Cervical Screening

Philippa Whitford Excerpts
Monday 19th July 2021

(2 years, 8 months ago)

Westminster Hall
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Philippa Whitford Portrait Dr Philippa Whitford (Central Ayrshire) (SNP) [V]
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It is an honour to serve under your chairmanship, Mr Pritchard. First, I want to extend my sympathy to Fiona’s family and friends, who were moved by her loss to set up the petition in her name. I have seen at first hand the impact of cervical cancer, as one of my friends lost her beautiful and vibrant daughter at the age of just 28 to this horrible disease. As a breast cancer surgeon for more than 30 years, I know the devastation caused by the death of any young woman.

Before we go further, I want to emphasise that any woman with symptoms of vaginal discharge or bleeding should not wait for a screening appointment, but should go and see her GP. There is usually a simple cause, but it is always important to get checked out.

Although the petition specifically calls for annual cervical smear tests, what we are all actually trying to achieve is the prevention and eventual elimination of cervical cancer, as called for by the World Health Organisation last August. For that we have to understand the cause of cervical cancer, and that is where our knowledge has developed considerably. We know that 99.7% of cervical cancers are caused by high risk strains of human papillomavirus, or HPV, and that is therefore the target of our efforts. This is through a two-pronged strategy, providing protection to the younger generation through vaccination against HPV and using more sensitive polymerase chain reaction testing to detect HPV on cervical smear samples to identify those at increased risk.

The HPV vaccine was introduced for young teenage girls in 2008 and initially included those up to 18 years, so that they would be vaccinated before leaving school. Research from the Scottish cervical screening programme in 2017 reported a reduction in the presence of HPV in the smears of vaccinated women from 30% to 4.5%, and by 2019 demonstrated an 89% fall in grade 3 cervical intraepithelial neoplasia—the cell changes that can evolve into cervical cancer if left untreated. That dramatic reduction in CIN 3 among the first cohort of vaccinated girls gives great hope that we will see a fall in cervical cancer in that age group in the coming years.

The vaccine is now also provided to boys, both to protect them from other HPV-related cancers and to provide additional protection to women by reducing how many men carry HPV in the first place. It is vaccination against HPV that really offers the chance to eliminate this terrible disease by the end of the decade. To achieve that, we need to vaccinate 90% of all teenagers, and our uptake rates have drifted below that level over the past five years. Some of that is likely due to fears that the vaccine was associated with health issues such as chronic fatigue or regional pain syndromes. However, a review by the European Medicines Agency found that those conditions were very common among teenagers generally, and there was no increase among those who had been vaccinated.

To reduce the risk of cervical cancer, we need to get rid of the stigma of HPV and ensure that all women and young people understand its importance in the development of cancer. It is a very common virus, which, in the vast majority of cases, causes no harm and is cleared by the body’s own defences, but some strains pose a higher risk of causing malignant change. After vaccination, the other critical approach to preventing cervical cancer is, of course, screening itself, but here too the focus is now on detecting HPV as the driver of cervical changes that can eventually lead to cancer. Classical cytology, which looks for abnormal cells within cervical smears, does not pick up every case, while PCR, about which we have heard so much during the pandemic, is more sensitive in detecting HPV and identifying the women at higher risk.

The UK National Screening Committee has therefore recommended changing to a two-step testing procedure, with the cervical sample tested for HPV first and then cytology performed on those samples that contain virus. Currently, that is carried out on one sample, which is collected in the traditional way—a clinician having to visualise the cervix directly. If the sample contains HPV, cytology is carried out on the cervical cells. If any changes are found, the patient is referred to a gynaecologist for a colposcopy, where the cervix is examined and biopsied to assess the grade of cell changes.

If the woman is HPV-positive but has no cell changes and therefore would never have been highlighted under the old system, she will undergo repeat screening the following year; if the virus persists after two years, even without cell changes, she will be referred for colposcopy. By focusing on the presence of the virus, women carrying HPV and at higher risk are provided with more intensive follow-up. It is the UK National Screening Committee that has recommended that women who are HPV-negative and therefore at very low risk are offered routine repeat screening every five years, from the ages of 25 to 65. That system has been fully rolled out in Scotland since March last year, but I highlight that the same approach is planned across all four UK nations once the PCR testing and data systems are in place.

Screening remains vital in detecting cervical cancer and its precursors in women who did not have the opportunity to be vaccinated against HPV. But uptake is at a 20-year low, with just over 70% of women attending overall. Attendance is even lower among younger women and those from minority ethnic groups or more deprived communities, as well as among lesbian or transgender people, who make mistakenly think that they are less at risk of HPV infections. The challenge is there for how to engage more women to take part in cervical screening. Changing to annual cervical examination might actually cause more women to withdraw from the programme.

HPV is found in only about 10% of cervical smear tests, so carrying out a simple vaginal swab to test for HPV could reduce the number of women who have to undergo a formal cervical smear with direct visualisation of the cervix. That would avoid the need to use a speculum and reduce the discomfort, which puts some women off taking up future appointments. It would also greatly reduce the difficulties experienced by those with physical or learning disabilities. Indeed, disabled women have been campaigning for years about the fact that those with the greatest physical difficulties often struggle to take part in screening at all.

A team at Dumfries and Galloway health board in Scotland established a trial in 2012 in which over 5,000 women took vaginal swabs themselves as well as getting a formal cervical smear done in the traditional way. That demonstrated both the accuracy and acceptability of this approach and the team is working with the Scottish Government to consider making that part of our routine screening programme. The UK National Screening Committee is still evaluating that approach, but research by Jo’s Cervical Cancer Trust suggests that this simpler method of sampling could get more women to engage and take up HPV testing as the first step of screening.

The issue is particularly important among groups that currently have a much higher risk of cancer but a lower engagement with a screening programme. NHS England has now begun a trial offering self-administered HPV swabs to 31,000 women in parts of London who have failed to attend their routine appointments. My one gripe with that excellent project was that the publicity and social media around its launch described the tests as self-administered smear tests instead of explaining that they were simple vaginal swabs, which a woman should easily be able to carry out at home. That caused a lot of consternation among women, who wondered how on earth they were meant to ensure that they visualised, or took a sample from, their own cervixes. It could put some off from trying to take the sample in the first place. Describing them as smear tests could also lead someone who is HPV-positive to fail to attend their GP practice for formal assessment, if they are under the mistaken impression that they have already had a cervical smear.

The NHS project in London is designed to engage those who have not taken up their routine invitations, but I hope that simple vaginal swabs to test for HPV will eventually become a routine step available to all women—whether self-administered in the privacy of their own home, or by a clinician in their local GP practice. HPV vaccination holds the potential to drastically reduce the number of young women who are even at risk of cervical cancer, but screening will always be important in order to detect cell changes or early cancer, and all of us need to encourage high uptake of both vaccination and screening. Although I recognise the anguish that led Fiona’s family to start the petition, I hope they can see that our understanding of this terrible disease and its cause opens up new and better approaches to eliminating cervical cancer in this coming decade, so that other families do not suffer the loss that they are going through.