Cervical Cancer Screening

Martin Horwood Excerpts

Thursday 1st May 2014 Commons Chamber

[Martin Horwood (Cheltenham) (LD)]

It is an honour and a pleasure to follow the hon. Member for West Ham (Lyn Brown), as well as other Members, particularly my right hon. Friend the Member for Sutton and Cheam (Paul Burstow) and, indeed, the hon. Member for Wirral South (Alison McGovern), whose speech was a moving tribute to Sophie Jones—her constituent—and her family. I also congratulate the hon. Member for Liverpool, Walton (Steve Rotheram) on securing this timely debate.

I welcome the Government’s work on cancer in general. Their Be Clear on Cancer campaigns, which began in 2011, have been producing good work, which is now being done in conjunction with Public Health England. I should probably declare a non-pecuniary interest here: my wife is the director of one of Public Health England’s regional centres.

I feel some sympathy with the Minister. I am sure that her instinct was to trust her brief from the Department, and its representation of the risks and statistics attached to cervical cancer and screening. I suspect that, being a member of the coalition, I have a similar brief before me now. I have to say, however, that deeper examination of those risks and statistics casts grave doubt on the Department’s current interpretation of them.

I have benefited from some forensic research carried out by my constituent and friend Mel Gladwin. Mel works for an organisation in Cheltenham that is well known for its forensic examination of data, but she contacted me in connection with today’s debate because in 2003, at the age of 22, she was diagnosed with a very aggressive form of cervical cancer. I am delighted to say that she is now perfectly healthy, and has a bouncy seven-year-old son. Her life was saved by effective treatment. The treatment was effective because Mel’s condition was diagnosed early, and it was diagnosed early because she was part of a routine screening programme for those aged under 25. Mel, her family and I are all pretty well convinced that she would not be with us today if that routine screening programme had not existed.

Mel tells me that in 2009, the Advisory Committee on Cervical Screening cited two specific reasons for not restoring screening for those aged under 25. One was that it caused significant anxiety. That view appears to have been based not on any recent evidence, but on evidence dating back to the 1970s and 1980s, when survival rates generally were much lower, a much greater stigma was attached to cancer, and, I suspect, anxiety levels were higher. I believe that cancer now constitutes a largely curable disease in the public imagination, and that anxiety levels may not be quite the same. In any event, I think that when anxiety is balanced against the risk of death, most people would rather be sure that they were safe, even if the cost of that was some anxiety.

The principal reason given by the ACCS for its decision was the potential risk of premature birth if the women concerned had children later in life. That evidence was presented to the committee by Professor Peter Sasieni of Queen Mary, University of London—the self-same Peter Sasieni who conducted the much more robust 2012 study referred to by hon. Members today. It was a study of 44,000 women, including 2,000 to 3,000 under the age of 25, and was much larger than the earlier studies and based in England, whereas the others were done in Scandinavian countries where the incidence was different and the treatment appears to have been somewhat different. Therefore, this research is much more robust and relevant.

Although my right hon. Friend the Member for Sutton and Cheam presented the results in quite a qualified way, actually, the British Medical Journal was pretty robust in its conclusions when it published them:

“After adjusting the results to account for the type of treatment and whether it had occurred before or after the birth, the researchers found that there was no increased risk associated with treatment. The researchers concluded that the increased risk of preterm birth in women who have been treated for cervical disease was due to common factors that increased the risk of both cervical disease and preterm delivery, and not to the treatment itself.”

The BMJ could not really have been clearer, yet that evidence has never been formally reviewed by the ACCS.

That suggests that there is no strong reason not to screen women under 25, but perhaps we should balance that against whether there is a strong reason actually to screen women under 25, because the Department must also take that into consideration. Mel comes from a talented family. Her father, as luck would have it, is a mathematician and computer scientist at the university of Kent’s school of computing. He has looked at research produced by Cancer Research UK on the incidence of diagnosis of cervical cancer in various age cohorts. The statistics are very strange. The incidence of diagnosis at 25 has tripled in just the last few years—a huge spike in the statistics—and is many times the incidence at 24 and lower ages, which appears, strangely, to have reduced. It is also higher than the incidence at 26, so something very odd is happening. What was previously a gradual increase in incidence of diagnosis by age cohort now contains a massive spike.

Peter Welch, Mel’s father, is not medically qualified but he is a statistician and knows his statistics. His conclusion was pretty clear:

“The figure shows a dwindling of diagnosed cervical cancers in the 20-24 year group since they stopped being screened and a massive spike in those aged 25 (discovered on their first screen). That dwindling is very unlikely to be because the prevalence of cervical cancer has dwindled. The huge spike—approximately 10 times the counts for the individual year groups 20 through 24 and 3 times the counts for the year groups 26 through 29—is most likely because of cancers that would have been prevented by screening now developing and cancers that would have been found earlier now being found late.”

In other words, withdrawing routine screening has suppressed the numbers at 25 and younger, and massively increased them at age 25. That is a very serious conclusion. If it is true and the conclusions of the second batch of Sasieni research are true, the inescapable conclusion is that we have denied screening to young women whose lives would have been saved, and increased the risk at the age of 25 and above of people having had undiagnosed cancer before then.

I am very glad that Mel is happy and healthy, but she clearly attributes her survival to the routine screening programme. This issue is now in urgent need of review. We are not talking about vast numbers of young women —there were about 45 in 2010, according to the most recent available statistics—but their lives might be being put at risk each year, and the Government must reflect urgently on the issue and reconvene the ACCS to look again at the most recent and robust research.

--- 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.