Rachel Paul’s change.org petition has gained traction across social media, as she urges Public Health Wales to renege on their change to Cervical Cancer Screening. Lengthening the interval between screening from 3 to 5 years, the body argues that recent changes to how the screening programme is performed warrant the change.
January is Cervical Cancer Awareness Month and later this month, Jo’s Cervical Cancer Trust, the UK’s leading Cervical Cancer Charity, will hold its Cervical Cancer Prevention week in the UK (17-23 January). Jo’s Cervical Cancer Trust was founded in 2000 by James Maxwell, whose wife Jo died in 1999, 4 years after she was first diagnosed.
Rachel Paul’s petition, addressed to the Welsh Government and Public Health Wales, reads:
“From 1 January 2022, if you are aged 25-49, the gap between routine tests has now changed from 3 to 5 years, meaning an additional 2 years between cervical screening and potentially seeing further deaths from cervical cancer!
On average 3197 cases of cervical cancer are discovered each year with 854 deaths between 2016-2018, with only 51% surviving this type of cancer for more than 10 years.
99.8% of cervical cancer cases are preventable (according to cancer research UK).
INCREASING THE LENGTH OF TIME BETWEEN CERVICAL SCREENING IS PUTTING LIVES AT RISK!”
Rachel Paul, Change.org Petition writer
Righteous outrage?
At the time of this article’s publication, the petition had garnered over 905,0000 signatories, making it close to being one of the top signed petitions on the site. 10,000 signatures have been added just this morning as I was researching and writing this article; I’ve had to change the figure twice already.
Comments on the petition reveal the outrage the signatories feel for the change;
“3 years is long enough”,
“Just another one of the governments [sic] bad decisions to save money”,
“Cervical screening is simple and effective in detecting early signs of cancer. To increase the time between screenings to 5 years is a retrograde step! The upper age limit for regular screening is 64 – which us far too early – so a 5 year gap could mean some won’t be screened from age 60! Dreadful thought. So it should remain at 3 years and no upper age limit!”
My treatment to prevent cervical cancer
As someone who has had treatment to prevent cancer in my cervix, I am always naturally concerned by any changes to the current screening programme. The results of my very first smear were abnormal – they showed I had CIN3, which are “severely abnormal” cells found on the surface of my cervix. Usually caused by the Human Papillomavirus (HPV), CIN3 is not cancer but can spread and is often a precursor to cancer of the cervix. The decision taken by my gynaecologist was that I should have a LLETZ procedure. Large loop excision of the transformation zone (LLETZ) is an outpatient surgery to remove some of the cervix. Mine was performed in 2010 and the gynaecologist told me that he had removed so much of my cervix that he recommended that, should I become pregnant in the future, I should have the “competency” of my cervix checked as I was now at risk for late-term miscarriage.
Essentially, he had taken so much of the cervix that it had been significantly shortened. I was extremely concerned by this in 2015, when I became pregnant with my first child and had to fight to get an ultrasound to check how it all looked, ensuring that I didn’t need a cervical stitch to keep her in place as she grew and the effects of gravity might threaten the pregnancy. I’ve had three term pregnancies now, so thankfully he was wrong and my cervix has been nothing but competent in that regard.
Public Health Wales apology
The petition has not fallen on deaf ears, however – Public Health Wales (PHW) has directly addressed the outrage and apologised for the confusion around what’s changing. They admit that not enough has been done to clearly explain the rationale and evidence around the change:
“We are sorry. We haven’t done enough to explain the changes to cervical screening and have caused concern. We are working to make this clearer and more information will be available as soon as we can today and in the coming days.”
Why the change? The evidence examined
The change has been made because of the success of the HPV vaccination programme introduced in Wales in 2018. Now, 90% of the tests performed show no high risk for cervical cancer and it’s this that prompted the UK National Screening Committee to recommend lengthening the time taken between screening from 3 to 5 years.
Dr Hillier, PHW’s screening division director, told the BBC
“If you have HPV high-risk found in your sample but no cell changes, we will bring you back for cervical screening in a year’s time and if that carries on, we will keep looking at you every year for three years”
A study published in the Lancet in November 2021 demonstrated that our vaccine programme dramatically reduced cervical cancer rates by almost 90% in women in their 20s, who were offered the vaccine aged 12-13.
However it’s unclear whether the change to 5-yearly cervical cancer checks will only be offered to the cohort of young people who have been offered the HPV vaccine.
The justification for the change is outlined in detail in “What cervical screening is appropriate for women who have been vaccinated against high risk HPV? A simulation study”, published in 2017.
The risks of screening
Although it seems that screening for cancer should be frequent, what is often missed by those proposing more regular screening is the risk of false positives. More screening does not always result in finding more cases of cancer – it can mean more anxiety, more false positives and unnecessary treatment, as no screening programme is infallible or 100% correct all of the time.
One outspoken critic of various screening programmes is GP Dr Margaret McCartney. Writing for the BMJ in 2019, she criticised the views of Mike Richards, who was tasked with an independent review of adult screening programmes:
Calling for financial incentives, increased uptake, reorganisation, and restructuring, Richards writes: “Every day of delay is a missed opportunity to catch a person’s cancer or disease at an earlier point, and potentially save their life.”
Margaret McCartney on Mike Richards’ review on adult screening programmes
More good than harm? Informed consent is crucial
Though many of us lay people may agree with Richards’ view of the importance of screening programmes, McCartney warns “It is because it is rare for screening programmes to offer more good than harm that we need specialist consideration that understands the science which underpins it—and this includes rigorous cost effectiveness analysis. Resources spent on screening healthy people cannot be given to people who are dealing with the reality of deprivation, early multimorbidity, and under resourced mental health services.”
She also says: “The UK National Screening Committee is one of the few bits of the NHS which works very well. It stands for evidence, for cool assessment of cost effectiveness and potential harms, and calm consideration”
McCartney, who wrote The Patient Paradox: Why Sexed-Up Medicine Is Bad For Your Health, said she was concerned about people having the treatment I did not being adequately warned about the risks involved. In that, I must agree. Before I had my LLETZ procedure I was not warned that it could mean that I was at risk of late-term miscarriage because of a shortened cervix and that is crucial to my decision making. Procedures given without full knowledge mean they are not being performed with informed consent.
McCartney worries that a false positive test is a far higher risk than the risk you won’t have your life prolonged by screening.
Talking to The Herald in 2012, Dr McCartney spoke out about why she opts out of Cervical Cancer screening entirely.
“We know from research if you take 1000 women and screen them for 35 years, you can prevent one death from cervical cancer.”
“[T]o get that reduction, around 150 women would also get “an abnormal result” which could be false positive or require repeated smear tests. Another 50 women would require treatment for cells deemed abnormal but which might not develop into cancer.
https://www.heraldscotland.com/news/13054346.cancer-screening-no-thanks-says-gp/
Kate Sanger, Head of Communications and Public Affairs at Jo’s Cervical Cancer Trust published a blog yesterday to address the facts “Behind the Headlines” and said
“As HPV primary screening is more sensitive and accurate, meaning changes are picked up earlier, evidence shows it is safe for those who test negative for high risk HPV to be screened less often.”
Kate Sanger, Head of Communications and Public Affairs at Jo’s Cervical Cancer Trust
Sanger also directly addresses the safety of the changes and says
“HPV makes cells change slowly, over many years. If abnormal cells in the cervix develop between tests, they can be picked up at the next test. Cervical cancer is a slow growing cancer and takes many years to develop.
Kate Sanger, Head of Communications and Public Affairs at Jo’s Cervical Cancer Trust
It may be useful to remember that many cell changes and HPV infections will clear on their own. Screening programmes want to maximise the benefits they bring, while avoiding unnecessary tests and the risk of overtreatment. There are many who find screening and gynaecological examinations difficult”
Kate Sanger, Head of Communications and Public Affairs at Jo’s Cervical Cancer Trust
Though critics will point at the cost-savings associated with the change, it’s clear that over-diagnosis is a risk of screening and that advances in science, including our amazing HPV vaccination programme are already making huge changes to the rates of cervical cancer. What’s also important to remember is that screening isn’t there for when you have unusual gynaecological symptoms.
Seek help if you have unusual symptoms
If you are experiencing vaginal bleeding that is unusual for you, changes to vaginal discharge, pain or discomfort during sex, pain in your lower back or in your pelvis, that you seek help from your GP.
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