as the investigation progresses.

Despite the tragic circumstances in this case, I reassure the House that the NHS cervical screening programme is one of the most well regarded in the world. More than 3 million women are screened every year. Experts estimate that the programme saves up to 4,500 lives in England alone. However, it has to be based on the best available evidence. The best independent evidence shows that routine screening of women under 25, on balance, does more harm than good. The UK national screening committee reviewed the age of cervical screening in 2012—although some Members have said that the last review was earlier or later than that—and confirmed the English policy of not screening those aged under 25 as it has no impact that can be seen on the detection rates of cervical cancer in young women and gives rise to a high number of false positives, which cause anxiety and, more importantly, lead to unnecessary investigations and treatments that can have side effects.

The UK NSC review in 2012 followed a review of the age at which cervical screening starts by the Advisory Committee on Cervical Screening, or ACCS, which is made up of experts in a range of disciplines, third sector representatives from Jo’s Cervical Cancer Trust and patients. The ACCS review took place in May 2009 to consider the raising of the screening age from 20 to 25, and it confirmed that decision. The 2012 review was partly a response to the Jade Goody effect mentioned by some hon. Members today and was intended to reconsider that decision. The ACCS was unanimous in deciding that there was no reason to lower the age from 25, which is in line with World Health Organisation guidelines.

Some of the reasons behind that decision have been mentioned. The research presented showed that there was little or no impact on detection rates in those aged up to 30, no clear evidence of an increase in the incidence of cervical cancer following the change to the screening age in 2004, no new scientific evidence was available to support the reintroduction of screening and one in three young women aged under 25 would have an abnormal result when screened, as opposed to one in 14 from all women who are screened. That shows a lot of false positives in young women.

[Martin Horwood]

Will the Minister give way?

[Jane Ellison]

If the hon. Gentleman is going to draw my attention to the statistics he presented, I am happy to look at them in detail and, indeed, I have a partial answer to some of his questions.

[Martin Horwood]

indicated dissent.

[Jane Ellison]

I will give way very quickly, but I need to get through my speech.

[Martin Horwood]

I was interested to know when in 2012 the UK NSC met. The second Sasieni research was only published in August 2012 and the Cancer Research UK statistics were published in the BMJ in 2013, so they have not been reviewed as far as I know.

[Jane Ellison]

As I said, the hon. Gentleman presented quite a detailed statistical submission and I shall respond to him after the debate rather than off the cuff. His statistics deserve better than that.

Cervical cancer is thankfully very rare in women aged under 25. As has been said, there were 47 cases in England in 2011, the last year for which we have figures. That is less than 2% of all cases and there were two deaths. Obviously, we will consider the statistics presented by the hon. Member for Cheltenham (Martin Horwood), but we are aware that in 2009-10—this also relates to the points made by other hon. Members, and most strongly by the hon. Member for West Ham (Lyn Brown), about health inequalities—an extra 600,000 women came forward for screening, many as a result of the publicity surrounding the death of Jade Goody. Many of those women were from lower socio-economic and hard-to-reach groups, and they are more often at risk. That is an important statistic and we need to consider that again.

It may help the House if I briefly run through the science behind the abnormal screening results in younger women. Primarily, they are caused by the fact that they have a high rate of HPV infection, as the cervix in young women is more prone to infection with transient HPV, both because it has not yet matured and because younger women might be exposed more often to different types of HPV. Furthermore, some of the few cancers found in young women are unusual and rare tumours that differ from the type we screen for, such as small cell tumours that can develop rapidly and are very dangerous. However, some are HPV-associated tumours that develop at a young age and sometimes simply as a rapidly developing cancer. The key thing in such cases is rapid referral and an appropriate medical response.

In its 2009 report, the ACCS was concerned that young women presenting to primary care with symptoms of cervical cancer were not always given the best advice. I know that that will be a concern not only to Sophie’s family but to all of us in this House and to the NHS. We know that for many GPs, seeing a patient with cervical cancer is rare, and potentially only one GP in 16 will see a new case each year. That is quite a statistic. To help GPs make the right clinical decisions, new guidance for primary care on the management of young women with gynaecological symptoms was developed and sent to all GPs in England in March 2010. The guidance was developed by a multi-disciplinary group, and supported by all the relevant royal colleges. I undertake to raise the issue again with the Royal College of Obstetricians and Gynaecologists and the Royal College of General Practitioners to explore the best way to remind GPs of the guidance.

I reiterate that whatever her age, if a woman is concerned about abnormal symptoms she should contact her GP, who will be able to examine and refer her urgently to a gynaecologist if clinically appropriate. The House might not be aware that the guidance is explicit that in any case where a woman is showing symptoms, best practice is that she should not be referred for screening. That is because a cervical screening test is aimed at women without symptoms. It is a screening, not a diagnostic test, and waiting two weeks for the result could delay examination by a gynaecologist. That is a really important point to bring out in the debate. If someone has symptoms, we want to get them urgently from symptom to diagnosis via a referral, and a screening test could further delay that.

I want to talk a little, as others have, about the human papilloma virus, or HPV. Many Members have mentioned the fact that we have identified high-risk types of the virus and that the vaccination programme sprang from that identification of risk. The programme was introduced in 2008 for girls aged 12 to 13. Its aim was to prevent cervical cancer related to the HPV types covered by the vaccine, which covers about 70% of all cervical cancers. The programme has been a big success. More than 7.8 million doses have been given so far in the UK since 2008, and we have among the highest rates of HPV vaccine coverage in the world, with 86% of girls eligible for routine vaccination in England in the 2012-13 academic year completing the three-dose course, and 90% receiving at least two doses.

It may be of interest to Members to hear that the Merseyside area team reports a higher than national average take-up of the HPV vaccine, with 87.8% of girls vaccinated with all three doses in 2012-13. In Wirral and Sefton, that figure was 90%. However, we cannot be complacent and we want to get the fullest possible coverage. That is something about which MPs, as well as Ministers, can do a lot to spread the word. When we go into schools, a good question to ask might concern the coverage and whether there are particular groups of parents or people from particular backgrounds who do not take up the vaccine.

It is expected that the programme will eventually save more than 400 lives a year from cervical cancer. The first indication that the programme is successfully preventing infection with HPV types 16 and 18 in sexually active young women in England was published in the scientific journal Vaccine, and showed that the proportion of infected rates in 16 to 18-year-olds fell from 17.6% in 2008 to 6.6% between 2010 and 2012. That is major progress, so the take-up of the vaccine is really important.

We encourage all girls, irrespective of religion or ethnic background, to receive the HPV vaccination. NHS England is responsible for making arrangements to implement the programme for eligible girls and young women in the local area, taking into account local circumstances, such as the number of independent or special schools and the number of girls who are not in school. Interestingly, I was informed that Surrey has a much lower take-up, so perhaps we need to consider how to deal with girls in independent schools, or other local circumstances. NHS England is also responsible for ensuring that local programmes meet the national specifications.

We are using our growing knowledge of HPV to modernise the NHS’s cervical screening programme by considering HPV infection alongside the screening programme and looking for abnormalities and seeing how they can interact. Public Health England is also promoting the use of the HPV test as a primary screen, which is very interesting. A lot of work is going on, and the first evaluation report of the pilot is due in spring 2015. Cancer Research UK has estimated that, when fully implemented, HPV primary screening could prevent hundreds of cancers a year.

There are some particular matters to which I would like to draw the attention of the House, as I have a little time. The Prime Minister’s £50 million GP access fund will support more than 1,400 practices covering every region to offer extra services for those who struggle to find appointments that fit in with family and work. That is important and responds to one of the points made by the shadow Minister.

I hope we can show that despite tragic cases such as Sophie’s, the age at which screening starts in England is based on sound evidence. It has been carefully considered by members of expert committees pretty recently. However, I am very aware that we need to keep all evidence under review. I have already had a brief conversation with the chief medical officer about this. Members may be aware that one of my fellow Ministers is a specialist in this area of medicine, so we will make sure that we look again at the points that have been made in the debate.

There is much we can do as a House and as a country to reduce the number of women who suffer from this devastating disease. I urge every woman invited to screening to take up the opportunity, as we know that 25% of women in the 25-to-30 age group do not. On screening, I do not have time to describe the work in detail, but I can assure Members that Public Health England has work under way specifically to look at low coverage in certain areas and to work on local action plans to improve that coverage.

I want to do more to urge employers to support their staff. Again, evidence from Jo’s Cervical Cancer Trust, representatives of which I met on Monday evening and discussed some of these issues with, suggests that many younger women do not want to ask an employer for time off for a smear test. I will look at what we can do through work that is already going on with employers to see how we can encourage them to make it clear to young women that they do not have to go through an embarrassing conversation to get time off for that. I will be looking at that further with Jo’s Cervical Cancer Trust.

If Members who called the debate and spoke in it have the appetite for it, I am happy to devote a special day in Parliament to what we can do on take-up of screening and of HPV vaccination. I would love to do that piece of work with hon. Members if they want to work with me on that, because much of this is down to local and specific community factors. A one-size-fits-all national programme is not adequate. As part of Be Clear on Cancer, we have a pilot programme on ovarian cancer which will be running this spring, so we are moving into those gynaecological issues. We will look at the review of that to see whether there is more we can do in this area. Work is under way, but there is so much more we can do working together.

[Lyn Brown]

I am grateful to the Minister and I will certainly take her up on that. May I remind her of the hysteroscopy campaign, which we could perhaps dovetail into that work?

[Jane Ellison]

Of course. I remember that I responded to the hon. Lady on the detail of that.

I have started to write routinely to the chairmen of health and wellbeing boards to make them aware of issues that are of interest to parliamentarians and changes in law or guidance. I undertake to mention this subject, particularly in the context of Sophie Jones’s case, in my next letter to health and wellbeing board chairmen, to draw it to their attention. There is a 1 million study under way by the National Institute for Health Research under its health technology assessment programme to look at the issues of effective interventions for younger women on the take-up of screening, so work is in progress.

[Mr Baron]

Will the Minister update the House briefly on whether there has been any progress on work regarding how we will hold underperforming CCGs to account, once the one-year cancer survival figures are published from June onwards?

[Jane Ellison]

I applaud my hon. Friend for taking a further opportunity to draw that to my attention—we met on Monday evening and discussed it. That will be part of the Department’s response to the all-party group’s report, and I undertake to update him further. I note, as he does, that he raised the matter with the Prime Minister recently and I will keenly pursue the points that he has made.

Finally, I thank all the staff involved in the national screening programme and those who deliver the important HPV vaccination programme for all their hard work. More power to the elbow of those who are looking for ways at local or national level to reach more young women, for all the reasons outlined by so many Members in so many excellent speeches. We can do so much more to achieve greater awareness and greater take-up, to get greater numbers of people screened and taking up the HPV vaccine. All that is work that we as Members of Parliament, I as a Minister and many people involved in our health services around the country can take part in. I recognise that for Sophie’s family, nothing we do can make up for her loss, but it can be part of her legacy. I thank Members for bringing this debate to the House.